When Academic Internal Medicine Insight wanted the perspective of the American Board of Internal Medicine (ABIM) on the “controversial topic” of competency-based education and training (CBET), I was struck by the framing of the topic as controversial. The concept of CBET, which has been formally recognized and studied in education for over 40 years, was the foundation for the Accreditation Council for Graduate Medical Education (ACGME) Outcome Project, which began over 10 years ago. The primary focus of CBET is the learner’s attainment of mastery of knowledge, skills, and attitudes in specific competencies. This focus requires a major shift in thinking, summarized by Sullivan in 1995: “In a traditional educational system, the unit of progression is time and it is teacher-centered. In a CBET system, the unit of progression is mastery of specific knowledge and skills and is learner-centered” (1).
The implications for residency training are significant. Carol Carraccio and Robert Englander contrasted the current traditional educational approach with that of a competency-based system (Table).
CBET requires a learner to be the primary driver of his or her own education, necessitates more robust assessment and feedback, and focuses on knowledge application rather than just acquisition. The one distinguishing feature of CBET causing the most consternation is that residents could progress through the educational process at different rates. The argument is that the most capable and talented individuals should be able to make career transitions earlier, while others will require more time to attain a sufficient level of knowledge, skills, and attitudes to enter independent practice. This idea is consistent with Anders Ericsson’s work on the need to tailor the educational experience so that it continually challenges the learner, but at the same time is not too easy or too hard (3).
The underlying concept of CBET has been supported from organizations as diverse as the American College of Physicians, the Society of General Internal Medicine, the American College of Cardiology, and the Association of Program Directors in Internal Medicine. In 2007, the Alliance for Academic Internal Medicine (AAIM) recommended that “graduate medical education programs should fully adopt and implement competency-based education, evaluation and advancement.” But these organizations, and others, have differed sharply on the form that CBET should take.
External pressures are also driving the desire to explore CBET, make training more efficient, and create mechanisms to shorten training for appropriately qualified individuals. Given growing concern over the decreasing number of residents entering clinician-investigator careers, altering the training pathway in combination with shortening training time is seen as one mechanism to address this shortage. Rekindled interest in an “accelerated” pathway into primary care training in which qualified medical students enter residency training in the fourth year of medical school is also considered a mechanism to address the primary care shortage. However, CBET must also address how the less-skilled learners will be remediated and what happens if remediation is unsuccessful. CBET is about all learners, not just the most talented who can move through training more quickly. Many learners require and should receive more time in training with an appropriate emphasis on areas of deficiency.
ABIM recognizes the substantial forces that make a rapid transition to variable-timed residency program difficult even if the community agreed such an approach was desirable. Workforce issues, training program capacity, dependency on residents for both service and teaching needs, current graduate medical education financing, and other issues raise significant questions and highlight some possible unintended consequences of a broad program of CBET. Much work remains to be done in creating a learner-centered, outcomes-based training model not centered on time.
It is in this context that ABIM has begun the exploration of CBET. ABIM recognizes this evolution will be long, with this first phase of work lasting years. Programs will need support from ABIM and the educational community to implement outcomes-based education and understand that some programs will want to carry out experimental pilots of different training approaches. ABIM recognizes the concern and fear about how these experimental pilots might be conducted and what the implications might be for future policy decisions. However, as leadership expert Warren Bennis noted, “Innovation by definition will not be accepted at first. It takes repeated attempts, endless demonstrations, monotonous rehearsals before innovation can be accepted and internalized by an organization. This requires ‘courageous patience’” (4).
The exploration of new approaches to internal medicine training is not without precedent for ABIM. In fact, built into our requirements is the opportunity for training programs to bring proposals to modify the emphasis and nature of training based on career needs and special circumstances. However, current policies still limit the amount of flexibility in training.
ABIM has supported pilots that examined different pathways into residency. For example, in the 1990s, ABIM and the American Board of Family Medicine participated in a joint pilot program that allowed students at a select number of medical schools that emphasized primary care training to enter residency during the fourth year of medical school. Although this program was discontinued after a prolonged evaluation period, interest in this pathway has been renewed because of primary care physician shortages.
ABIM also currently supports a number of combined training programs that lead to certification in two to three specialties with reductions in total time of training. The most prominent example is internal medicine-pediatrics. At a total of four years, the overall training period is reduced by two years (a 33% reduction). Other combined programs include internal medicine with dermatology, neurology, psychiatry, emergency medicine-critical care, family medicine, and genetics. The logic of these combined residencies is that many competencies are shared among the disciplines (e.g., interpersonal and communication skills, professionalism, practice-based learning and improvement and systemsbased practice), and that “maturation” will still occur under supervision and guidance. Another ABIM pathway, the research pathway, reduces the amount of clinical training but requires a substantial amount of time in research training.
ACGME is already committed to residency redesign through the 21 EIP-approved programs and milestones projects. It is incumbent on all stakeholders to develop greater understanding of our ability to assess competency in trainees with certifying and assessment tools that link to accreditation of programs. The move to an outcomes-based accreditation system, as well as a renewed call for objective demonstration that graduates are truly competent to provide high quality patient-centered care, requires an evolution to competencybased training. ABIM has developed a process to engage the diverse community of organizations involved in this issue. ABIM is not wedded to any specific idea or proposal but will seek innovation and ideas from the community. For any training redesign program to be successful, it needs to be embraced by a broad group of stakeholders who share the goal of improving the quality of internal medicine physicians that come out of US medical schools. They must be willing to come together to challenge assumptions and drive innovation. We look forward to working with the internal medicine community in that process.
Wendy Levinson, MD
Chair, Board of Directors
American Board of Internal Medicine
1. Sullivan R. JHPIEGO Strategy Paper. Baltimore, MD: 1995. Online. http://www.reproline.jhu.edu/ english/6read/6training/cbt/cbt.htm#CBT. Accessed August 21, 2008.
2. Carraccio C, Wolfstahl SD, Englander R, Ferentz K, Martin C. Shifting paradigms: From Flexner to competencies. Acad Med. 2002;77:361-367.
3. Ericsson KA. An expert-performance perspective of research on medical expertise: The study of clinical performance. Med Educ. 2007;41:1124-1130.
4. Bennis W, Namus B. Leaders: The Strategies for Taking Charge. New York, NY: 1997.
Levinson W. Time for innovation: The ABIM view of competency-based education. Academic Internal Medicine Insight. 2009;7(3):6-7.