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      Using Contribution Analysis to Evaluate Competency-Based Medical Education Programs : It’s All About Rigor in Thinking

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          Abstract

          Competency-based medical education (CBME) aims to bring about the sequential acquisition of competencies required for practice. Although it is being adopted in centers of medical education around the globe, there is little evidence concerning whether, in comparison with traditional methods, CBME produces physicians who are better prepared for the practice environment and contributes to improved patient outcomes. Consequently, the authors, an international group of collaborators, wrote this article to provide guidance regarding the evaluation of CBME programs.CBME is a complex service intervention consisting of multiple activities that contribute to the achievement of a variety of outcomes over time. For this reason, it is difficult to apply traditional methods of program evaluation, which require conditions of control and predictability, to CBME. To address this challenge, the authors describe an approach that makes explicit the multiple potential linkages between program activities and outcomes. Referred to as contribution analysis (CA), this theory-based approach to program evaluation provides a systematic way to make credible causal claims under conditions of complexity. Although CA has yet to be applied to medical education, the authors describe how a six-step model and a postulated theory of change could be used to examine the link between CBME, physicians' preparation for practice, and patient care outcomes.The authors argue that adopting the methods of CA, particularly the rigor in thinking required to link program activities, outcomes, and theory, will serve to strengthen understanding of the impact of CBME over time.

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          Most cited references 25

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          Systematic review: the relationship between clinical experience and quality of health care.

          Physicians with more experience are generally believed to have accumulated knowledge and skills during years in practice and therefore to deliver high-quality care. However, evidence suggests that there is an inverse relationship between the number of years that a physician has been in practice and the quality of care that the physician provides. To systematically review studies relating medical knowledge and health care quality to years in practice and physician age. English-language articles in MEDLINE from 1966 to June 2004 and reference lists of retrieved articles. Studies that provided empirical results about knowledge or a quality-of-care outcome and included years since graduation or physician age as explanatory variables. We categorized studies on the basis of the nature of the association between years in practice or age and performance. Overall, 32 of the 62 (52%) evaluations reported decreasing performance with increasing years in practice for all outcomes assessed; 13 (21%) reported decreasing performance with increasing experience for some outcomes but no association for others; 2 (3%) reported that performance initially increased with increasing experience, peaked, and then decreased (concave relationship); 13 (21%) reported no association; 1 (2%) reported increasing performance with increasing years in practice for some outcomes but no association for others; and 1 (2%) reported increasing performance with increasing years in practice for all outcomes. Results did not change substantially when the analysis was restricted to studies that used the most objective outcome measures. Because of the lack of reliable search terms for physician experience, reports that provided relevant data may have been missed. Physicians who have been in practice longer may be at risk for providing lower-quality care. Therefore, this subgroup of physicians may need quality improvement interventions.
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            The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada

             G. R. Baker (2004)
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              Conceptual frameworks to illuminate and magnify.

              In a recent study of the quality of reporting experimental studies in medical education, barely half the articles examined contained an explicit statement of the conceptual framework used. Conceptual frameworks represent ways of thinking about a problem or a study, or ways of representing how complex things work. They can come from theories, models or best practices. Conceptual frameworks illuminate and magnify one's work. Different frameworks will emphasise different variables and outcomes, and their inter-relatedness. Educators and researchers constantly use conceptual frameworks to guide their work, even if they themselves are not consciously aware of the frameworks. Three examples are provided on how conceptual frameworks can be used to cast development and research projects in medical education. The examples are accompanied by commentaries and a total of 13 key points about the nature and use of conceptual frameworks. Ultimately, scholars are responsible for making explicit the assumptions and principles contained in the conceptual framework(s) they use in their development and research projects.
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                Author and article information

                Journal
                Academic Medicine
                Academic Medicine
                Ovid Technologies (Wolters Kluwer Health)
                1040-2446
                2017
                June 2017
                : 92
                : 6
                : 752-758
                Article
                10.1097/ACM.0000000000001479
                28557934
                © 2017

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