CBME at Oregon Health & Science University

Competency-Based Medical Education (CBME) focuses design (and the designer) on learner objectives and outcomes.  Milestones, which are created through the study of typical development, help track a learner’s progress from novice to expert across any number of tasks. Information about a learner’s progress is collected from diverse sources in a variety of ways and kept in a developmental portfolio.  The portfolio is reviewed by the learner and their academic coach on a regular basis for the purpose of developing action plans. 

Hallmarks of Competency-Based Education

  • Competencies with milestones (+/- EPAs)
  • Curriculum and instructional approaches that allow for the assessment of competencies.  Typically involves combinations of active and social learning: case-based, problem-based, team-based, and workplace-based.
  • Formative and authentic assessment
  • Longitudinal portfolios to track progress

Implications of Competency-Based Assessment

  • Portfolios are typically digital platforms which interface with other university IT systems [e.g. learning management system, registrar, electronic medical record].  For more information about how Vanderbilt integrated their portfolio platform see Spickard et al. (2016)
  • Best practices in portfolio assessment demand the inclusion of academic coaching. A number of studies indicate that students – especially medical students – require training in self-assessment, reflection, and regulation.  Portfolios do not work without guidance.
  • Portfolio assessment best supports self-regulation and personalized learning when there are multiple learning pathways available to students. 
  • While milestones suggest the ‘typical’ developmental trajectory of learner progress, not all students will progress at the ‘typical’ speed.  Performance is prioritized over hours/time spent on learning a task.  A pure CBME program will allow for time- variable progression

This is my third CBME-related post. The first post reviews the basic vocabulary and North American players.  It also reviews Vanderbilt University School of Medicine as the best-documented (as in “most published”) example.  The second post delves into the relationships between competencies and EPAs (entrustable professional activities) and the role of workplace-based assessment in CBME. This post will focus on the personalized learning facet of CBME by describing one university’s approach to portfolios, personal learning pathways, and time-variable progression.

As I’ve said before, this is a blog post, not a peer-reviewed article. It consists entirely of information gleaned from the internet and my early attempts to make sense of it all.  If I got something wrong about OHSU’s programming, first – my apologies and second – please contact me on Twitter. If you have more information, I would love to talk! 

Oregon Health & Science University School of Medicine

OHSU School of Medicine is a Core EPA Pilot school. Unlike its pilot partner, Vanderbilt University, OHSU had not started its CBME transformation before the pilot (see this post for a description of Vanderbilt’s UME reforms and the Core EPA Pilot Program).  

Why did they do it?

Beyond the general context for reform described in my first post, it appears that the educational reform at OHSU may have been driven by the results of a 2012 LCME site visit.

Who did the work?

Best resource for learning more

Mejicano, G. C., & Bumsted, T. N. (2018). Describing the journey and lessons learned implementing a competency-based, time-variable undergraduate medical education curriculumAcademic Medicine93(3), S42-S48.

Curriculum Transformation Steering Committee (CTSU)

At the direction of the Dean of the School of Medicine, the CTSU spent six months researching medical education before settling on these desired qualities:

  • Learner-centered education
  • Emphasis on critical thinking, inquiry, and lifelong learning 
  • Personalized learning
  • Integrated curriculum
  • Active learning
  • Competency-based education
  • 21st-century skills

The committee received a $1 million grant from the AAMC to continue their work and the school was later selected to be a part of the Core EPA project. 

The Foundational Phase Development Team 

At the direction of the Associate Dean for UME, a multidisciplinary team (scientists – clinicians – educational specialists) met weekly for 10 months to accomplish the following tasks:

  • Developed a new integrated curriculum (seven integrated course blocks with longitudinal threads).
  • Mapped new course goals to the ACGME competencies
  • Wrote session-level objectives
  • Described a general framework for instruction and student assessment that were consistent with the qualities laid out by the CTSU.

The Foundations Operation Team

The operation team consisted of the course directors who would select faculty to lead individual sessions and develop assessments consistent with the framework laid out by the development team.

What did they do?

Best resource for learning more

OHSU School of Medicine MD Program. (2018). Your MD Student Information. Retrieved from: https://www.ohsu.edu/xd/education/schools/school-of-medicine/academic-programs/md-program/curriculum/your-md-details.cfm

The Operation Team launched the new curriculum (“Your MD”) in 2014. Details are best described in the program website, but briefly:

Pre-Matriculation Self-Assessment.  Students do this before they start the program.  I would like to know more but cannot find it online.

Foundations of Medicine.  For the first 18 months, students engage in seven integrated science blocks, one longitudinal preceptor experience, College activities, and assessments. 

  • Didactic Blocks. Each of the seven didactic blocks integrate basic and medical science and addresses relevant combinations of the following conceptual themes: anatomy, biochemistry, cell biology, embryology, genetics, histology, microbiology, pharmacology, professionalism, ethics, communication, epidemiology, biostatistics, evidence-based medicine, informatics, health policy, patient interviewing, and physical exam. The curriculum is case-based.  Typical instructional approaches include large group, small group, laboratory groups, clinical skills, and independent learning.  
  • Preceptorship and Narrative Medicine. A longitudinal clinical experience that takes place in the foundational medicine phase of the program.  Students work directly with practicing physicians in a clinical setting and focus on all ACGME core competencies. 
  • Colleges Activities. A robust, personalized, longitudinal approach to student affairs curricula that continues throughout the program (Foundations & Clinical). 
    • Learning Communities.  Students choose one of seven learning communities (e.g. Acute Care Medicine, Global Health and Urban Underserved, Surgical Specialities). All learning communities engage students in academic opportunities, career advising, financial planning, interprofessional education, leadership, service learning, and wellness but will align the content of such activities to meet the interests of the group.  Students may attend any of the activities across colleges, but they must select one “home base” from which to attend regularly.  Approaches to curricula & instruction generally include expert panels, field trips, and workshops.
    • Portfolio Coaching. The colleges provide individual and group coaching around professionalism, professional identity, career counseling, academic advising, reflection and self-assessment.
  • Assessment.  Takes place every Friday and includes a combination of ExamSoft quizzes, clinical skills quizzes, and science skills quizzes.

Transition to Clinical Experiences (2 weeks). A simulation ‘bootcamp’ for students entering the clinical years, the experience aligns with the core EPAS, which enables pre-post assessment and sets student expectations around what they are meant to accomplish.  This is a gateway course – students cannot proceed without passing this experience.  

Clinical Experiences.  After completion of the Foundations of Medicine, students engage in clinical experiences earlier than the traditional timeline (e.g. at 18 months instead of  24 months). In some cases, this will mean (in future cohorts) that students can finish their undergraduate medical training in as little as three years instead of the traditional four years.

  • Traditional core clinical experiences.  Traditional core experiences (e.g. pediatrics, surgery, etc) are required
  • More electives, earlier. Elective options are available from the beginning of the clinical experience (as compared with the traditional model which limits electives to the fourth year of training). 
  • Intersessions. Two-week sessions between clinical experiences that integrate foundational science into the clinical experiences.  Also address issues such as health disparities and communication. 
  • Scholarship. Students choose from two different pathways for this dedicated time. 
    • Scholarly Project.  A mentored inquiry-based research project designed by the student.  Past projects have ranged from performing traditional clinical or basic science research to developing a business plan for a medically-related startup or proposing public health-related legislation. 
    • Physician-Scientist Experience.  Students interested in pursuing clinical translational research or research medicine can use this time to be mentored and gain research experience.  Those who extend this experience to a year can earn a Masters Degree in Clinical Research.

How will they…implement competency-based assessment? 

Best resource for learning more

Mejicano, G. C., & Bumsted, T. N. (2018). Describing the journey and lessons learned implementing a competency-based, time-variable undergraduate medical education curriculumAcademic Medicine93(3), S42-S48.

Portfolios.  “The Research in Evaluation Data for Educational Improvement” digital portfolio provides real-time visualization of a learner’s academic progress and all the data points associated with that progress.  Eventually, this will consist of documentation of achieved competencies and EPAs.  

Badging. Portfolios will also contain digital badges for achieved Core EPAs.  Students must earn all 14 core EPA badges via summative assessments made by the Entrustment Group [Note: I think this process is still very much in research & development; I found this pdf – updated 2-26-2017 online but cannot verify if this is still the current plan…I will keep looking].  Summative assessment appears to rely on a variety of data points.  Mejicano & Bumstead (2018) provide this list but with minimal explanation:

  • Qualified assessor evaluation
  • Peer and/or patient input
  • Instruments provided by the AAMC
  • Simulation experiences
  • Reflection exercises
  • Gateway assessments
  • Procedure and required encounters
  • OHSU’s four components from clinical experiences

Individualized Learning Plan. Portfolio coaches (assigned to students through the College for the duration of the program) and students create an individualized learning plan.  While the time spent in Foundations will be fixed at 18 months, the clinical experiences portion of the curriculum provides significant temporal flexibility.


Featured Image by Matheus Ferrero on Unsplash

 

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