Implementing competency-based medical education: What changes in curricular structure and processes are needed?

Background In competency-based medical education emphasis has shifted towards outcomes, capabilities, and learner-centeredness. Together with a focus on sustained evidence of professional competence this calls for new methods of teaching and assessment. Recently, medical educators advocated the use of a holistic, programmatic approach towards assessment. Besides maximum facilitation of learning it should improve the validity and reliability of measurements and documentation of competence development. We explored how, in a competency-based curriculum, current theories on programmatic assessment interacted with educational practice. Methods In a development study including evaluation, we investigated the implementation of a theory-based programme of assessment. Between April 2011 and May 2012 quantitative evaluation data were collected and used to guide group interviews that explored the experiences of students and clinical supervisors with the assessment programme. We coded the transcripts and emerging topics were organised into a list of lessons learned. Results The programme mainly focuses on the integration of learning and assessment by motivating and supporting students to seek and accumulate feedback. The assessment instruments were aligned to cover predefined competencies to enable aggregation of information in a structured and meaningful way. Assessments that were designed as formative learning experiences were increasingly perceived as summative by students. Peer feedback was experienced as a valuable method for formative feedback. Social interaction and external guidance seemed to be of crucial importance to scaffold self-directed learning. Aggregating data from individual assessments into a holistic portfolio judgement required expertise and extensive training and supervision of judges. Conclusions A programme of assessment with low-stakes assessments providing simultaneously formative feedback and input for summative decisions proved not easy to implement. Careful preparation and guidance of the implementation process was crucial. Assessment for learning requires meaningful feedback with each assessment. Special attention should be paid to the quality of feedback at individual assessment moments. Comprehensive attention for faculty development and training for students is essential for the successful implementation of an assessment programme.

Traditionally, clinical learning for medical students consists of short-term and opportunistic encounters with primarily acute-care patients, supervised by an array of clinician preceptors. In response to educational concerns, some medical schools have developed longitudinal placements rather than short-term rotations. Many of these longitudinal placements are also integrated across the core clinical disciplines, are commonly termed longitudinal integrated clerkships (LICs) and often situated in rural locations. This review aimed to explore, analyse and synthesise evidence relating to the effectiveness of longitudinal placements, for medical students in particular to determine which aspects are most critical to successful outcomes. Extensive search of the literature resulted in 1679 papers and abstracts being considered, with 53 papers ultimately being included for review. The review group coded these 53 papers according to standard BEME review guidelines. Specific information extracted included: data relating to effectiveness, the location of the study, number of students involved, format, length and description of placement, the learning outcomes, research design, the impact level for evaluation and the main evaluation methods and findings. We applied a realist approach to consider what works well for whom and under what circumstances. The early LICs were all community-based immersion programs, situated in general practice and predominantly in rural settings. More recent LIC innovations were situated in tertiary-level specialist ambulatory care in urban settings. Not all placements were integrated across medical disciplines but were longitudinal in relation to location, patient base and/or supervision. Twenty-four papers focussed on one of four programs from different viewpoints. Most evaluations were student opinion (survey, interview, focus group) and/or student assessment results. Placements varied from one half day per week for six months through to full time immersion for more than 12 months. The predominant mechanism relating to factors influencing effectiveness was continuity of one or more of: patient care, supervision and mentorship, peer group and location. The success of LICs and participation satisfaction depended on the preparation of both students and clinical supervisors, and the level of support each received from their academic institutions. Longitudinal placements, including longitudinal integrated placements, are gaining in popularity as an alternative to traditional block rotations. Although relatively few established LICs currently exist, medical schools may look for ways to incorporate some of the principles of LICs more generally in their clinical education programmes. Further research is required to ascertain the optimum length of time for placements depending on the defined learning outcomes and timing within the programme, which students are most likely to benefit and the effects of context such as location and type of integration.

The past few years have seen rapid advances in communication and information technology (C&IT), and the pervasion of the worldwide web into everyday life has important implications for education. Most medical schools provide extensive computer networks for their students, and these are increasingly becoming a central component of the learning and teaching environment. Such advances bring new opportunities and challenges to medical education, and are having an impact on the way that we teach and on the way that students learn, and on the very design and delivery of the curriculum. The plethora of information available on the web is overwhelming, and both students and staff need to be taught how to manage it effectively. Medical schools must develop clear strategies to address the issues raised by these technologies. We describe how medical schools are rising to this challenge, look at some of the ways in which communication and information technology can be used to enhance the learning and teaching environment, and discuss the potential impact of future developments on medical education.