Building a competency-based curriculum: the agony and the ecstasy

Abstract

Physician competencies have increasingly been a focus of medical education at all levels. Although competencies are not a new concept, when the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) jointly agreed on six competencies for certification and maintenance of certification of physicians in 1999, it brought about renewed interest. This article gives a brief overview of how a competency-based curriculum differs from other approaches and then describes the issues that need to be considered in the design and implementation of such a curriculum. In order to achieve success, a competency-based curriculum requires careful planning, preparation and a long-term commitment from everyone involved in the educational process. Building a competency-based curriculum is really about maintaining quality control and relinquishing control to those who care the most about medical education, our students. In the face of the many challenges that are facing undergraduate medical education (UME), including declining availability of teaching patients and over-burdened faculty, instituting quality control and relinquishing control will be necessary to maintain high quality.

Appendix A

Case study of competency-based curriculum implementation at the Indiana University School of Medicine (IUSM)

The Indiana University School of Medicine (IUSM) experience provides an example of faculty buy-in and faculty development being critical to the success of a competency-based curriculum. IUSM adopted the nine competency curriculum scheme of Brown University in 2000. After adoption, there was substantial resistance from faculty who taught all four UME years. Basic science faculty generally objected to trying to teach and assess what they felt were ‘touchy-feely’ competencies such as interpersonal skills and professionalism, while 3rd and 4th year faculty generally objected to adding anything to an already overburdened, overloaded curriculum. Thus buy-in was essential.

To promote buy-in and prepare faculty for their roles in the new curriculum, ‘early adopter’ faculty members ran a series of workshops across the statewide medical education system, first for basic science faculty. These workshops emphasized that people normally evaluate each other on the basis of their interpersonal and communications skills as well as professionalism in their daily lives. Thus evaluating medical students on these competencies was a natural extension of this normal process.

An important part of the workshop was to have basic science faculty reflect on past classes to remember the student(s) whom they felt lacked the interpersonal skills to become a competent physician yet had the knowledge base required to pass discipline and USMLE exams. Discussion centered on contrasting how this type of student would have been dealt with in a competency based curriculum. Next, faculty were asked whether they would prefer to be treated or have a family member treated by a physician who was judged competent in nine competency areas versus one not competent in one or more of these nine competencies. This further reinforced the general usefulness of the competency-based curriculum in the basic science years.

The next part of the workshop was designed to assure basic science faculty that they could teach and assess competencies, emphasizing that each basic science course need not address all competencies, but should do several of them.

The assessment form to be used in all courses contained multiple descriptors emphasizing behaviors and attitudes that were assessed on a three-point scale: (1) below attainment, (2) average attainment, and (3) exemplary attainment. It was pointed out that the goal was to identify outliers, and that these outliers would be remediated before being allowed to progress to the clinical years. Emphasis was placed on multiple observations of each competency, not a single assessment. Several examples were given of exercises in basic science that could be used to teach and assess particular competencies, and faculty were urged to come up with other examples in their courses.

Workshops for faculty in years 3 and 4 followed the same general structure but emphasized that many of the competencies were best taught and assessed in the clinical years of UME. Each clerkship was originally asked to embrace only one competency to minimize the impact on overburdened clinical faculty. Over the years, many of the clerkships have adopted multiple competencies as part of their program.

Faculty development has been an ongoing process in bringing faculty ‘up-to-speed’ on the competencies due to faculty turnover. Another reason for continual faculty development is that the evaluation process has been “fine tuned” over the years, so faculty need their skills upgraded. This has especially been true for student remediation upon non-attainment of competencies.

Information on the IUSM Competency Curriculum can be found at the following web site http://meca.iusm.iu.edu/.