Competency-Based Medical Education and the Ghost of Kuhn: Reflections on the Messy and Meaningful Work of Transformation

Training for the future of the genetic counseling profession: Exploring the assessment and adaptation of graduate programs' didactic curriculum

Since the first genetic counseling program (GCP) was established in 1969, there has been a proliferation of growth and demand for genetic counselors. Advances in technology, affordable access to genetic testing, public genomic health initiatives, and diversifying clinical and non-clinical roles comprise a dynamic environment that GCPs must respond to. While there is extensive literature regarding how other health professions adapt their curricula to changing environments, this has yet to be documented and explored for genetic counseling. This study aimed to understand how GCPs evolve their didactic curricula to keep up with the rapidly changing professional landscape. An online survey was used to recruit program leadership of fully accredited GCPs for semi-structured interviews. These interviews explored four critical factors of didactic curricular change, including drivers, implementation, barriers, and mechanisms for evaluation after a change has been made. Interview transcripts were analyzed using reflexive thematic analysis based on iterative discussions with prioritization of excerpts from the codes that had been most commonly applied across multiple transcripts. Multiple factors were identified that program leadership must appropriately weigh when making curricular change decisions. The factors that were considered major influences by all participants included national accreditation standards, program stakeholders, sponsoring institutions and local genetic counseling communities, and the genetic counseling profession as a whole. Our data also demonstrated the extensive role program leadership plays in the adaptation of didactic curricula. With GCP leadership constantly identifying, implementing, and evaluating complex didactic curricular change, there is a need for further exploration of this topic and development of genetic counseling specific resources and tools.

In EPAs we trust, is quality and safety a must? A cross-specialty analysis of entrustable professional activity guides

PURPOSE

The inclusion of quality improvement (QI) and patient safety (PS) into CanMEDS reflects an expectation that graduating physicians are competent in these areas upon training completion. To ensure that Canadian postgraduate specialty training achieves this, the translation of QI/PS competencies into training standards as part of the implementation of competency-based medical education requires special attention.

METHODS

We conducted a cross-specialty, multi-method analysis to examine how QI/PS was incorporated into the EPA Guides across 11 postgraduate specialties in Canada.

RESULTS

We identify cross-specialty variability in how QI/PS is incorporated, positioned, and emphasized in EPAs and milestones. QI/PS was primarily referenced alongside clinical activities rather than as a sole competency or discrete activity. Patterns were characterized in how QI/PS became incorporated into milestones through repetition and customization. QI/PS was also decoupled, conceptualized, and emphasized differently across specialties.

CONCLUSIONS

Variability in the inclusion of QI/PS in EPAs and milestones has important implications considering the visibility and influence of EPA Guides in practice. As specialties revisit and revise EPA Guides, there is a need to balance the standardization of foundational QI/PS concepts to foster shared understanding while simultaneously ensuring context-sensitive applications across specialties. Beyond QI/PS, this study illuminates the challenges and opportunities that lie in bridging theoretical frameworks with practical implementation in medical education, prompting broader consideration of how intrinsic roles and emergent areas are effectively incorporated into competency-based medical education.

Evaluating Competence by Design as a Large System Change Initiative: Readiness, Fidelity, and Outcomes

Program evaluation is an essential, but often neglected, activity in any transformational educational change. Competence by Design was a large-scale change initiative to implement a competency-based time-variable educational system in Canadian postgraduate medical education. A program evaluation strategy was an integral part of the build and implementation plan for CBD from the beginning, providing insights into implementation progress, challenges, unexpected outcomes, and impact. The Competence by Design program evaluation strategy was built upon a logic model and three pillars of evaluation: readiness to implement, fidelity and integrity of implementation, and outcomes of implementation. The program evaluation strategy harvested from both internally driven studies and those performed by partners and invested others. A dashboard for the program evaluation strategy was created to transparently display a real-time view of Competence by Design implementation and facilitate continuous adaptation and improvement. The findings of the program evaluation for Competence by Design drove changes to all aspects of the Competence by Design implementation, aided engagement of partners, supported change management, and deepened our understanding of the journey required for transformational educational change in a complex national postgraduate medical education system. The program evaluation strategy for Competence by Design provides a framework for program evaluation for any large-scale change in health professions education.

Adoption of Internal Medicine Milestone Ratings and Changes in Bias Against Black, Latino, and Asian Internal Medicine Residents

BACKGROUND

The 2014 adoption of the Milestone ratings system may have affected evaluation bias against minoritized groups.

OBJECTIVE

To assess bias in internal medicine (IM) residency knowledge ratings against Black or Latino residents-who are underrepresented in medicine (URiM)-and Asian residents before versus after Milestone adoption in 2014.

DESIGN

Cross-sectional and interrupted time-series comparisons.

SETTING

U.S. IM residencies.

PARTICIPANTS

59 835 IM residents completing residencies during 2008 to 2013 and 2015 to 2020.

INTERVENTION

Adoption of the Milestone ratings system.

MEASUREMENTS

Pre-Milestone (2008 to 2013) and post-Milestone (2015 to 2020) bias was estimated as differences in standardized knowledge ratings between U.S.-born and non-U.S.-born minoritized groups versus non-Latino U.S.-born White (NLW) residents, with adjustment for performance on the American Board of Internal Medicine IM certification examination and other physician characteristics. Interrupted time-series analysis measured deviations from pre-Milestone linear bias trends.

RESULTS

During the pre-Milestone period, ratings biases against minoritized groups were large (-0.40 SDs [95% CI, -0.48 to -0.31 SDs; P < 0.001] for URiM residents, -0.24 SDs [CI, -0.30 to -0.18 SDs; P < 0.001] for U.S.-born Asian residents, and -0.36 SDs [CI, -0.45 to -0.27 SDs; P < 0.001] for non-U.S.-born Asian residents). These estimates decreased to less than -0.15 SDs after adoption of Milestone ratings for all groups except U.S.-born Black residents, among whom substantial (though lower) bias persisted (-0.26 SDs [CI, -0.36 to -0.17 SDs; P < 0.001]). Substantial deviations from pre-Milestone linear bias trends coincident with adoption of Milestone ratings were also observed.

LIMITATIONS

Unobserved variables correlated with ratings bias and Milestone ratings adoption, changes in identification of race/ethnicity, and generalizability to Milestones 2.0.

CONCLUSION

Knowledge ratings bias against URiM and Asian residents was ameliorated with the adoption of the Milestone ratings system. However, substantial ratings bias against U.S.-born Black residents persisted.

PRIMARY FUNDING SOURCE

None.

Is it Time for Competency-Based Education to Move Forward in Pharmacy Education?

Competency-based education is rapidly emerging as a paradigmatic shift in health professions education, as we grapple with the realities of ever-changing and increasing demands of society and health systems. While pharmacy educators are becoming more familiar with this paradigm, colleagues in medical education have been exploring models and methods of competency-based education for many years, and their experiences can be illuminating for us. The persistent question that drives continuous quality improvement in pharmacy education and the development of initiatives within American Association of Colleges of Pharmacy might be stated as "Is there a better (more effective, more efficient) way to prepare pharmacists (future and current) to meet the medication-related needs of the public?"

Overcoming the barriers to implementation of competence-based medical education in post-graduate medical education: a narrative literature review

To ensure that residents are equipped with the necessary skills for practice, competence-based medical education (CBME) represents a transformative change in postgraduate medical education, which is being progressively introduced across Canadian specialty residency programs. Successful implementation will require adjustments to curriculum, assessment, and evaluation, with careful attention to the unique needs in the local context, including resident and faculty development. This narrative review of the literature aimed to determine the potential barriers to the successful implementation of CBME and the strategies by which they can be addressed, with a specific consideration of the author's program in pediatrics in Manitoba. Eleven articles were identified with a specific focus on the implementation of CBME in the post-graduate setting, and 10 were included in the review after critical appraisal. Three key themes emerged from the articles: the value of broad stakeholder engagement and leadership, the importance of faculty and resident development, and the development of specific support systems for the educational curriculum. Different strategies were considered and contrasted for addressing these important themes. This review provides important insights and practical approaches to the barriers that should be useful as programs prepare for the implementation of CBME.

Impact of educational instruction on medical student performance in simulation patient

OBJECTIVES

This study aimed to evaluate the effects, and timing of, a video educational intervention on medical student performance in manikin-based simulation patient encounters.

METHODS

This prospective mixed-methods study was conducted as part of the University of Toledo College of Medicine and Life Sciences undergraduate medical curriculum. One hundred sixty-six students second-year students participated in two simulations on a single day in September 2021. A 7-minute video intervention outlining the clinical diagnostic approach to pulmonary complaints was implemented. Students were randomized into 32 groups which were divided into two cohorts. One received the video prior to simulation-1 (n=83) and the other between simulation-1 and simulation-2 (n=83). Each simulation was recorded and assessed using a 44-point standardized checklist. Comparative analysis to determine differences in performance scores was performed using independent t-tests and paired t-tests.

RESULTS

Independent t-tests revealed the video-prior cohort performed better in simulation-1 (t₍₃₀₎= 2.27, p= .03), however in simulation-2 no significant difference was observed between the cohorts. Paired t-test analysis revealed the video-between cohort had significant improvement from simulation-1 to simulation-2 (t₍₁₅₎= 3.06, p = .01); no significant difference was found for the video-prior cohort. Less prompting was seen in simulation-2 among both the video-prior (t₍₁₅₎= -2.83, p= .01) and video-between cohorts (t₍₁₅₎= -2.18, p= .04).

CONCLUSIONS

Simulation training, and targeted educational interventions, facilitate medical students to become clinically competent practitioners. Our findings indicate that guided video instruction advances students' clinical performance greater than learning through simulation alone. To confirm these findings, similar investigations in other clinical training exercises should be considered.

Core competencies for a biomedical laboratory scientist - a Delphi study

BACKGROUND

After completing university education, biomedical laboratory scientists work in clinical laboratories, in biomedical research laboratories, in biotech, and in pharmaceutical companies. Laboratory diagnostics have undergone rapid development over the recent years, with the pace showing no signs of abatement. This rapid development challenges the competence of the staff and will most certainly influence the education of future staff. This study aimed to examine what was considered the necessary competencies needed to pursue a career as a biomedical laboratory scientist.

METHODS

A modified Delphi technique was used, with the panel of experts expressing their views in a series of three questionnaire. Consensus was defined as the point which 75 % or more of the panel participants agreed that a particular competency was necessary.

RESULTS

The study highlights the perceived importance of mostly generic competencies that relate to quality, quality assurance, and accuracy, as well as different aspects of safety, respect, trustworthiness (towards patients/clients and colleagues), and communication skills. The results also stress the significance of self-awareness and professionality.

CONCLUSIONS

We identified important competencies for biomedical laboratory scientists. Together with complementary information from other sources, i.e., guidelines, laws, and scientific publications, the competencies identified can be used as learning outcomes in a competency-based education to provide students with all the competencies needed to work as professional biomedical laboratory scientists.

OSCE rater cognition - an international multi-centre qualitative study

INTRODUCTION

This study aimed to explore the decision-making processes of raters during objective structured clinical examinations (OSCEs), in particular to explore the tacit assumptions and beliefs of raters as well as rater idiosyncrasies.

METHODS

Thinking aloud protocol interviews were used to gather data on the thoughts of examiners during their decision-making, while watching trigger OSCE videos and rating candidates. A purposeful recruiting strategy was taken, with a view to interviewing both examiners with many years of experience (greater than six years) and those with less experience examining at final medical examination level.

RESULTS

Thirty-one interviews were conducted in three centres in three different countries. Three themes were identified during data analysis, entitled 'OSCEs are inauthentic', 'looking for glimpses of truth' and 'evolution with experience'.

CONCLUSION

Raters perceive that the shortcomings of OSCEs can have unwanted effects on student behaviour. Some examiners, more likely the more experienced group, may deviate from an organisations directions due to perceived shortcomings of the assessment. No method of assessment is without flaw, and it is important to be aware of the limitations and shortcomings of assessment methods on student performance and examiner perception. Further study of assessor and student perception of OSCE performance would be helpful.

The changing face of postgraduate anaesthesia teaching curriculum: Need of the hour!

The speciality of anaesthesiology is evolving rapidly. The recent pandemic witnessed anaesthesiologists as the front-liners catering not only as critical care physicians but also as trainers and even administrators. Today, anaesthesiologists are required to have not just sound clinical knowledge but also proficiency in skills and techniques and aptitude for leadership. The recently introduced competency-based postgraduate training programme for anaesthesiology in India with its specific learning objectives envisages the creation of competent specialists with a broad range of skills who are competent not only to handle effectively medical problems but also acquire the basic teaching skills, communication skills and leadership qualities. The curriculum marks a paradigm shift from university-based, passive, teacher-centric to student-centric, active teaching-learning methods including problem-based and self-directed learning. The mindset, lack of adequately trained faculty, infrastructure, learning resources and time constraints form the major impediment in the successful implementation of the new curriculum.

Integrative medicine and health in undergraduate and postgraduate medical education

Background and objective: Integrative Medicine and Health (IMH) is a theory-based paradigm shift for health, disease and health care, which can probably only be achieved by supplementing medical roles and competences. Definition of IMH: The definitions of the Academic Consortium for Integrative Medicineand Health 2015 and the so-called Berlin Agreement: Self-Responsibility and Social Action in Practicing and Fostering Integrative Medicine and Health Globally are used. The basic features of evidence-based Integrative Medicine and Health (EB-IMH) are based on the recommendations on EBM by David L. Sackett. Global State of Undergraduate and Postgraduate Medical Education (UG-PGME) for IMH: The USA and Canada are most advanced in the development of IMH regarding practice, teaching and research worldwide. Despite socio-cultural peculiarities, they can provide guidance for Europe and especially for Germany. Of interest here are competences for UG-PGME in IMH in primary care and in some specialist disciplines (e.g. internal medicine, gynecology, pediatrics, geriatrics, oncology, palliative care). For these specialties, the need for an interprofessional UG-PGME for IMH was shown in the early stages of development. UG-PGME for IMH in Germany: In the course of the development of the new Medical Licensure Act in Germany (ÄApprO), based on a revision of the National Competence-based Catalogue of Learning Objectives for Medicine (NKLM 2.0) and new regulations for Postgraduate Medical Education in Germany, suggestions for an extension of UG-PGME are particularly topical. To some extent there are already approaches to IMH. Old and new regulations are set out and are partly compared. As a result, some essential elements of IMH are mapped in the new ÄApprO. The new regulations for Postgraduate Medical Education do not mention IMH. Conclusion: The development of medical competences for IMH in the continuum of the UG-PGME could be supported by the coordinated introduction of appropriate entrustable professional activities (EPA) and IMH sub-competences combined with appropriate assessment.

Designing health professional education curricula using systems thinking perspectives

BACKGROUND

Medical students navigate complex personal learning pathways from entry into medical school, through an educational program, and into life-long practice. However, many stakeholders have called for substantive reforms in contemporary curricula, citing concerns about the lack of key abilities amongst newly graduated doctors to work in complex healthcare environments. Despite the need for educators to focus on curricula design, there is a paucity of overarching perspectives that allow synthesis of the various curricular elements in a way that lends meaningfulness and appreciation to the students in terms of navigating the immediate program requirements and beyond. Without such guidance, educators risk creating fragmented program designs that can lead to both unintended and unactionable outcomes for students as well as curriculum designers. Using systems thinking, we set out to address this gap by providing an overarching perspective for curriculum designers to appreciate the relationships and the interactions of the various curricular elements that inform and impact student's preparedness for practice.

METHODS

By framing a curriculum as a complex adaptive system, we used soft systems thinking to develop an initial prototype of a conceptual curricular toolkit, underpinned by an appraisal of relevant literature within health professional education and the broader educational context. The prototype was further refined iteratively after critical reflection by the authors with a diverse range of national and international colleagues via posters, short communications, and workshops at several conferences, and through social media.

RESULTS

We describe how the 3P-6Cs toolkit captures a learner's personal journey through an educational program into a field of practice by logically linking the three key elements: the personal, the program, and the practice. We demonstrate its application in three examples related to contemporary health profession education curricula. These are: creating integrated educational designs to capture students' developmental continua, conceptualising immersive clinical placements in non-traditional settings, and complexity-consistent evaluation of curricular interventions.

CONCLUSION

Applying the 3P-6Cs curricular toolkit to problems of curricula (re)design can provide overarching perspectives that enable educators to have a better understanding of how integration of elements within education programs can inform and impact student's preparation for lifelong practice.

Harnessing insights from an activity system - OSCEs past and present expanding future assessments

Objective Structured Clinical Examinations (OSCEs) are a dominant, yet problematic, assessment tool across health professions education (HPE). OSCEs' standardised approach aligns with regulatory accountability, allowing learners to exchange exam success for the right to practice. We offer a sociohistorical account of OSCEs' development to support an interpretation of present assessment practices. OSCEs create tensions. Preparing for OSCE success diverts students away from the complexity of authentic clinical environments. Students will not qualify and will, therefore, be of no use to patients without getting marks providing evidence of competence. Performing in a formulaic and often non patient-centred way is the price to pay for a qualification. Acknowledging the stultifying effect of standardising human behaviour for OSCEs opens up possibilities to release latent energy for change in medical education. In this imagined future, the overall object of education is refocused on patient care.

Health Systems Science in Medical Education: Unifying the Components to Catalyze Transformation

Medical education exists in the service of patients and communities and must continually calibrate its focus to ensure the achievement of these goals. To close gaps in U.S. health outcomes, medical education is steadily evolving to better prepare providers with the knowledge and skills to lead patient- and systems-level improvements. Systems-related competencies, including high-value care, quality improvement, population health, informatics, and systems thinking, are needed to achieve this but are often curricular islands in medical education, dependent on local context, and have lacked a unifying framework. The third pillar of medical education-health systems science (HSS)-complements the basic and clinical sciences and integrates the full range of systems-related competencies. Despite the movement toward HSS, there remains uncertainty and significant inconsistency in the application of HSS concepts and nomenclature within health care and medical education. In this Article, the authors (1) explore the historical context of several key systems-related competency areas; (2) describe HSS and highlight a schema crosswalk between HSS and systems-related national competency recommendations, accreditation standards, national and local curricula, educator recommendations, and textbooks; and (3) articulate 6 rationales for the use and integration of a broad HSS framework within medical education. These rationales include: (1) ensuring core competencies are not marginalized, (2) accounting for related and integrated competencies in curricular design, (3) providing the foundation for comprehensive assessments and evaluations, (4) providing a clear learning pathway for the undergraduate-graduate-workforce continuum, (5) facilitating a shift toward a national standard, and (6) catalyzing a new professional identity as systems citizens. Continued movement toward a cohesive framework will better align the clinical and educational missions by cultivating the next generation of systems-minded health care professionals.

Nationwide introduction of a new competency framework for undergraduate medical curricula: a collaborative approach

Switzerland recently introduced PROFILES, a revised version of its national outcomes reference framework for the undergraduate medical curriculum. PROFILES is based on a set of competencies adapted from the CanMEDS framework and nine entrustable professional activities (EPAs) that students have to be able to perform autonomously in the context of a predefined list of clinical situations. The nationwide implementation of such a competency- and EPA-based approach to medical education is a complex process that represents an important change to the organisation of undergraduate training in the various medical schools. At the same time, the concepts underlying PROFILES also have to be reflected at the level of the Federal Licencing Examination (FLE) and the national accreditation process. The vice-deans for education mandated a Swiss Working Group for PROFILES Implementation (SWGPI) to elaborate a guide presenting the principles and best practices based on the current scientific literature, to ensure the coherence between the future developments of the medical curricula and the evolution of the FLE, and to propose a coordinated research agenda to evaluate the implementation process. On the basis of the literature and analysis of our national context, we determined the key elements important for a successful implementation. They can be grouped into several areas including curricular design and governance, the assessment system and entrustment process, faculty development and change management. We also identified two dimensions that will be of particular importance to create synergies and facilitate exchange between the medical schools: a systematic approach to curriculum mapping and the longitudinal integration of an e-portfolio to support the student learning process. The nationwide collaborative approach to define strategies and conditions for the implementation of a new reference framework has allowed to develop a shared understanding of the implications of PROFILES, to promote the establishment of Swiss mapping and e-portfolio communities, and to establish the conditions necessary for ensuring the continuous alignment of the FLE with the evolving medical curricula.

Entrustable Professional Activities: Correlation of Entrustment Assessments of Pediatric Residents With Concurrent Subcompetency Milestones Ratings

BACKGROUND

In competency-based medical education, subcompetency milestones represent a theoretical stepwise description for a resident to move from the level of novice to expert. Despite their ubiquitous use in the assessment of residents, they were not designed for that purpose. Because entrustable professional activities (EPAs) require observable behaviors, they could serve as a potential link between clinical observation of residents and competency-based assessment.

OBJECTIVE

We hypothesized that global faculty-of-resident entrustment ratings would correlate with concurrent subcompetency milestones-based assessments.

METHODS

This prospective study evaluated the correlation between concurrent entrustment assessments and subcompetency milestones ratings. Pediatric residents were assessed in 4 core rotations (pediatric intensive care unit, neonatal intensive care unit, general inpatient, and continuity clinic) at 3 different residency training programs during the 2014-2015 academic year. Subcompetencies were mapped to rotation-specific EPAs, and shared assessments were utilized across the 3 programs.

RESULTS

We compared 29 143 pairs of entrustment levels and corresponding subcompetency levels from 630 completed assessments. Pearson correlation coefficients demonstrated statistical significance for all pairs (P < .001). Multivariate linear regression models produced R-squared values that demonstrated strong correlation between mapped EPA levels and corresponding subcompetency milestones ratings (median R ² = 0.81; interquartile range 0.73-0.83; P < .001).

CONCLUSIONS

This study demonstrates a strong association between assessment of EPAs and subcompetency milestones assessment, providing a link between entrustment decisions and assessment of competence. Our data support creating resident assessment tools where multiple subcompetencies can be mapped and assessed by a smaller set of rotation-specific EPAs.

Competencies and Feedback on Internal Medicine Residents' End-of-Rotation Assessments Over Time: Qualitative and Quantitative Analyses

PURPOSE

To examine how qualitative narrative comments and quantitative ratings from end-of-rotation assessments change for a cohort of residents from entry to graduation, and explore associations between comments and ratings.

METHOD

The authors obtained end-of-rotation quantitative ratings and narrative comments for 1 cohort of internal medicine residents at the University of Illinois at Chicago College of Medicine from July 2013-June 2016. They inductively identified themes in comments, coded orientation (praising/critical) and relevance (specificity and actionability) of feedback, examined associations between codes and ratings, and evaluated changes in themes and ratings across years.

RESULTS

Data comprised 1,869 assessments (828 comments) on 33 residents. Five themes aligned with ACGME competencies (interpersonal and communication skills, professionalism, medical knowledge, patient care, and systems-based practice), and 3 did not (personal attributes, summative judgment, and comparison to training level). Work ethic was the most frequent subtheme. Comments emphasized medical knowledge more in year 1 and focused more on autonomy, leadership, and teaching in later years. Most comments (714/828 [86%]) contained high praise, and 412/828 (50%) were very relevant. Average ratings correlated positively with orientation (β = 0.46, P < .001) and negatively with relevance (β = -0.09, P = .01). Ratings increased significantly with each training year (year 1, mean [standard deviation]: 5.31 [0.59]; year 2: 5.58 [0.47]; year 3: 5.86 [0.43]; P < .001).

CONCLUSIONS

Narrative comments address resident attributes beyond the ACGME competencies and change as residents progress. Lower quantitative ratings are associated with more specific and actionable feedback.

Competency Committees in Undergraduate Medical Education: Approaching Tensions Using a Polarity Management Framework

Implementing competency-based medical education in undergraduate medical education (UME) poses similar and unique challenges to doing so in graduate medical education (GME). To ensure that all medical students achieve competency, educators must make certain that the structures and processes to assess that competency are systematic and rigorous. In GME, one such key structure is the clinical competency committee. In this Perspective, the authors describe the University of Michigan Medical School's (UMMS's) experience with the development of a UME competency committee, based on the clinical competency committee model from GME, and the first year of implementation of that committee for a single cohort of matriculating medical students in 2016-2017.The UMMS competency committee encountered a number of inter dependent but opposing tensions that did not have a correct solution; they were "both/and" problems to be managed rather than "either/or" decisions to be made. These tensions included determining the approach of the committee (problem identification versus developmental); committee membership (curricular experts versus broad-based membership); student cohort makeup (phase-based versus longitudinal); data analyzed (limited assessments versus programmatic assessment); and judgments made (grading versus developmental competency assessment).The authors applied the Polarity Management framework to navigate these tensions, leveraging the strengths of each while minimizing the weaknesses. They describe this framework as a strategy for others to use to develop locally relevant and feasible approaches to competency assessment in UME.

The relationship between students' perception of the educational environment and their subjective happiness

BACKGROUND

Happiness, a subjective judgment about one's quality of life, is influenced by environmental factors and should be considered as an important goal of medical education, which should support each learner's development as a person as well as a professional. However, although several studies have reported on the correlation between Dundee Ready Educational Environment Measure (DREEM) scores and students' academic achievement, few have investigated the relationship between DREEM scores and students' subjective happiness. This study examined different perceptions of the educational environment between phases of the curriculum and determined which DREEM subscales affect the overall level of happiness.

METHODS

We used the Korean version of the DREEM questionnaire and a single item measure of happiness on a scale of 0 to 10. First we analyzed student perceptions of the educational environment according to their demographic characteristics using independent sample t-tests and one-way analysis of variance. A multiple regression analysis was performed to reveal which subscales affect the overall level of happiness while controlling for grade point average (GPA) and other demographic characteristics.

RESULTS

The subjects were 239 medical school students across all stages of the curriculum. The students' overall perception was more positive for the educational environment during Phase 3 (clerkship) than Phase 1 (pre-medical). Among the DREEM subscales, this difference was especially prominent in Students' Perception of Learning and Students' Academic Self-Perceptions. In contrast, no difference in the subjective perception of happiness was found between phases. The effect of GPA on happiness became insignificant under the control of other variables, but the influence of the Students' Social Self-Perceptions (SSSP) subscale remained significant.

CONCLUSIONS

The students' overall perception of the educational environment was more positive during the clerkship period than in the pre-medical period. Based on our finding that the SSSP correlates significantly with subjective happiness, we suggest that institutions promote not only students' academic development but also their happiness by fostering an appropriate educational environment.

Comparing Curricular Reform in Medical Schools and the Ship of Theseus: Insights Regarding Philosophical and Ideological Characteristics

Most of the curricular reforms are either imprecise, lacking appropriate contextualization or keen in "lifting" the solution from one context and fixing it in some other context. The greatest obstacle for curricular reform is something intrinsic [philosophical and ideological] and related to the general disposition of educators to resist the change and love status quo. We would like to put forth that viewing reforms under these lenses is the ultimate requirement and when winds of reform begin to blow in curriculum, definitely it would become unstoppable and one reform would give birth to the necessity for other reform. This commentary intends to discuss the under emphasized intricacies related to curricular reform by comparing it with analogy of "The Ship of Theseus."

Entrustment Ratings in Internal Medicine Training: Capturing Meaningful Supervision Decisions or Just Another Rating?

The implementation of Entrustable Professional Activities has led to the simultaneous development of assessment based on a supervisor's entrustment of a learner to perform these activities without supervision. While entrustment may be intuitive when we consider the direct observation of a procedural task, the current implementation of rating scales for internal medicine's non-procedural tasks, based on entrustability, may not translate into meaningful learner assessment. In these Perspectives, we outline a number of potential concerns with ad hoc entrustability assessments in internal medicine post-graduate training: differences in the scope of procedural vs. non-procedural tasks, acknowledgement of the type of clinical oversight common within internal medicine, and the limitations of entrustment language. We point towards potential directions for inquiry that would require us to clarify the purpose of the entrustability assessment, reconsider each of the fundamental concepts of entrustment in internal medicine supervision and explore the use of descriptive rather than numeric assessment approaches.

Examining the clinical learning environment through the architectural avenue

Medical education has traditionally focused on the learners, the educators, and the curriculum, while tending to overlook the role of the designed environment. Experience indicates, however, that processes and outcomes of medical education are sensitive to the qualities and disposition of the spaces in which it occurs. This includes the clinical education within the patient care environment, termed the clinical learning environment (CLE). Recognition of this has informed the design of some new clinical learning spaces for the past decade. Competency-based clinical education can drive design requirements that differ materially from those associated with general purpose educational or clinical spaces. In this article, we outline two conceptual frameworks: (i) materialist spatiality and (ii) actor-network theory and consider how they can guide the design of spaces to support competency-based medical education and to guide the evaluation and discussion of the educational impacts of the spaces once built. We illustrate the use of these frameworks through discussion of the educational ambitions that underpinned the design of some recent clinical educational spaces. We close with practical points for consideration by educators and designers.

Changes in Perceived Supervision Quality After Introduction of Competency-Based Orthopedic Residency Training: A National 6-Year Follow-Up Study

OBJECTIVE

To evaluate the perceived quality of the learning environment, before and after introduction of competency-based postgraduate orthopedic education.

DESIGN

From 2009 to 2014, we conducted annual surveys among Dutch orthopedic residents. The validated Dutch Residency Educational Climate Test (D-RECT, 50 items on 11 subscales) was used to assess the quality of the learning environment. Scores range from 1 (poor) to 5 (excellent).

SETTING

Dynamic cohort follow-up study.

PARTICIPANTS

All Dutch orthopedic residents were surveyed during annual compulsory courses.

RESULTS

Over the 6-year period, 641 responses were obtained (response rate 92%). Scores for "supervision" (95% CI for difference 0.06-0.28, p = 0.002) and "coaching and assessment" (95% CI 0.11-0.35, p < 0.001) improved significantly after introduction of competency-based training. There was no significant change in score on the other subscales of the D-RECT.

CONCLUSIONS

After the introduction of some of the core components of competency-based postgraduate orthopedic education the perceived quality of "supervision" and "coaching and assessment" improved significantly.

Occupational noise-induced hearing loss in South African large-scale mines: exploring hearing conservation programmes as complex interventions embedded in a realist approach

Background. Complex interventions have been conducted in the field of public health to improve health at the individual, organizational policy or population level. In occupational audiology, hearing conservation programmes (HCPs), which are interventions to minimize or eliminate occupational noise-induced hearing loss, are currently not defined as complex interventions, despite them fitting the definition and features of complex interventions. Therefore, this study aimed to explore whether HCPs are a complex intervention, fitting the predefined criteria for complex interventions. Method. A qualitative, descriptive research design was conducted using three sources of data - document analysis, interviews and systematic review - to allow for triangulation. Data were collected through purposive sampling and qualitative content analysis was used. Results. This study confirmed that HCPs are a complex intervention founded on solid and consolidated theories. Therefore, these results paved the way for realist reviews to be conducted in the mining sector in South Africa in order to understand the mechanisms influencing the success or failure of HCPs locally. Conclusion. The success of HCPs in the mining sector depends on conducting contextually evidence-based evaluations such as realist reviews which can provide policy-makers with contextual evidence for why certain programmes do or do not work in certain settings.

Curriculum reform: Why? What? How? and how will we know it works?

In a recent IJHPR article, Dankner et al. describe a reform in one longitudinal strand within Basic Medical Education i.e." public health and preventive medicine curriculum" using a Competency Based Medical Education approach. This reform raises several concerns: What should prompt a medical school to change a curriculum? How should such change be conducted? What kinds of paradigms may inform such a change? What constitutes a success in a curricular reform? And, how can curricular reform be evaluated within a reasonable time framework?This commentary addresses these concerns and concludes that curricular reform should follow as much as possible the current wisdom of educational innovation and change strategy, follow a clear vision, mission, and selected educational paradigm, and pay attention to stakeholders, context, culture and politics. The design should allow for the emergence of unintended consequences. Implementation needs careful planning and monitoring and the evaluation should be multi-faceted. Finally, since all Israeli medical schools are now using the Competency Based Medical Education approach and aligning their curricula and testing accordingly, a fascinating collaborative opportunity exists to professionalize this process and hopefully make a positive impact.

Educational renewal of physician training in Australia and New Zealand: Multiple educational innovations in a complex environment

AIM

The Royal Australasian College of Physicians is renewing its specialty training programs and shifting towards competency-based medical education. Our aim is to improve the quality and rigor of training and graduate outcomes, and promote high standards of physician practice to serve the health of patients, families, and communities in a changing healthcare environment.

METHODS

We are progressing holistic change and multiple educational innovations in a complex environment. Numerous stakeholders, a disparate training landscape and a largely volunteer supervisor workforce pose challenges in supporting effective implementation. This paper describes our progress and experience with three key components of our education renewal program: curricular renewal, a new selection process and faculty development. It offers reflections on the practical challenges, lessons learned and factors critical for success.

CONCLUSIONS

Our experience highlights opportunities for training organizations to maximize their influence over workplace training experiences and outcomes by taking a systems approach to the design, delivery and evaluation of the components of education renewal. We found that design, development and delivery of our multiple educational innovations have benefited from co-design approaches, progressive and concurrent development, continual exploration of new strategies, and implementation as soon as viable with a commitment to iterative improvements over time.