CBD Community Touchpoint - December 2016

Date set for Competence by Design implementation

Date set for Competence by Design implementation

Dear colleagues,

If you have not already heard the news, Canada’s 17 medical schools and the Royal College have agreed to implement Competence by Design (CBD) starting July 1, 2017. We have dedicated this edition of Touchpoint to this important decision, which highlights the commitment across the medical education community to transform our learning and assessment framework to one that is competency-based.  Throughout this issue you will learn about our next steps, our focus on faculty development and how we are aligning accreditation.  You will also hear from leaders in medical education, as well as a resident, on what this change means to them.

Two specialties paving the way
I am pleased to inform you that effective July 1, 2017, both Anesthesiology and Otolaryngology – Head and Neck Surgery will launch their residency training under a new competency-based approach.

This agreement was achieved  at a conjoint meeting on November 25, 2016, between our Committee on Specialty Education, Cohort 1 specialty committees and Canada’s 17 postgraduate deans. 

Looking forward
Over the next seven months we will work with our medical school partners, specialty committees, CBD leads and residents to finalize preparations for the July 1, 2017 launch. We may yet run into challenges – in fact, we expect to. But we are clear in our intent. The collaborative working relationship we have built with our partners will enable us to recognize and overcome obstacles in a timely fashion and, most important, ensure that the expectations, challenges and concerns of all parties are taken into account as we move toward implementation.

I am very appreciative of the time and effort of all committee members and stakeholders currently working through the process who are engaging their communities, defining new national standards and sharing their learnings. For example, we are grateful to the Medical Oncology committee for their contributions in field testing many aspects of CBD that will allow us to improve our model.

Thank you to all of the committee members, partners and staff who contributed to this significant achievement.

Yours Sincerely,

Andrew Padmos, BA, MD, FRCPC, FACP
Chief Executive Officer


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Understanding the resident perspective: A conversation with Dr. Brie Yama

Understanding the resident perspective: A conversation with Dr. Brie Yama

Dr. Yama is a Pediatric Chief Resident at The Hospital for Sick Children in Toronto, and is also one of the Chief Residents for the International Conference on Residency Education (ICRE). She is passionate about medical education and is the Resident Representative on the Royal College Pediatrics CBD Working Group. We caught up with her for this issue of CBD Community Touchpoint to gain a deeper insight into the resident perspective, including how CBD will affect residents and patient care.

What are the biggest differences between the current system and CBD?
There are two differences that have me the most excited. The first is that CBD is skill based rather than time based. The assumption has been that exposure to learning over a pre-determined length of time is sufficient for acquiring specific skills. The time-based system works well, but a skill-based system under CBD will mean that if a particular resident needs more or less time to acquire a particular skill, the curriculum will be more flexible to accommodate this.

The second is the feedback component of CBD and the normalization of routine feedback that begins the moment a resident arrives. Under the current system we get feedback, but it’s less standardized and frequent than what CBD proposes. This makes evaluations feel very high stakes. CBD will shift that dynamic toward a culture of improvement by providing frequent observations and feedback on specific skills.

How do you think CBD will benefit residents?
Residents will have a clearer, more explicit understanding of how they’re faring than they do now. Most residents fit into the category of “doing well”, but they aren’t always aware of how they can focus their efforts to improve. CBD curriculum, via the core competencies and milestones, will highlight those areas that need improvement and residents will be supported in developing plans for advancement.

How will CBD benefit patients?
The benefits for residents go hand-in-hand with patient safety. The four-phases of the new CBD model will help residents transition through the various stages of training from the start of residency to preparation for independent practice. Each phase will have defined milestones that the resident will need to demonstrate for advancement, which will translate into excellent and safe patient care. Also, by focusing on improving specific skills, CBD allows for earlier identification of areas where a resident might need support. That will certainly translate into better patient care.

Do you foresee any challenges for residents as CBD is implemented?
I think one challenge might be the greater transparency of CBD compared to the current system. It touches on issues of privacy for residents because individuals may not progress at the same pace. The thing that is most exciting about CBD – the individualized, skill-based learning plan – is very different from the time-based plan that in a sense equalizes the residents. How widely will residents’ varying abilities be known to the people around them under CBD? We need to figure out how to navigate that.

Do you think residents should be excited about CBD?
Definitely. The important thing to remember is that we have a great medical education system in Canada and CBD will make it even better. It is going to help create physicians who, supported by mentors and coaches, can confidently and critically reflect upon and evaluate their own skills. It will re-emphasize the value of continual progress. Medicine involves a commitment to lifelong learning and CBD will support residents’ growth and development. This is important at all levels of training and practice. CBD is helping to shift us toward a culture of asking for help in the pursuit of clinical excellence.

How can the Royal College support residents during the transition to CBD?
The Royal College is already doing a lot of the things they need to. They’ve developed exciting strategies for engaging all stakeholders – especially residents – in discussions about how CBD will work and be implemented. They’re also collaborating creatively with program directors and faculty in ways that enable CBD to be the success we all imagine it will be.

Do you have any advice for future residents who will go through the CBD program?
To be honest, I’m kind of envious. It is exciting but it’s also intimidating. My best advice is for residents to keep their minds open to the potential of CBD. The feedback and mentorship components of the program will, ultimately, help train better doctors. I don’t have a single colleague who doesn’t want to do their absolute best by their patients. CBD will enable that.

Want to hear more about Brie’s thoughts on CBD? Check out our exclusive interview with Brie onsite at The Hospital for Sick Children.



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Faculty development: An essential element of implementing Competence by Design (CBD)

Faculty development: An essential element of implementing Competence by Design (CBD)

The Royal College recognises that faculty development is crucial to implementing CBD.  As the country moves towards implementation, we will continue to work with key stakeholders including speciality committees to create educational and faculty development resources that will support disciplines as they incorporate competency-based medical education into their programs.  Some examples include topics such as programmatic assessment, CBD 101, and competence committees. 

There are currently great resources on our website, and more are in development.  Newly designed web-pages in early 2017 will help people find these great resources.  We’re also introducing a new feature in Touchpoint, which will highlight a valuable faculty development resource in each edition.  In this edition we are featuring a PowerPoint slide deck introducing CBD.  This resource is designed so that anyone can introduce a group of people to the rationale and design for CBD.  It can be easily modified for longer or shorter sessions. 

In this edition, we feature a digital presentation called Competence by Design (CBD) Overview: 2015–2018. It gives a detailed explanation of CBD’s foundations, its various components, our plan for implementation and next steps. We tell the story through the eyes of a fictitious resident working her way through the system. Feel free to use these slides as you wish!


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Competence by Design: A Threat or an Opportunity?

Competence by Design: A Threat or an Opportunity?

Gillian Hawker, MD, FRCPC

Gillian Hawker, MD, FRCPC, Chair of the Department of Medicine at the University of Toronto, makes a compelling case for the value of CBD. In this piece, which was originally published as the Chair’s Column for the University of Toronto and has been republished in Touchpoint with Dr. Hawker’s permission, she explains how CBD will help her department pursue a patient-centred focus and align training with the future needs of the population. Dr. Hawker also briefly describes the infrastructure, professional development and time structure needed to make sure CBD succeeds.

There is a lot happening right now in the academic medicine environment, not least of which is the impending formal implementation of the new Competency by Design (CBD) framework for our residents.

In case you haven’t heard, CBD is the Royal College’s initiative to, “improve physician training and lifelong learning,” to, “transition specialist medical education from a traditional time-based model to a hybrid form of competency-based medical education (CBME).” ”CBD focuses on outcomes — organizes physician training around desired outcomes and looks at the needed competencies.” Brian Wong pointed out to me, the Frenk Lancet report on CBME published in the Lancet in 2010* clearly articulated that the main driver for CBME is to improve patient outcomes and these desired patient and health system outcomes determine the competencies physicians need to achieve these outcomes. To quote Brian, “…the most exciting part of CBME, if done well, is that it has the potential to shift learning from being solely learner centred, to being more patient centred."

CBME comes with a new lexicon. In place of our current methods of resident evaluation, we will assess residents’ achievement of educational ‘milestones,’ defined as, “observable markers of someone’s ability along a developmental continuum,” and competency to perform ‘entrustable professional activities’ or EPAs. From the Royal College, an EPA is, “a task in the clinical setting that a supervisor can delegate to a resident who has demonstrated sufficient competence. Typically, an EPA integrates multiple milestones. They are the tasks that must be accomplished, whereas milestones refer to the individual’s abilities.” If I have it right, an example of a milestone might be to be able to take a thorough history of a patient with multiple chronic conditions, while the EPA might be to develop and execute, with the patient, a treatment plan for condition X in the setting of multiple other conditions.

Well, I am by no means an education scholar, nor any kind of expert on CBD/CBME, but what I have learned about it thus far actually has me pretty excited and, frankly, optimistic that this will be good for us all – our faculty, our trainees and most importantly, our patients. However, I know not everyone shares my enthusiasm. So, I thought I would take this opportunity to tell you why I am positive about CBME, and what I am hearing from the experts.

A while ago, I spoke about my experiences in Addis Ababa with several of our hematology faculty, where we sat in and observed ALL trainee-patient interactions. I reflected on how much more gratifying it was to be able to play a hands-on role in working alongside the trainee as they took the history from the patient, examined them, formulated and relayed their opinions and treatment plan to the patient. I watched our own Gena Piliotis – a brilliant master clinician and teacher - gently guide the resident during the consultation. When it was clear that the resident was missing the forest for the trees or heading off on a perilous tangent, she would interject and ask simply, “You asked about X – tell me what you are thinking?” It was fantastic! To me, this was CBD in action! At point of care, learning was happening – and the patient was part of it!

But, clearly, we are not in Addis Ababa and, while I think there is a lot we can learn from these experiences, how CBME rolls out here will undoubtedly look different.

I spent a few days last week in Ottawa at CAPM – the Canadian Association for Professors of Medicine (i.e. the Chairs of Medicine across Canada). I learned, not surprisingly, that there is universal angst about the transition to CBD. We heard a terrific presentation on CBME from Dr. Ken Harris, Executive Director in the Office of Specialty Education at the Royal College. He explained that a major driver for the shift to CBME is the hope that with much more regular and frequent evaluations designed to guide the trainee towards achieving each milestone, and ultimately the EPAs, there will be a greater willingness - both on the part of faculty members and trainees — to engage in meaningful conversations about residents’ performance. I see this also as an opportunity ultimately, to reflect on and talk about how to make knowledgeable, skilful and compassionate doctors. Is there any evidence that this will be the case? Is there evidence that this will help us produce more competent physicians? No, not exactly, but is there anyone who doesn’t think we could be doing a better job of resident evaluation?    

There is currently such pressure – real and imagined – to give every trainee a high rating, even when undeserved. A faculty member’s annual review, likelihood of being recognized as an excellent teacher, and promotion through the ranks are very much tied to their evaluations as a teacher and, whether we like it or not, a teacher who is critical of a trainee is at risk of receiving a bad evaluation. From the resident’s perspective, a subspecialty training spot, admission to a graduate program, or even possibly a job, might be perceived as ‘on the line’ if their performance is anything but stellar! What is wrong with ‘meeting expectations?’ If CBME has potential to lead to more meaningful and timely feedback to our trainees, then that can only be good.

Two of the department’s strategic foci are to ensure the patient is at the centre of all we do, and to align our training with the future needs of the population. I see CBD as a potential vehicle by which to accomplish these goals.

Let me explain why.

First, by nature of the evaluation structure for CBD, it will be incumbent on our faculty to spend more time with our trainees and patients at point of care, whether at the bedside or in clinic. My understanding is that this doesn’t mean that the faculty member will be required to sit in for the duration of the entire interaction, but rather to provide sufficient and regular ‘spot checks’ to ensure milestones are being met and, ultimately, that EPAs are achieved. While this is, in my opinion, a good thing — more time for teaching at point of care —where do any of our teachers find this time? We understand that CBD cannot simply be laid on top of everything you are already doing! For CBME to work, we must stop doing some things. What do we give up? It would be great to hear from those of you who are current residents and faculty members – what do you think?

Second, while I am a proponent of the CanMEDS framework, I find the chopping up of the core competencies into distinct constructs doesn’t always translate well to teaching physicians how to care for patients. Too often, in my opinion, the ‘intrinsic’ competencies** – communicator, advocate, collaborator and even leader, may be over-shadowed by the traditional ‘medical expert’ focus of medical education and, as a result, relegated to discussions at academic half day or noon-time lectures rather than at point of care. CBD presents us the opportunity to change this – to take a more holistic approach to medical training that, through increased interactions between learners, teachers and patients at point of care, allows us to explore ALL aspects of being a physician in a more comprehensive manner.

Third, related to my second point above, when one has relatively limited time with any one trainee, it can be very difficult to complete the POWER evaluation. There hasn’t been enough time to really get to know the resident (a bigger problem in the ER and ambulatory settings than perhaps in in-patient care). Again, I think CBME may help. I imagine that it might be quite intuitive to answer the question, “Is this trainee ready to do X (rheumatology consult, joint injection, etc.) on their own?” Or, “Would I want this physician treating my family members?” after a day working with them? It’s akin to recognizing when a medicine trainee fully understands when a patient is ‘sick.’ This understanding is fundamental in internal medicine – it determines the speed of action required to manage the patient and can be critical to whether a patient lives or dies – it also to a great extent determines when faculty become comfortable ‘entrusting’ the resident with the care of such patients. When I think about CBME in this frame, it makes a lot of sense! Until a resident can consistently take a detailed history, without missing key points, they aren’t ready to be independent consultants. And those that have difficulty communicating with patients in an empathetic manner – even in stressful situations – aren’t the ones I would want caring for my family members. Inherently, this makes sense.

For these reasons, I am excited and optimistic about CBME, but want to ensure that we have the infrastructure, professional development, and time structure in place to ensure its success. Fundamental to the success of CBD are the following:

  1. Time – we must free up precious time to enable more point of care teaching opportunities;
  2. Simplicity – the evaluation framework we put in place should be as simple as possible and speak to what we all recognize as a “great physician;”
  3. Faculty buy-in – CBME will require willingness on the part of our teachers to evaluate trainees honestly, fairly and constructively;
  4. Trainee buy-in – CBME will also require openness on the part of our residents to receive constructive – and frequent – feedback on their performance as physicians. All feedback, if useful, cannot be positive – but it can all be constructive.

As always, the devil will be in the details, but we are in really good hands. The challenge with implementing CBD is to do so in a way that provides new opportunities for dialogues between trainees and faculty around the development of clinical expertise and enhances the department’s tradition of excellence and innovation in education. In other words, the aim is to improve upon past success while putting a unique U of T stamp on Competency by Design. Many of our faculty members have been leading the CBD/CBME charge at the Royal College, and our Vice-Chair, Education, Arno Kumagai, has hit the deck running. Soon, he will be posting a new leadership position in the department - a faculty lead for CBME. Interested candidates are encouraged to contact Dr. Kumagai.

As always, let us know what you think about all this – all suggestions are welcome!

*Frenk J, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet 2010

**Sherbino J, Frank JR, Flynn L, Snell L. Intrinsic Roles" rather than "armour": renaming the "non-medical expert roles" of the CanMEDS framework to match their intent. Adv Health Sci Educ Theory Pract 2011 Dec;16(5):695-7.


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Three infographics explain our CBD journey

Three infographics explain our CBD journey

The Royal College and our medical school partners are working toward a July 2017 CBD implementation for the first cohort of residents. We know you have questions about how we work with the specialty committees to begin the journey towards implementing a competency-based approach to residency training. To help explain – and to give you an overview of CBD more generally – we drew up three infographics that help explain this journey:

  1. Competence by Design: Patient-Centred, Learner-Driven, Competency-Enabled

    Get a big-picture overview of CBD, including the key benefits such as the introduction of tailored learning experiences, and detailed tracking of learners’ progress.

    Competence by  Design: Patient-Centred, Learner-Driven, Competency-Enabled

  2. Working Together to Implement CBD

    See for yourself how we work with our specialty committees to define new standards and their unique implementation plan. This infographic provides a high-level briefing.

    Working Together to Implement CBD

  3. See Yourself in CBD

    What does a future with CBD hold? How will programs and learners benefit over the long term? Find out by viewing this infographic.

    See Yourself in CBD

Check them out!


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Why CBD? Viewpoints from our medical education community

Why CBD? Viewpoints from our medical education community

Check out this new CBD video, which uses a series of interview clips to put CBD in context as the Royal College’s version of CBME, and describes in detail how CBD will benefit residents and programs. As the expert physicians interviewed here explain, CBD enables teachers and learners to communicate well enough that they can target particular competencies at specific moments during a learner’s training. The bottom line? CBD is the right choice for training better doctors in the 21st century.


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Accreditation 101: What is it and why is it changing?

Accreditation 101: What is it and why is it changing?

Within residency education, accreditation is a quality improvement process to ensure adherence to national standards across all programs and universities (e.g. consistent quality). This ensures that graduating medical doctors from across Canada are ready to enter practice with the competencies needed to deliver excellence in care.

But how do we ensure the excellence of our accreditation system?

Several years ago we embarked on a review of our accreditation system, along with our partners at the College of Family Physicians of Canada (CFCP) and the Collège des médecins du Québec (CMQ). We identified several areas where we can improve; this month, we’re launching national consultations on our proposal. We’d love to know what you think!

Updating the system to align with 21st century practice

While the current accreditation system has its strengths (i.e. its systematic, rigorous process and peer review), there are also a number of challenges and inefficiencies. In 2012, we led focus groups and interviews with postgraduate deans and other stakeholders and the majority of those interviewed believed that a major transformation was required.

There were a number of important areas where significant challenges were identified:

  • lack of emphasis on quality program outcomes;
  • inappropriate categories of accreditation;
  • resident input is not always optimized;
  • time-consuming, paper-based process;
  • overemphasis on accreditation as a high stakes, at times punitive, “snapshot in time” site visit; and
  • idiosyncratic decision-making.

Working towards a new system

In 2013, we partnered with the CFPC and the CMQ to form the Canadian Residency Accreditation Consortium (CanRAC) and to develop a new accreditation system. Together, we have created a proposal that aims to preserve the strengths of the current system, while also modernizing it and aligning it with best practices and competency-based medical education.

Current System

  • Systematic rigorous process
  • Peer review
  • Manual, paper-based
  • Episodic, “snap-shot in time” site visit
  • Process-based standards that don’t focus enough on outcomes
  • Unclear categories of accreditation
  • Resident input not optimized
  • Inconsistency of decision-making
  • High stakes, punitive

Proposed System

  • Systematic rigorous process
  • Peer review
  • Digital platform
  • Continuous cycle of accreditation
  • More explicit standards with an increased focus on outcomes
  • Revised, clearer categories of accreditation
  • Robust system for resident involvement
  • Standardized and reproducible

Gradual implementation

Transitioning to a new accreditation system is complex. We know that universities and programs will need time and support to prepare. As such, accreditation visits for 2016 remain status quo. Initial prototype testing will continue through 2019. The plan is for the new standards and processes to apply to all programs and schools being reviewed after July 1, 2019. Learn more about our implementation plans on www.canrac.ca.

Have your say: National consultations begin November 2016

This month, CanRAC is launching a comprehensive national consultation process. We want to hear from you about the proposed new standards for faculties of medicine and residency programs, as well as the proposed new accreditation process. For more information, please visit http://www.canrac.ca or email info@canrac.ca

How will competency-based medical education impact accreditation changes?

CanRAC’s proposal aims to align residency accreditation with 21st century best practices. This includes the shift towards competency-based medical education, which is reflected in the Royal College’s Competence by Design (CBD) initiative and the CFPC’s Triple C curriculum.

Learn how accreditation reform aligns with CBD.


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