Skill Switch

Knowing how to do something doesn’t necessarily translate into the ability to actually do it. And yet, for the last century, medical education has been organized around two things: structure and content. It was a classic formula that reigned unchallenged – until the 1970s, when the concepts surrounding “competency-based education” first came to light. And once on the scene, the idea of teaching people by competencies rather than knowledge rapidly gained traction.

With competency-based education, we don’t just ensure that the learner has the information for a given task, but also that they can demonstrate the competencies required to complete it. So it goes beyond pure knowledge by encompassing skills and attitude as well, and it demands that learners show social accountability. The public needs to know that professionals in training can do their jobs safely and effectively. That wasn’t happening with traditional medical education and it fueled a sea change. Now, pathology is also moving toward a competency-based model of medical education (CBME).

Knowledge versus competency

To understand competency, it helps to relate the concepts to childhood activities with which we’re all familiar. If you want to teach a six-year-old how to ride a bicycle, you won’t begin with a lecture on the parts of the bike, the laws of physics, and the rules of the road. Instead, you’ll teach what’s actually involved in the process of riding the bike and perhaps add a firm push... The child will watch other people do it, then start copying and practicing. And practicing. Later, you can start adding extra knowledge (with a focus on safety) as appropriate. But no one needs to know how a bicycle is put together to ride one!

We’ve developed multiple educational frameworks for teaching competencies, but all of them deal with the overarching roles of a physician. Obviously, the central role is that of medical expert, but there are other ones – called intrinsic roles – that each physician needs to fulfill:

• Health advocate
• Collaborator
• Communicator
• Leader
• Scholar
• Professional

These six roles are integral to any physician’s day-to-day work – but because they’re quite broad, it’s difficult to teach or assess them as competencies. A better way is to use a proxy – entrustable professional activities. These are the tasks that form the core of any given specialty, so that each physician in that specialty should be able to perform them competently. It’s far easier to assess trainees by observing them while they perform those tasks than to try to pin down the nebulous overarching concept of a competency.

In pathology, examples of entrustable professional activities include performing intraoperative consultations, gross examinations, and autopsies; preparing complete and accurate pathology reports; communicating results effectively with clinicians; and participating in multidisciplinary cancer conferences or tumor boards. Every competent pathologist must be able to do these things – so if you want to infer that trainees have the necessary competencies, you can do so by watching them perform each of these tasks.

Why is this so important? Because until recently, the way we taught medicine hadn’t changed for ages; we were still trying to teach every student everything we knew about medicine. In reality, most doctors don’t need all of that knowledge to practice competently. That’s a point that becomes especially true when you consider how far medicine has advanced over those years; the amount of knowledge we have now is completely overwhelming. We need to focus on teaching students the things they really need to be competent, safety-conscious physicians. Trying to fill their brains with everything from medicinal leeches to molecular pathology is a Sisyphean task!

How to train toward competency

If you want to know whether or not a six-year-old can ride a bike, you have several options. You could write a multiple-choice exam or you could ask open-ended questions such as, “What would you do if a car crossed your path?” and “How do you stop a bicycle?” But far better than either of those options is simply to observe and correct along the way, providing effective feedback on the things the child is doing right and wrong.

Now, let’s say that I want to teach something a little more complicated – pathology, for example. Until recently, we taught the entire pathology curriculum to every medical student, but only about one in 100 students is going to choose that specialty. Do they need to know all of that to become clinicians? Isn’t it more important that I teach them how to interpret the pathology results they’ll receive as non-specialists? We need to look at the curriculum and see what these students really need to do to be competent as non-pathologists. Of course, the concepts of pathology are really important – but do they need extensive microscopy training, for instance, or is it more important for them to understand and integrate the concepts into their practice?

Clinicians need to know how to choose pathology tests and interpret their results. What is the best type of biopsy to increase yield in different clinical scenarios? What is the current role of molecular pathology? How do we interpret immunohistochemistry results? How do we use those things in the differential diagnosis of cancers, or for predictive biomarker testing? This is the pathology 21st-century physicians are going to need – especially those who work with pathologists rather than as pathologists. I might give my students a stack of pathology reports and ask, “What are you going to do with this patient based on these reports?” That’s far more valuable for most of them than handing them slides and asking them to provide a diagnosis. I want my students to ask, how will this affect treatment? Prognosis? Management? What does this pathology mean for my patient?

Since we’ve begun using CBME, I’ve noticed that newly trained pathologists are much more aware of system failures and communication/collaboration issues than their older colleagues. Now, when I talk to my residents, they are completely familiar with the different competencies required for a pathologist – so when we discuss a topic like quality assurance (QA), they understand that it requires a number of extra steps to increase patient safety, they know how to check the “nuts and bolts,” and they do it automatically because they view it as a necessary part of being a practicing pathologist. In the past, QA was seen as the province of lab management – but it’s far better for the people who are actually doing the work to incorporate QA. It plays into the intrinsic roles we discussed – leader, health advocate, collaborator, communicator – and I think it goes a long way toward minimizing errors and failures.

A training transition

In the beginning, students were a little hesitant to get on board with such a radically different system. It didn’t take long for them to grasp its importance, though. We practice a lot – for instance, after tumor boards, I debrief with my residents. “What did you see? What did and didn’t you like about the discussion?” Their answers aren’t just from the perspective of the medical expert anymore; now, they talk about professionalism, communication, and collaboration between doctors. They understand that the patient is at the center of care, and that it’s more important for medical team members to work well with one another than for individual physicians to remain in the ivory tower of their own expertise. It’s very motivating for them to see pathologists getting out from behind the microscope and providing direct patient care.

Now that we’ve been CBME-focused for several years, incoming trainees can look to older ones for guidance and role modeling. But many of them are already familiar with the system – medical schools not just in Canada, but internationally, are now using competency frameworks similar to those in our postgraduate program. The framework from Canada’s Royal College of Physicians and Surgeons is used in more than 30 jurisdictions around the world, so it’s clear that CBME is here to stay. And with good reason; we have preliminary results indicating that trainees might learn more effectively with the new model.

Assessment plays a huge role in CBME – most of which is formative (observing and offering specific feedback on how to improve). Over multiple cycles of observation and feedback, the learner acquires the competencies, and it’s easy to trace the sources of any difficulties and ensure that there are no obstacles to progress. After completing the formative assessment cycle, you also perform a summative assessment to evaluate the learner – but it’s not a pass/fail scenario; instead, you get an overall idea of their performance and understanding. Finally, you decide if additional training is needed or if the student is ready to practice the activity independently.

It’s a bit like giving a series of “micro-licenses” for individual competencies. When they’ve collected all of those micro-licenses, the training is finished. The process allows faster learners to progress at their own pace without creating difficulties for those who need more time. It also allows educators to accommodate variability in a learning group without punishing students at either extreme.

You might be concerned that, with students progressing at different speeds, there is potential for stigma. And though that may be true, I think the advantage of respecting learners’ individual needs far outweighs the risk. In Canada, we have a large number of international medical graduates, which creates different backgrounds at the beginning of residency. Some may be more advanced than Canadian graduates, whereas others may not have reached quite the same stage of development. But the inequities don’t stop there. One student might encounter health problems during training; another family problems; another might have a child. You can’t treat residents as a homogeneous population, and I think CBME allows you to respect them as individuals. The milestones of progress are no longer the years of training; instead, they are the stages of competency – and that allows for much more adaptability.

Will this lead to a structural change in the way medical schools are run? For sure. But for now, we’re implementing CBME in waves of a sort. The first wave was to help people understand exactly what CBME is and introduce them to the frameworks. Now, we’re starting to change training programs from knowledge-based to competency-based models. That takes time, because we need more teaching hours; we need faculty development; we need changes to examination procedures; we need transition periods for trainees moving from education into practice. We’re working on bringing in all of those changes, but a major overhaul like this can’t be done in a day.

Beyond the schoolhouse walls

The CBME concept isn’t limited to trainees and offers benefits at every level. For instance, the Canadian Association of Pathologists is restructuring its national conference to incorporate those same principles. We’re bringing in more interactive sessions, more workshops, more parallel learning tracks to accommodate different needs and interests, and a series of interdisciplinary sessions to access the expertise of non-pathologists. We’re also introducing an overarching theme that is important to all pathologists, regardless of scope or specialty. For 2017, the theme is “wellness” – how to develop strategies for a sustainable career in pathology. So many of us are overworked and under-resourced – how can we address those problems without compromising patient care?

In the next few years, we’re planning to introduce a leadership summit at the conference, and to begin providing performance assessments. The Royal College mandates assessments for recertification, so we’re going to offer opportunities for practicing pathologists to complete them on-site. We’re also expanding on the availability of interprofessional education, which we hope will help pathologists better understand the notion of collective competency and collaborative practice. Collaborative practice is a real cornerstone of CBME – and we must remember that even if an individual is competent, the team as a whole might not be, and that still ultimately leads to poor patient care. To guarantee that every patient receives the best possible care, we need to teach pathologists how to work within a team – not in isolation. And we need to ensure that professionals from all areas are equally competent, equally involved, and equally respected as members of the health care team.

As you can tell, we have many ideas for improvements, and the concept of competencies runs through them all! In my opinion, knowledge is easily acquired; translating that knowledge into action is the difficult part. You can always look up information (though you certainly can’t retain it all in your head permanently); knowing how to apply it in context is a skill that can only be acquired through time and training. Why is this so important? Because we want to make pathologists leaders in the field. I often feel like we simply wait for things to happen, and I’d like that to change. I’d like to see us become role models for other specialties. I’d like to see us play a part in the evolution of medical training – and of medicine as a whole. Transitioning to a new model of education is the first step along the path to leadership, and I’m looking forward to the rest of the journey.

Skill Switch

The Slide and The Sequence

The Cornerstone of Competency