Competency-based education

Education is a kind of continuing dialogue, and a dialogue assumes, in the nature of the case, different points of view.

Robert Maynard Hutchins (1899–1977)

Robert Maynard Hutchins was an educational philosopher, Dean of the Yale University Law School in New Haven, Connecticut, and President and Chancellor of the University of Chicago in Illinois.¹ Hutchins became one of the most influential members of the school of secular perennialism in education. Perennialists believe that “one should teach the things that one deems to be of everlasting importance to all people everywhere. They believe that the most important topics develop a person. As details of fact change constantly, these cannot be the most important. Therefore, one should teach principles, not facts.”¹ Not surprisingly, this view of education has been controversial.

Canadian family medicine education is itself undergoing transformation and debate about the best way to train residents for the changing world of practice and a path of lifelong learning and maintenance of expertise. Until recently, residency training has been primarily time-based—what Hodges calls the “tea steeping” approach to graduate medical education.² Residents spend time training in various specialties and settings with the expectation that they will acquire the necessary knowledge, skills, professional values, and motivation to go out into practice. The past decade has seen a movement away from time-based training to a competency-based medical education (CBME) model that focuses on observable and measurable outcomes. Among the forces behind this change are a focus on risk management, consumer rights, patient safety, and expansion of the physician work force.³

Over the next few months in Canadian Family Physician, readers will see more articles about competency-based family medicine education. This month’s issue features the first of a series of peer-reviewed research articles by Allen and colleagues (page e331),⁴ who describe the process by which the Board of Examiners of the College of Family Physicians of Canada developed the definition of competence in family medicine. There is also a practical Program Description by Ross and colleagues (page e323), which discusses a method to assess family medicine residents’ competence in various skills.⁵

Competency-based medical education is not without its critics.^3,6 Talbot states that in training physicians we are striving for something “nearer to expertise than competence” and that in “terms of assessment [of competence], the danger is always that we ask questions related to those things that may be more easily measured instead of asking the more difficult questions.”⁶ While the appeal of CBME is the establishment of consistent standards across varying settings, there is great concern that this approach will “limit the reflection, intuition, experience and higher order competence necessary for expert, holistic or well-developed practice.”⁶

In spite of such criticisms, CBME in family medicine is here to stay. Recognizing the challenges of developing and implementing CBME, a group of international medical educators formed the International CBME Collaboration in 2009. The collaborators’ objectives are to review the international CBME literature, identify controversies in need of clarification, explore future directions, and propose consensus definitions that can be useful to educators around the world.⁷ Canadian Family Physician looks forward to bringing you more information and discussion about competency-based education in the months to come.