News and Commentary An Education System that Works for Everyone

Macy Conference Chair Catherine R. Lucey, MD, discusses the importance of transitioning to competency-based, time-variable health professions education.

Our current time-bound, fragmented health professions educational systems do not yet fulfill our professions’ compact with society for care that is consistently aligned with patient goals, informed by the best of current evidence, delivered by teams of professionals whose effectiveness is measurably excellent, and continuously improved in all domains. Our health professions’ compact with our learners and faculty similarly falls short of our goals for education that is life-long, learner-centered, assessment-informed, and embedded into high-functioning delivery systems. Fortunately, pedagogical advances in our understanding of how young people become expert health professionals have occurred alongside the tremendous biomedical advances of the past century. Application of educational theory to the complex workplace learning experiences of health professional learners suggests that a revolutionary shift from course- and clerkship-based, time-bound education to competency-based, time-variable education is needed to bring us closer to the ideal system that meets the needs of our learners, our faculty, and, most importantly, our patients.

Competency-based, time-variable (CBTV) education begins by designing educational programs with an explicit and relentless focus on the needs of patients and society for improved health and health care. Competency-based, time-variable education recognizes that the privilege of teaching and learning in the clinical environment demands that the amount of responsibility and level of supervision assigned to each learner is determined by measuring competency, not by tabulating the number of weeks, months, or years spent in the program. Faculty and learners alike are aware of the requirements for competency development and together identify opportunities for the learner to be observed, assessed, and coached as they engage with different patients, in different contexts of care, with a variety of team members. Unlike the current model of education, assessment is not grade assigned at the end of a clerkship of predetermined length because of a general sense of the learner’s ability. Instead, learners are empowered to engage with faculty in a continuous process of goal-directed personal improvement. Learners who meet competency goals prior to the usual end of a particular phase of education can either accelerate transition to the next stage of education or use additional time to deepen their competencies, engage in scholarly activities, or devote time to personal goals, such as family building.

Competency-based, time-variable education requires new programmatic and regulatory structures and models. Academic institutions, licensing agencies and certification boards must shift their requirements from time-based (credit hours, program length) to achievement-based. Accreditors and regulators must redirect their attention to outcomes of education rather than on processes of education. Proposed changes of this magnitude require careful analysis and planning. The 2017 Macy Foundation conference on achieving competency-based, time-variable education set out to evaluate the evidence for embarking on this journey of pedagogical change for health professions education around the world. All who participated in this three day conference, summarized in the attached monograph agreed that the time has come to reshape health professions education of the 21st century to achieve our collective goal of ensuring that every patient has access to the type of health care professional that we would choose for someone we loved. The potential of this new paradigm to accelerate the fulfillment of our compact with society for improved health care and our commitment to our learners for effective and efficient learning across the span of their education and careers is extraordinary. We hope that the attached monograph and the special issue of Academic Medicine (to be issued on Feb. 28) that expands on this work will encourage you to join us in exploring this revolutionary change.

Catherine R. Lucey, MD is the Executive Vice Dean, Vice Dean for Education, Professor of Medicine, and Faustino and Martha Molina Bernadett Presidential Chair in Medical Education at the University of California, San Francisco (UCSF) School of Medicine. Dr. Lucey chaired the 2017 Macy Conference, Achieving Competency-Based, Time-Variable Health Professions Education.

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