Intended for healthcare professionals

Careers

An end to box ticking: an overhaul of competency based education

BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i3020 (Published 14 June 2016) Cite this as: BMJ 2016;353:i3020
  1. David Black, medical director
  1. Joint Royal Colleges of Physicians Training Board, Regents Park, London NW1 4LB
  1. david.black{at}jrcptb.org.uk

Abstract

An overhaul of competency based education should lead to a clearer picture of a doctor’s ability at the end of training, says David Black

In 2004 competency based postgraduate medical education (CBE) was launched for doctors training under the new foundation programme curriculum. By 2008 the 31 curricula owned by the Joint Royal Colleges of Physicians Training Board (JRCPTB) met the new standards set by the Postgraduate Medical Education and Training Board for CBE.

The arguments for this style of education seemed overwhelming: it would formally observe what physicians actually did in the workplace as opposed to what they were able to show they could do in an exam.

Yet from the start CBE was controversial,1 trainers found it difficult to deliver and implement in a consistent way. An early study showed that of over 800 foundation year 1 trainees, undertaking 15 assessments each, only 1% scored less than five on a seven point Likert scale, where seven was highly satisfactory.2 A review in 2010 found that there was little evidence that other workplace based assessment tools led to improvements in performance.3

Even the terminology of assessment has caused problems. Many trainers and trainees did not understand that workplace based assessments were formative: assessment for learning. Instead they were treated as if they were summative and high stakes: assessments of learning.

In 2012 the Academy of the Medical Royal Colleges introduced supervised learning events (SLE) to emphasise the formative nature of most workplace based assessments.4

A further weakness of CBE was the large number of competencies requiring “sign off”—meaning that meetings with educational supervisors became little more than box ticking exercises.

Trust issues

Significant change is needed and a way forward is being developed in both the training and literature.

The new approach is to focus on the outcome of training and to define that in terms of the work that a trainee is trusted to do.56 By the end of training, doctors are “trusted” to undertake all work tasks independently and without supervision.

These tasks are known as entrustable professional activities (EPAs) or competencies in practice (CiP). A CiP is defined as “a critical part of professional work that can be identified as a unit to be entrusted to a trainee once efficient competence has been reached.”7

The concept is helpful in two ways:

  • It drives curriculum writers to identify the most important tasks to be mastered in the outcome of training, and

  • Each task can then be linked explicitly to the most crucial competencies which are then observed during normal clinical practice.

CiPs emphasise the role of observation and judgment, and replicate real life practice. For example, a consultant must decide what each trainee can be trusted to do, as well as determine the amount of supervision, direct or indirect, that they need to undertake activities safely. These kinds of judgments are routinely made in the workplace and are based on the experience of the consultant. By the end of training a doctor must be trusted to undertake all the key critical tasks needed to work as a consultant—and that becomes the outcome and end point of training.

Outcomes

In the UK the regulator expects the new curricula to be outcome driven.

The 2016 foundation programme curriculum is based on 20 outcomes,8 and the General Medical Council (GMC) has also recently consulted on the generic professional capabilities that must now underpin all new curricula, again based on an outcome model.9

For the past 18 months the three UK Royal Colleges of Physicians and the 31 specialties that are part of JRCPTB have been designing new curricula based on the use of CiPs. Underpinning the training of all physicians will be a new internal medicine curriculum, which will incorporate all of the GMC’s generic professional capabilities.

A process of discussion and debate has led to agreement on 14 competencies in practice for the new internal medicine curriculum. It is hoped that this will lead to a much more authentic and simplified way of assessing, supporting, and documenting a learner’s progress.

It moves away from a process of box ticking and toward a process that says, “I trust you to do these work activities. If not, I need to identify the underlying competencies that need to be developed so that you can progress to the next level of trust.”

Widespread discussion with the trainee committees of the three Royal Colleges of Physicians, as well as those that design and deliver the 31 JRCPTB curricula suggest that this is a realistic and sensible way to reform CBE. Throughout the year JRCPTB will work with volunteer trainee and trainer groups on a “proof of concept” study to see if this theoretical approach really does simplify assessment in the current challenging NHS environment.10

Footnotes

  • I have read and understood BMJ policy on declaration of interests and declare that I have no competing interests.

References