Overcoming Barriers to CBME Implementation

In this discussion, we are focusing on competency-based medical education (CBME) within existing training frameworks rather than time-variable training programs. However, time variability may be considered in certain contexts as well. While there may be many benefits to widespread adoption of CBME, there are some challenges that must be addressed deliberately, including those outlined below.

Cost

The cost of implementing CBME is variable based on the needed or desired resources to measure competency. Development and validation of assessment models, faculty time, instructional resources such as simulation, and data infrastructure are all potentially costly requirements of CBME. Important considerations are whether CBME is cost-effective and what return it provides on investment. This is a particularly salient concern for department chairs, who have to balance training needs with clinical efficiency and cost containment. Cost may be mitigated by use of previously existing institutional resources, which confer minimal (if any) additional cost. It should also be noted that many of these resources are already part of existing educational and assessment structures, which reduces the marginal cost of transitioning to CBME.

Resources

Educational program leaders may face challenges in securing the resources needed to develop and implement high-quality assessments that are sufficiently rigorous to determine progression through levels of training. While this may be partly related to cost, other considerations include educators’ knowledge and training in assessment methods, access to data collection and management software, access to psychometric and data analytic support, availability of time in the curriculum to devote to competency assessment. As part of continuing professional development of education specialists, preferential attention can be directed at mastery of resources that support CBME. The Accreditation Council for Graduate Medical Education (ACGME) and other national organizations also provide faculty development relevant to CBME. 

Time

Educational program leaders have a wide range of responsibilities outside of CBME implementation, and in many cases, are under-supported for the needs of their programs in primary areas of resolving accreditation issues and developing educational content. CBME may also rely heavily on day-to-day assessments conducted in the clinical setting, where faculty have numerous competing priorities and little time or cognitive space for assessment. Assessments conducted outside of the clinical area solve that problem (e.g., simulation), but require investment in faculty time and training. Whether directed by CBME or another learning strategy, regular real-time assessments are a cornerstone of medical education at all levels. It is imperative that departmental culture support this aspect of the educational mission. 

Logistics

Eliminating time-based training is a daunting proposition for leaders of programs that rely on having a set number of learners each year to provide clinical service. Rather than viewing CBME as a disruptor to time based education, it is important to remember that there are many examples of successful CBME implementation within the confines of time-based promotion. Some ideas include: adopting the Master Adaptive Learner model with the underlying Precision Education construct to meet each learner where they are and allow them to advance their skills or reduce their supervision within their currently assigned area of service. Those who need extra work to master a mandatory concept may be able to rebalance their time and “borrow time” from areas in which they have expertise, or to lengthen their training time when needed. 

Resistance to Change

This is a factor for all stakeholders, but trainees, educators, and administrative leaders have all reacted to CBME with skepticism in some cases. They have expressed concern about the rationale for CBME, the impact on their workload, and effects on wellness, stress and morale. Stakeholders may need to be educated on how CBME can enhance training and lead to greater accountability and self-directed learning. When one considers change in medical education throughout history, each new movement has had to overcome skepticism and adopt real-time modifications to engender buy-in and optimize the system. A concerted effort can effect change to adopt CBME moving forward.

Data Quality Challenges

Ensuring assessment data with sufficient reliability and validity evidence to permit high-stakes entrustment decisions is not easy, and requires significant investment in assessor development, and in infrastructure to collect, manage, and analyze data. Some programs may struggle to amass sufficient high-quality data to make defensible judgments of learner competency. Fortunately, technology has made data collection simpler and less costly than ever before, and even relatively basic programs now have the computing power to perform necessary analyses. It is also crucial to remember that sound data form the basis of any assessment structure, and in an era of ever-increasing accountability requirements, medical education programs must ensure that they are prepared to provide supporting evidence when certifying the competency of their graduates.