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.

Inspired by the Harvard Business Review Cases and initially led by Dr. Teresa Chan (@TChanMD) and Dr. Brent Thoma (@Brent_Thoma), the Medical Education In Cases (MEdIC) series puts difficult medical education cases under a microscope. On the last Friday of the month, we pose a challenging hypothetical dilemma, moderate a discussion on potential approaches, and recruit medical education experts to provide “Gold Standard” responses. Cases and responses are made available for download in PDF format – feel free to use them! If you’re a medical educator with a pedagogical problem, we would love for you to get involved in the MEdIC series! Send us your most difficult dilemmas (guidelines) and help the rest of us bring our teaching to the next level.

Tamara McColl, MD FRCPC

Tamara McColl, MD FRCPC

Associate Editor, ALiEM MEdIC Series
Emergency Physician, St. Boniface Hospital, WRHA
Academic Lead, Educational Scholarship
Department of Emergency Medicine
University of Manitoba