Emancipating education
Abraham Lincoln Presidential Library
Springfield, IL
September 28, 2013
Felix Ankel, MD
Watson
Human
Curate
From Hierarchies to Networks
Community of Practice
Community of practice
Create
All,
We recently had a case where an intern, when asked by the nurse taking
care of a patient with a NSTEMI, said it was okay for the patient to go to
the bathroom off monitor. You guessed it; the patient subsequently was
found in arrest in the bathroom. In our reactionary culture, some of our
faculty are advocating for all decisions to go through the 3rd year resident
and to make sure the intern doesn’t make decisions that adversly affect
patient care. So, the questions for the collective:
• Do you have a formal statement about what interns are
allowed to do?
• If not formally, do you have a process of what interns are
allowed to do?
• Are the nurses the “determiners” of who to go to?
The “Miracle” of Medical Education
Slide credit Eric Holmboe
•Autonomy
•Complexity
•Context
Autonomy
Able to take full responsibility
for going beyond existing
standards and creating own
interpretations
From the professional standards for conservation,
Institute of Conservation (London) 2003, Based on the
Dreyfus model on skill acquisition
Complexity
Holistic grasp of complex
situations, moves between
intuitive and analytical
approaches with ease
From the professional standards for conservation,
Institute of Conservation (London) 2003, Based on
the Dreyfus model on skill acquisition
Context
Sees overall “picture” and
alternative approaches; vision
of what may be possible
From the professional standards for conservation, Institute
of Conservation (London) 2003, Based on the Dreyfus
model on skill acquisition
The Light at the End of the Tunnel…
…Is a Freight Train
1. Explosion of medical knowledge:
need to re-conceptualize competence
2. The growth of performance
measurement: quality and safety
indicators, patient experience, etc.
3. Shift to interprofessional care and
changing scope of practice
4. Advances in cognitive science:
expertise, retrieval practice, situated
and distributed cognition, etc.
5. Critical role of “context” – complex
adaptive systems
6. Growing public pressure to change
7. HIT/Clinical Decision Support
Slide credit Eric Holmboe
Why CBME: 21st Century Healthcare
Frenk J, et al. Health professionals for a new century:
transforming education to strengthen health systems in an
interdependent world. Lancet. 2010
Next Accreditation System
Case Logs
Resident &
Faculty
Opinions
Milestone
Reporting
(semi-annually)
22
Continuous
Oversight &
Improvement
Emphasis
Program &
Institutional
Information
Uniformity of Milestone Reporting
• 5 levels of proficiency
– Novice, Beginner, Competent, Proficient, Expert
• Level 4 - The ABEM certification standard
– By definition where an individual should be at time of
graduation
•
•
•
•
Level 5 - Attained after practice
Narrative anchors
Based on knowledge, skills and abilities (KSAs)
Balance between
– Deconstruction (microtasks)
– Integration (complex performance)
Reliabilities across methods
slide created by Cees van der Vleuten 2012
CaseTesting
Based
Time in
Oral Long
Short
Hours MCQ1 Essay2 PMP1 Exam3 Case4 OSCE5
1
0.62
0.68
0.36
0.50
0.60
0.47
2
0.76
0.73
0.53
0.69
0.75
0.64
4
0.93
0.84
0.69
0.82
0.86
0.78
8
0.93
0.82
0.82
0.90
0.90
0.88
1Norcini
et al., 1985
2Stalenhoef-Halling et al., 1990
3Swanson, 1987
4Wass
et al., 2001
2002
5Petrusa,
What are the characteristics of a
highly functioning CBME system?
Structure- and Competencyprocess-based
Based
Driving Force:
Curriculum
Content
Outcome
Driving Force: Process
Teacher
Learner
Path of learning
Hierarchical
Non-hierarchical
Responsibility for
content
Teacher
Student and teacher
Goal for educational
encounter
Program completion
Knowledge acquisition Knowledge application
Fixed time
Variable time
Carraccio C, Wolfshtal SD, Englander R, Ferentz K, Martin C. 2002. Shifting paradigms:
from Flexner to competencies. Acad Med 77(5):361-367. p 362.
“This has resulted in the world’s
first pilot of a competency (as
opposed to time) based
orthopedic training program”
Macrotrends
•
•
•
•
From hierarchies to networks (CoP)
From individual experts to wisdom of crowds (CCC)
From knowledge to competency (CBME)
From carrots and sticks to autonomy, mastery, and
purpose (Dreyfus and Dreyfus)
• From function to design (CLER visit)
• From argument to story (narrative anchor)
Drivers and themes for innovation
• Curation and
Aggregation
• Communities of
Practice
• Creation of Tools
• Assessment
• Time
• Money
Competency by design
Thank you
•
•
•
•
•
•
•
Brad Gordon
Rob Cooney
Jessie Nelson
Derek Schmidt
Jason Frank
Ali Jalali
Cees Van der Vleuten
•
•
•
•
•
Tom Nasca
Mary Healy
David Griffen
Julie Kirkham
Eric Holmboe