CBD Community Touchpoint - September 2018


CBD Community Touchpoint

Official CBD newsletter of the Royal College

Created to inform, support and connect. About

Message from the CEO

Royal College CEO Andrew Padmos

Dear Colleagues,

One of the fundamental elements of Competence by Design (CBD) is the shift in how we see and use assessment in the training of residents. Over the last few months, a common theme across our outreach visits is a desire for more information on how the new model of assessment changes the resident learning experience. We heard you, and to help provide clarity, the focus of this edition of Touchpoint is on assessment in a CBD world.

I encourage you to read closely the column from Dr. Viren Naik, Director of Assessment at the Royal College, where he discusses the value of transitioning from assessment in its traditional manner of a “decision”, to a place where assessment is a deliberate practice for learning. Our feature article focuses on workplace-based assessment (WBA), including providing clarity around such concepts as documented observations and the RX-OCR model. It also illustrates how WBA is promoting a supportive culture for residents, and in turn, opening the door to a growth mindset.

The term assessment can be an intimidating word for many learners. As clinicians, we can relate to those moments in our training where the fear of failure impeded our opportunity to learn. I believe this important shift, where the primary purpose of feedback is for learning and improvement, is one of the key ways that CBD will ultimately produce graduates who excel in 21st century health care.


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


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Dr. Viren Naik: Why CBD is the right move for Canada

Message from Viren

Dear Colleagues,

Residency education in Canada is very good. We have graduated competent specialists from our programs to serve Canadians for many years. The global interest in our postgraduate medical education system is a tangible marker of our quality. In an era where all industries are committed to quality improvement, we have to ask ourselves if we can do even better?

Competency by design (CBD) appreciates that our learning environment and learners have changed. In this “brave new world”, the evolution in our education will feel more pronounced in some disciplines depending on the extent to which their learning environments are different. CBD will “raise the waterline” for all programs to focus on outcomes of education. Trainees will receive regular documented feedback based on observations made by their clinician supervisors. Programs will have the necessary data to make informed decisions on a trainee’s progress.

The Royal College exams will still be an important external biopsy that a trainee has achieved the knowledge and judgment necessary for practice. The difference in CBD is that trainees will be better informed of their exam readiness from regular measurement and feedback against clinically relevant activities (EPAs and milestones). Different components of the exam will move earlier into training, no longer serving as terminal events of training. The benefit to trainees will be a meaningful period to transition to practice without the burden and stress of the exam.

Ultimately, these changes will not only benefit our learners, but our patients as we even better prepare doctors for practice in the 21st century.


Viren N. Naik MD MEd MBA FRCPC
Director, Assessment


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Rethinking assessment: The role of WBA in supporting CBD

Rethinking assessment: The role of WBA in supporting CBD

Under Competence by Design (CBD), workplace-based assessment (WBA) is the process through which clinician teachers provide timely and formative feedback in the clinical setting to promote resident learning. WBAs promote a supportive learning culture for residents through regular, documented observation and coaching.

Here are three ways that WBA is transforming teaching and learning to help residents excel in 21st century health care.

1. Change the language to change the culture

Language can be a powerful thing, and the term assessment can be an intimidating word for many learners. As part of CBD, the Royal College is encouraging the use of language that promotes a culture of constructive feedback and documented observation.

“For some learners, the word ‘assessment’ is scary and brings negative memories and associations. For these learners, using the word ‘observation’ instead of ‘assessment’, helps them to understand that the primary focus of someone watching and documenting their performance is to help them improve, as opposed to passing or failing them," explains Nancy Dudek, MD, MEd, FRCPC, one of the Royal College’s Clinician Educators who is focusing on WBA.

As your program shifts to CBD, consider your context and audience first, and then choose the language that will resonate best. The following terms can be used interchangeably, but often have a different impact: workplace-based assessment, work-based assessment, and documented observation.

2. Coaching in the moment: Embracing a growth mindset

Regular and timely conversations between a learner and an observer are a critical element of WBA. Frontline clinical teachers are encouraged to observe trainees in practice and provide written and verbal feedback designed to promote learner growth.

“We are seeing a culture change where we are moving away from assessment in its usual manner of a ‘decision’, but rather ‘assessment for learning’ where there is an opportunity for coaching and really allowing for that growth mindset’,” explains Farhan Bhanji, MD, MHPE, FRCPC, a CanMEDS Clinician Educator and the Associate Director of Assessment at the Royal College.

RX-OCR diagram
Coaching in the Moment requires clinicians to establish rapport and set expectations with their residents, observe the residents doing their daily work, provide coaching feedback, and record the encounter. Frequent observation is a key ingredient in resident learning and assessment.

This model, known as “coaching in the moment”, follows the RX-OCR step-by-step process: Rapport, EXpectations, Observe, Coach, Record. In RX-OCR, feedback is given to the resident and then documented in various WBA tools chosen by individual specialty committees and programs. These individual WBAs are aggregated and ultimately paint a picture of a trainee’s performance and progress over time. Competence committees study these overall pictures to make holistic judgements on the progress of a resident.

3. Aligning WBAs with individual programs

As is the case with EPAs and Milestones, individual specialty committees and programs are able to tailor their individual assessment programs. There are four CBD observation templates designed by the Royal College, which help establish a common language of assessment and prompt conversations about the essential ingredients of competence, as well as the factors contributing to entrustment decisions. Some programs/disciplines may have other valid assessment tools that they will choose to include in their assessment program. We support and encourage their continued use, even after a program transitions to CBD.


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Pocket full of Change

Pocket full of Change

ACE your change

One of my favourite new must-read change books of 2018 is New Power: How power works in our hyperconnected world — and how to make it work for you by Jeremy Heimans and Henry Timms. Heimans and Timms have studied hundreds of global change movements and have identified three key patterns about how to make change happen and our role in it. Their primary thesis is that in our 21st century connected age power is shifting from primarily old power, which is top-down and held by a few, to new power, which is shared, participatory and peer-driven. These shifts have incredible implications for how we lead change. This is especially true with a change like CBD that involves health and education professionals who, understandably given their intrinsic motivation, do not respond well to control and being managed with restrictive processes. Rather they need to be trusted in advance, confronted with their freedom to choose and given room to exercise their agency (i.e., new power according to Heimans and Timms) in an environment where their collective mission can thrive.

new power book cover

With this issue of CBD Community Touchpoint focusing on the role assessment plays in CBD, and the accompanying new behaviours reflected in the RX-OCR model – setting expectations, observing, coaching and recording - this is the perfect time to apply key ideas about how to spread change to create a culture of assessment for learning. According to Heimans and Timms, for change to spread it must be ACE.

  • Actionable — Ask people to take an action. This is the shift from a passive consumer who is being changed to an active participant and an agent in the change who answers a concrete call to action for their own reasons (they are motivated).
  • Connected — Create a peer connection to set off a network/multiplier effect with people you care about or share values and a common mission with. This builds a community for the change which can start small with a few champions, show progress/small wins, share outcomes and social copying and spreading over time to go viral.
  • Extensible — empowers people to make it their own and allows the change to be customized, remixed and/or reshaped by the professionals. The change has a common stem or essential elements and then encourages people to adapt it to fit their local context.

Applying ACE means that many people acting consistently over time in a specific manner (e.g., for CBD RX-OCR characterized by setting goals, observing, coaching and documenting) creates a culture of assessment for learning. Heimans and Timms offer The Ice Bucket Challenge as a perfect example of such an application of the three ACE patterns. It was actionable in several ways. It asked people to make a donation, but that was not the primary action. It also asked people to create and share a video and to nominate friends to take part. That brings us to connected. It was connected on many levels — to the immediate peer group, to celebrities who participated and to a new global group supporting ALS (Amyotrophic Lateral Sclerosis). It was extensible in that every action was unique and personalized. Every participant also became a creator and a producer which in turn led to even greater participation.

ACE is well aligned with recent findings in positive psychology, in particular, self-determination theory. SDT states that people are more likely to embrace change if it meets human needs for competence, autonomy and relatedness. Together, ACE and SDT offer us a practical checklist for designing our change initiatives and enabling their success.

  1. Do people have a clear call to action that enables them to develop and show competence?
  2. Are people personally connected to the change and part of a community of practice?
  3. Are people able to be involved and participate in designing, planning and adapting the change to fit their context?

These three patterns — actionable, connected and extensible — help us understand what makes some change movements so effective at engaging people and achieving desired change goals.

Does the ACE framework help you understand why CBD ideas have spread or not?

How might you use it to ACE CBD at your site and embed the new assessment behaviours in the daily life of your program?

For more reading:


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The faces behind WBA

Did you know that through their roles as Royal College clinician educators, four #MedEd leaders are playing a key role in supporting workplace-based assessment?

Wade GoftonWade Gofton MD MEd FRCSC
Royal College Clinician Educator
Associate Professor, Division of Orthopaedic Surgery, University of Ottawa
Departments of Surgery and Innovation in Medical Education

Nancy DudekNancy Dudek MD MEd FRCPC
Royal College Clinician Educator
Professor, Division of Physical Medicine & Rehabilitation, University of Ottawa

Daniel DuboisDaniel Dubois, MD, FRCPC
Royal College Clinician Educator
Associate Program Director - CBD Lead
Department of Anesthesiology & Pain Medicine, University of Ottawa

Rob AndersonRob Anderson MD, FRCPC
Royal College Clinician Educator
Associate Professor of Anesthesiology - Northern Ontario School of Medicine
Program Director Anesthesiology
Health Sciences North Simulation Lab, Medical Lead


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Resource Spotlight: Assessment Tools

The Royal College Resource Directory is stocked with a range of resources to support your CBD assessment work.

Workplace-based Assessment

Three resources to teach the concepts of CBD assessment: customizable PowerPoint, reference guide and two-page handout.

Competence Committee Case Scenarios

An online activity meant to provide direction and support for competence committee deliberations.

Understanding the Coaching Model

Explaining the role of coaching in learning and progression. Presentation slides, video and 2-page summary of how coaching can develop resident competencies.

Entrustability Scale Training

An online training module for clinical teachers in rating practice performance using entrustability scales and descriptors.

Change Checklist and Presentation

Tips, resources and lessons to help guide the program director role in leading a large change initiative in their program.

Observation Templates

Sample templates of the types of forms you will find in Resident ePortfolio. Complete the terms and conditions form to request a copy.

Questions? Please contact us for help: cbd@royalcollege.ca.


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The CBD Community Touchpoint e-newsletter informs the medical community about issues, developments and activities that are related to CBD implementation across Canada.

Mark your calendars!

ICRE is coming to Ottawa September 26, 2019.

Competency-based Medical Education (CBME) is always a popular topic at the annual International Conference on Residency Education (ICRE). The 2018 track focussed on themed sessions about Lessons Learned and Best Practices from early pioneers in the implementation of CBME, the important role of Coaching and Feedback, and Preparing to Transition to CBME. Stay tuned for 2019 details coming soon.