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MEdIC Series: The Case of the Competency Conundrum

2017-07-17T15:14:07+00:00

Welcome to season 4, episode 9 of the ALiEM Medical Education in Cases (MEdIC) series! Our team (Drs. Tamara McColl, Teresa Chan, John Eicken, Sarah Luckett-Gatopoulos, Eve Purdy, Alkarim Velji and Brent Thoma) is pleased to welcome you to our online community of practice where we discuss the practice of academic medicine!

This month, we present a case of a residency competency committee that has competing opinions surrounding competency based medical education (CBME) advancement principles when faced with a superstar resident who has met the requirements of his program and may complete his training ahead of the usual trajectory.

MEdIC: The Case of the Competency Conundrum

By Dr. Tamara McColl

Allison had been a member of the residency program competency committee for the last year and was still trying to find her bearings. As a relatively new clinician educator, CBME was a completely novel language and a much different approach to learner assessment than she was used to. Over the last several months, however, she felt like the committee had finally found some synergy and were working together with this new common language and a collective purpose – to improve the quality of resident education and ultimately improve patient care.

Today’s competency committee meeting had taken a rather interesting twist and the group was immersed in a heated discussion. The committee was reviewing evaluations for one of their fourth year residents, Josh. He had served as the chief resident of the program and was very highly regarded by his peers and faculty alike. He functioned well above the level of his fellow colleagues – his knowledge base was strong, he was clinically and procedurally gifted and he demonstrated superior leadership and communication skills. The committee had joked in the past that Josh probably could have been ready to graduate after only two years of residency! A similar yet more serious discussion resurfaced at today’s meeting and was met with competing opinions.

“We have never had a resident this advanced – I think it’s worth further discussion! Josh has completed all of the requirements of our residency program and has met all of the EPAs for an emergency resident. I think we can all agree that he already functions like an attending physician and that we would all feel comfortable leaving him alone in the department, unsupervised. I think we should revisit our earlier dialogue regarding his advancement,” stated Allison, perplexed by the resistance her statements have met.

“I hear you, Allison, but we also have to consider other factors before deciding on something this huge! I know we’ve brought this up already, but the argument about the service component of his training is very important. He would only benefit from further exposure. I mean, how many chest tubes or intubations before someone becomes an expert in an area? I don’t think this is a discussion of purely pumping out competent residents. We want to train the best!” countered Kevin, a more senior physician among the group.

“I agree with Kevin. We have never done something like this before and need to be careful not to set a precedent we’ll later need to adhere to! We need to consider the impact of such a decision on his fellow residents and I agree that the service component of residency is equally as important as the educational one. Who’s going to cover his shifts if he leaves? This is a real concern that can’t be dismissed,” added Karen, another senior clinician educator.

“Ok, well let’s table this discussion. We’ll bring it up again at our next meeting in 2 months. Shall we move on?” Asked Kevin.

Allison felt uneasy about the way this issue was left. What was the point of this new CBME curriculum if they weren’t following the basic principles for advancement?

Discussion Questions

  1. What issues do you think are underlying the hesitancy of this committee to progress a resident who is clearly meeting all requirements of his residency program?
  2. How would you approach this issue as a member of the competency committee?
  3. How can the committee make the process of resident advancement more clear to avoid such heated discussion in the future?

 


Weekly Wrap Up

As always, we will post the expert responses and a curated commentary derived from the community responses 2 weeks after the case is published.

Our 2 expert discussants will be:

  • Dr. Brent Thoma
  • Dr. Teresa Chan

On July 14,  2017 we will post the curated commentary and expert responses to this case! After that date, you may continue to comment below, but your commentary will no longer be integrated into the curated commentary. That said, we’d love to hear from you, so please comment below!

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental. Also, as always, we will generate a curated community commentary based on your participation below and on Twitter. We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

MEdIC Series: The Concept
Tamara McColl, MD FRCPC MEd(c)

Tamara McColl, MD FRCPC MEd(c)

Associate Editor, ALiEM MEdIC Series
Emergency Physician, St. Boniface Hospital, WRHA
Academic Lead, Educational Scholarship
Department of Emergency Medicine
University of Manitoba
  • I will be writing a lengthier response later, but one of the problems that I see here is the combination of data, and how little we know about people’s reading of two very different portfolios of information…

    What are the processes of thinking for these “meta-raters” (faculty who interpret and combine data from raters to make a decisions)?

  • Loice Swisher

    Even though I am not Canadian, the issue of changing the complement of residents in a year is something that I would think any residency would struggle with regardless of the reason (death, illness, poor fit and leaving for something else, etc). In general, having fewer than expected residents tends to impact those that are left- perhaps more shifts, perhaps less elective time. In a much more concerning scenario, I’ve wonder if that could be the reason weaker residents were passed on to the next year.

    I have come to see the competency committees to be a floor which one should not have a resident go below rather than a ceiling that they have broken through.

    • Tamara McColl

      Love that last line, Loice! Thanks for sharing your thoughts!

  • Rob Woods

    Great topic team. This is going to come up as a discussion point for sure in the coming years. I’m sure we can all remember a peer or trainee who was well ahead of the curve and probably could have functioned quite well with less time in training. I believe there is no substitute for experience and even great residents are guaranteed to make mistakes as staff. We never stop learning and benefitting from feedback and coaching. In our medical culture right now, we stop being assessed once we get that staff ticket. Hopefully we can use CBME to build on the culture of programmatic and lifelong assessment through a dashboard, so we are able to continue our development in a meaningful way through our careers. If and when we are able to have this culture shift, having someone finish residency training early would be okay. Until then, I would lean towards simply supporting that trainee to be even better until the ‘improvement support system’ of a residency program is complete.

  • Victoria Brazil

    Thanks for another great case. Highlights the tensions between service and learning, and interrogates the meaning of çompetency based advancement.

    On the latter issue – i like the line…..”competency …. to be a floor which one should not have a resident go below rather than a ceiling that they have broken through.”

    Working in a system where our emergency physicians are 7 – 8 years postgraduate before they finish their specialty training – i see some value in volume of experience even after ‘good enough’ is achieved.
    The challenge is not to neglect those those doing well, and to ask them to step up to roles you may not be asking of all their peers. Its a chance to develop habits of deliberate practice and aspiring to excellence, while still having guidance.

    The issue of being an employee and having a service commitment versus taking a purely ‘learner role’as a resident is perhaps the sharper sticking point here. I have a personal view that being an effective employee is part of being an excellent emergency physician, despite our flawed systems and institutions. Medical leadership requires us to be a part of these systems, not a distant self determining professional. So we should fulfill employment contracts we enter into as a general rule.

    In Australia, finishing training at different points in the year is a non-issue – it happens all the time. Our training is structured around the individual, not programs per se. Their total training time is 5 years – same for everyone (and time is irrespective of competence other than standard exams and WBAs – no ‘fast track’) . But trainees may have taken time off for personal reasons, to study, or may have worked part time for a period of their training. (shocking concepts for many American EM residencies i know…:-)
    Hence their ‘time expired’ may come any various points through the year. This is inconvenient for employers, but most are sympathetic if those people are offered a consultant ( attending ) job – and wished well as they depart. It does mean our directors of training spend a huge amount of time on recruitment and allocating trainees to various rotations ALL YEAR. Big job for the 70+ trainees at our institution for eg.

    So its quite possible to have more flexibility but it comes at enormous price, and i also look with envy at your very structured programs which achieve a lot in a shorter time. Fortunately i think both systems turn out quality EM doctors which is what the patients want. But a reasonable question for our taxpayers as to how to do that efficiently and still achieve high standards.
    Moves to CBME support that goal, even as we struggle to translate that to shorter training times.

    Thanks again for the discussion

    vb

  • Hi – a great case with a number of different issues (some interdependent and some not)

    1) Does the trainee themselves actually want to jump the hoops? Clearly this is relatively important, if they don’t want to progress rapidly but they could, why is this? Does it matter if their confidence doesn’t match their competence?
    2) I am taken by the strength of educational organisation in this institution. Clearly there is proactivity in some parts of the committee. I am not sure this is a universal occurrence and sadly much competence based educational review is left to the very end of an academic year with no interim review for those are the top and bottom of the progression spectrums. If trainees are to excel through programmes the organisation of those programmes must excel as well.
    3) Recruitment and Education are intimately linked. Something organisations in the UK are only beginning to realise. While moving through programmes at pace may be beneficial for the trainee, as this case alludes to, it might not be for the organisation. Can we manage systems which take into account that over a 7 year period rather than x numbers of trainees being needed we need x+y (y being the trainees who fast track their way through)
    4) And the flip side: If we have an educational theorem that states that competency can be gained at different speeds what about those who struggle? Is failing to progress allowed the same level of excess time in the system that a speedy progression would be allowed in a reduced time…

  • Kaif Pardhan

    This is a really great post and foreshadows many discussions that will be happening across Canada as CBD rolls out.

    There is so much to unpack here: The functioning of the committee, the influence of “éminence grise”in decision making, what role residents play vs. what role they are viewed as playing and what it means to be competent.

    The core issue that the committee appears to be struggling with is one the Competency Based Medical Education (CBME) is directly rebutting: That time equals competence. Having recently transitioned to being a staff physician, there is no question that I am continuing to learn, every day on the job. But the crux of the issue here is: would I have continued to learn more by going to work as a resident physician? the answer is a resounding “No”. There is a fear among many physicians that CBME will play a reductionist role in medical education, a trainee will be “good enough” after ticking all the boxes and not “excellent” or “exceptional”; however, this creates an environment where perfection will be the enemy of the good. In the “current’ model, there is no accountability from the institution to ensure that residents are continuing to learn once they have achieved the competencies or standards of training. They simply provide service at a significantly reduced cost, marking time until their training completes. This does our future colleagues, and society, a deep disservice. Perhaps worse, is when the reverse of the scenario occurs; where the competence committee has qualms about a trainee, but allows them to progress into independent practice.

    Competence committees will need to set clear guidelines, a priori, regarding what to do when situations such as these arise. Residency programs and universities find themselves in trouble primarily when no policy exists or when existing policy is not followed. If each discussion is allowed to occur on an ad hoc basis and the loudest/most experienced voice wins (see below), then there is no question that ambiguity and conflict will continue be a feature of these discussions.

    Finally, in this case, the inability of the committee to have a discussion, and of Josh to progress, was based on the word of Kevin, the “more senior physician” in the group. This is a documented phenomenon that the louder and/or more experienced voice in the room can derail a discussion and more senior physicians are given a degree of deference in these settings (the éminence grise” I referenced earlier). There is no question that the voice of experienced educators is critical; however, it cannot be allowed to overshadow or usurp the policies and purpose of a new curriculum roll out. The role of the chair of the competence committee is critical in managing the meeting, ensuring all views have equal hearing and that the policies of the program are followed. There is no harm in robust dialogue at the table, but members of the committee should feel that they are all rowing in the same direction rather than feeling as unsettled as Alison did in this case.