News and Commentary Lessons Learned: Building a Competency-Based Medical Education Pilot

Two years ago on this blog, we introduced a national demonstration pilot at four schools testing an exciting new model for medical education and training called, Education in Pediatrics Across the Continuum (EPAC). The Macy Foundation and the Association of American Medical Colleges (AAMC) have supported the project testing the feasibility of advancing learners from early in medical school to residency and then to practice based on their demonstration of competence rather than their time in the program. Each pilot site agreed to take on four cohorts of four students a year who were committed to a career in pediatrics and willing to stay at the institution for residency training. The first cohort joined the project in either the 2014-2015 or the 2015-16 academic year.

Now is an exciting time to update the health professions’ education community on our progress. We will begin with a spoiler alert by starting with the dramatic ending to this blog: For the first time in North American history, over the 2016-2017 academic year, several students have transitioned from undergraduate medical education (UME) to graduate medical education (GME) based on the demonstration of competence in a time-variable fashion.

The road to this point has been both fun and at times challenging. For the learners in the program and the many faculty who have participated, they would argue the journey is well worth it. EPAC is, in essence, the embodiment of the concept of competency-based, time variable education, a previously elusive and mostly aspirational goal for health professions’ educators. The pilot has elucidated some of the key ingredients to success:

  • Align the Regulatory Bodies: Time variable transitions in graduate education and training require either exceptions to the rules for many of the regulatory bodies or adaptations of the program for a few. For our pilot, these included the Liaison Committee for Medical Education (LCME), the National Residency Matching Program, the Accreditation Council for Graduate Medical Education (ACGME), the Federation of State Medical Boards (FSMB) and the respective state licensing boards for the states in which the four pilot schools reside. In the case of California, this included successfully lobbying the legislature to eliminate a time requirement for medical school as a requisite for licensing.
  • Align leadership at your institution: One of the early lessons we learned was that leadership had to be on board across the institution for success. In the case of our program, this included project leadership, educational leadership, and administrative leadership including the Dean. When leadership changed, we needed to get on the calendar of the new leaders quickly to let them know about EPAC and at times to even make changes in the project to ensure alignment with the new leadership’s vision.
  • Define the Outcomes and the Framework for Assessment: If you are going to advance based on competencies rather than time, then you have to have clear agreement on what those competencies are and how you are going to assess them! The EPAC national consortium all agreed that the Physician Competency Reference Set would be the desired outcomes and that Entrustable Professional Activities (EPAs) would be the framework for assessment. Entrustment on the Core Entrustable Professional Activities for Entering Residency (Core EPAs) thus provides the primary measure for the medical school to residency transition and entrustment on the Pediatric EPAs will be the core measure for the residency to practice transition.
  • Choose the right specialty/training program: Because this program a) requires its participants to agree to stay in pediatrics and to complete residency at the program of their medical school, and b) requires entrance into the program in the first or second year of medical school, this type of program is likely to be successful in specialties that tend to show consistency in interest over time. Pediatrics is the specialty that perhaps best meets that criterion. Other specialties in medicine that probably fit the bill include obstetrics/gynecology, general surgery, and family medicine—these may be great opportunities for the next specialties to try out the model.
  • Start before you’re ready: As with any major change, the enemy of good is perfect. It is impossible to anticipate all of the roadblocks and unintended consequences or benefits you will experience. At some point, you just have to take the dive and go for it! We set a start date to recruit our first cohort of students and we helped each other stick to it.
  • Learners are the best motivators! We cannot overestimate the power and motivation that comes with accepting learners into a new program. The responsibility to those students to provide a great experience was an amazing catalyst for some of the final touches at each of our pilot sites. The addition of learners to our twice yearly national consortium meeting also enhanced our meetings immeasurably at the same time it allowed the students to develop a network of “pioneers” from across the four sites.
  • Build continuous improvement into the program: No pilot or new program is perfect from the get go. Our program has improved with each new cohort because each site built improvement into its operations that includes frequent meetings between the students and the project leadership. At the national level, two wonderful consultants have helped us stay on the improvement pathway: Alan Schwartz who provides oversight of assessment in the program, and Dorene Balmer who provide oversight of program evaluation.

Next Steps
EPAC is the brainchild of Dr. Deborah Powell from the University of Minnesota Medical School, who first approached Dr. Carol Aschenbrener at the AAMC more than eight years ago with a hope and an idea. Eight years later we have (or almost have) chosen our fourth cohort and several students have already made the time-variable transition from UME to GME. Despite these successes, there is still so much to do and learn.

We are just entering the GME phase, and so will need to study the question: did time-variable progression work? Do the EPAC residents perform at least as well or better on the pediatric milestones and EPAs as their non-EPAC counterparts? Now that they are residents, can we advance them through residency based on competence rather than time? What does a time-variable transition from GME to practice or fellowship look like? Are there licensing and accrediting implications we haven’t thought of?

Once we complete selection of the four cohorts, will there be a fifth? How will sites convert these programs from innovation to operations? We also need to consider scale. What is the next specialty that could/should try the EPAC model? Can EPAC be expanded to other pediatric sites?

While there are many unanswered questions, one thing is certain— For the first time in North American history, over the 2016-2107 academic year, several students have transitioned from undergraduate medical education (UME) to graduate medical education (GME) based on the demonstration of competence in a time-variable fashionand that’s a story worth telling!

Learn more: New recommendations for designing and implementing competency-based, time-variable health professions education.

1.Englander R, Cameron T, Ballard AJ, Dodge J, Bull J, Aschenbrener CA. Toward a Common Taxonomy of Competency Domains for the Health Professions and Competencies for Physicians. Academic Medicine. 2013;88(8):1088-1094.
2.Ten Cate O. Entrustability of professional activities and competency-based training. Medical Education. 2005; 39: 1176-7.

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