CBME 진보: 임상가-교육자를 위한 헌장(Acad Med, 2016)

CBME 진보: 임상가-교육자를 위한 헌장(Acad Med, 2016)

Advancing Competency-Based Medical Education: A Charter for Clinician–Educators

Carol Carraccio, MD, MA, Robert Englander, MD, MPH, Elaine Van Melle, PhD, Olle ten Cate, PhD, Jocelyn Lockyer, PhD, Ming-Ka Chan, MD, MHPE, Jason R. Frank, MD, MA(Ed), and Linda S. Snell, MD, on behalf of the International Competency-Based Medical Education Collaborators

Background

국제적으로 CBME는 다양한 프레임워크로 도입되었음

Internationally, CBME is being adopted under a variety of frameworks, including

• CanMEDS,3

• the Accreditation Council for Graduate Medical Education competencies,4

• the Scottish Doctor Outcomes,5 and

• the Australian Curriculum Framework for Junior Doctors.6

 

이 헌장에서는 ten Cate의 CBME정의를 적용함: 하나 혹은 그 이상의 의료역량medical competencies에 해당하는 적절한 수준의 능력을 목표로 하는 의료전문직을 위한 교육

For the purposes of this charter, we adapt a definition of CBME recently proposed by ten Cate7: education for the medical professional that is targeted at a necessary level of ability in one or more medical competencies.

CBME가 도입된 이후, resource-intensive한 교육시스템을 도입하는 것에 대한 우려가 많았으며, 그것이 정말 더 나은 의사를 만드는 것인가도 증명되지 않았다. 그러나 CBME의 효과성에 대한 공식적 근거가 부족하더라도 우리는 이 모델을 지향해야 할 두 지식체bodies of knowledge를 가지고 있다. 첫 번째는 CBME의 building block이라 할 수 있는 교육이론이다.

Since the introduction of CBME, many concerns have been raised about implementing a resource-intensive system of education and training that is as yet unproven as a means of producing better doctors.8 However, if formal evidence of the effectiveness of CBME is lacking, we do have two bodies of knowledge that support the move to this model. First are sound advances in education theory that serve as the building blocks of CBME:

• 명확하게 정의된 성과 the importance of clearly defined outcomes,

• 학습자가 authentic setting에서 능동적 역할을 담당 learners taking an active role in their education and assessment within an authentic clinical setting, and

• 다수의 평가자와 다수의 방법을 이용한 형성적, 집중 피드백 formative and focused feedback from multiple assessors using multiple methods.9,10

 

두 번째는 우리는 우리의 현재 시스템이 최선의 의사를 양성하기에 부족하다는 근거가 충분하다. 의료과오에 대한 여러 문헌들.

Second, we have ample proof that our current system falls short of producing the best possible doctors:

• An Institute of Medicine (IOM) report,11

• the Canadian adverse events study,12 and

• adverse events and near-miss reporting in the United Kingdom13

...have documented high rates of preventable medical errors.

 

현재까지 CBME 도입에 대한 여러 장애물이 있어왔다.

Major barriers to CBME implementation to date have included

• (1) the time- and resource-intensive nature of competence assessment, which requires direct observation by multiple assessors in multiple settings;

• (2) the need for faculty development in teaching and assessing the competencies;

• (3) a misalignment between learning environments and learners’ chosen practice environments;

• (4) the logistical challenges of introducing competency- based advancement into a traditionally time-based system (where advancement is primarily based on satisfactory completion of medical school and prescribed number of years of specialty training); and

• (5) limited investment in health professions education, which accounts for less than 2% of expenditures globally in the health care industry.8,14,15

우리는 대중과 의학교육계에 CBME가 harm하지 않으며, 타당한 이론적 근거가 있고, 환자와 인구집단, 시스템 향상을 위한 습관을 체화시킨 의사 양성에 기여한다는 것을 보여줄 필요가 있다.

We need to demonstrate to the public and the medical education community that CBME does no harm, is based on sound educational theory, and contributes to the professional formation of physicians who embody the habits of working to improve patient and population care as well as systems of care.

CBME 헌장

The CBME Charter

 

서문 Preamble

Frank 등은 의학교육에서 성과바탕교육에 대해 다음과 같이 묘사했다. 

Frank et al16 have proposed the following description of competency-based education for medical education:

Competency-based education (CBE) is an approach to preparing physicians for practice that is fundamentally oriented to graduate outcome abilities and organized around competencies derived from an analysis of societal and patient needs. It de-emphasizes time-based training and promises greater accountability, flexibility, and learner-centeredness.

 

기본 원칙 Fundamental principles

교육은 반드시 serve하는 인구집단의 건강요구에 기반해야 한다.

Education must be based on the health needs of the populations served.

학부의학교육의 플렉스너적 전통에서는 quality gap과 의료 과오를 낳았다. CBME는 반대로 "해결되어야 할 건강 문제를 정의하고, 건강시스템의 퍼포먼스를 위하여 졸업생에게 필요한 역량을 밝히고, 교육과정이 역량을 달성하고, 성취와 부족한 점을 평가하도록 tailor되어야 한다"

Flexnerian tradition17 for undergraduate medical education (UME), The deficiencies that resulted from this education and training experience were explicitly brought to light by reports on quality gaps and medical errors.11–13,19 CBME, by contrast, “is a disciplined approach to specify the health problems to be addressed, identify the requisite competencies required of graduates for health-system performance, tailor the curriculum to achieve competencies, and assess achievements and shortfalls.”14

이 원칙의 중요성은 Berwick이 말한 "세 가지 목표"에 의해서 지지되며, '더 나은 건강, 더 나은 헬스케어, 그리고 낮은 가격'이다.

The importance of this principle is supported by the “triple aim” of Berwick et al21, which espouses better health, better health care, and lower cost.

교육과 훈련의 첫 번째 초점은 학습자에게 기대되는 성과가 되어야 하며, 교육시스템의 구조나 프로세스가 되어서는 안된다.

The primary focus of education and training should be the desired outcomes for learners rather than the structure and process of the educational system.

 

CBME는 강조점을 학습자가 어떤 지식을 적용할 수 있는 능력을 보여주게끔 하는데 둔다. CBME는 '기본 역량' 을 다양한 스펙트럼에서 요구하는데, 특정 역량은 직업 궤적에 따라서 선택되며, 학습자는 다음 단계로 나아가기 전에 반드시 역량을 보여주어야 한다. 이 원칙, 즉 "학습성과의 표준화와 학습 프로세스의 개별화" 는 최근 UME와 GME 개혁을 위하여 카네기 재단에서 발간한 보고서에 실린 네 가지 목표 중 하나이다. 또한 CBME에서 발달advancement한다는 것은 전문직정체성형성PIF 에도 근거를 두는데, 이것은 시간에 걸친 성숙 과정으로서 전문직업적 역량 개발의 핵심 요소이다.

CBME shifts the emphasis to the learner’s ability to demonstrate the application of that knowledge. CBME defines a broad spectrum of basic competencies, along with specific competencies aligned with chosen career trajectories, that learners must demonstrate before they advance to the next stage. This principle—“standardization of learning outcomes and individualization of the learning process”—is one of the four goals of the recent Carnegie Foundation report on reforming medical school and residency education.23 It is important to emphasize, that advancement in CBME predicated also on professional identity formation, a maturational process that occurs over time, is an integral component of the development of professional competence.24,25

 

의사의 양성은 교육, 훈련, 실천의 seamless 연속체에 있어야 한다.

The formation of a physician should be seamless across the continuum of education, training, and practice.

 

"종점을 염두에 두고 시작하라beginning with the end in mind"는 교육, 훈련, 실천의 전체 연속체가 "좋은 의사란 무엇인가"라는 질문의 공동의 비전으로서 informed될 수 있게 해준다. 이러한 shift는 입학시점부터 시작되어야 하며, 우리로 하여금 premedical candidate가 바람직하게 갖추어야 할 것이 무엇인지를 다시 검토하게 한다. 연속체의 정신을 떠올렸을 때, 이것은 기초의학을 전체 교육 훈련과정에 걸쳐서 통합시키는 것을 말하며, 환자 진료에 어떻게 적용되는지를 명시적으로 연결시켜야 한다.

Adopting a strategy of “beginning with the end in mind” will allow the entire continuum of education, training, and practice to be informed by a shared vision of what it means to be a good doctor. This shift must begin at the point of admission, requiring us to reexamine what we consider to be the desirable attributes of premedical candidates. In the spirit of the continuum, it also means focusing and integrating core basic science knowledge throughout education and training, and explicitly linking its application to patient care.23

 

교육과정과 평가의 연속성이 연속체에 걸친 학습을 더 효과적, 효율적, 의미있게 해줄 것이다.

Continuity of both curriculum and assessment across the continuum will make learning effective, efficient, and meaningful.

 

의학교육자들에게 요구되는 헌신

Commitments required of medical educators

 

도출된 넓은 범위의 역량을 포괄하는 교육, 평가, 롤모델링에 대한 헌신

Commitment to teaching, assessing, and role modeling the broad range of identified competencies.

Reaching beyond the traditional goals and objectives related to patient care and medical knowledge, these competencies include communication, professionalism, advocacy, scholarship, leadership, and practice and system improvement.3–6,28 For learners to embrace these compe- tencies as part of their professional formation, they must be made explicit in our curricula.

 

환자 안전과 학습자의 전문직업적 성장의 균형을 맞추는 supervision에 대한 헌신

Commitment to supervision that balances patient safety with the professional development of learners.

There is a basic core of knowledge and skills that faculty must learn to practice effective supervision Faculty must provide the structure and support to learners to facilitate their progression toward unsupervised practice.

모든 이해관계자들에게 투명성을 갖출 헌신

Commitment to transparency with all stakeholders.

환자. 학습자는 형성적, 건설적, 구체적 피드백을 환자/타 의료직종/동료/교수에게 받아야 하며, 학습자의 발달에 투자되는 모든 이해관계자와 협력해야 한다.

The voice of the patient—collectively and individually—must be attended In turn, the numerous stakeholders in health care deserve transparency regarding achievement of the targeted outcomes. To be able to improve their performance, learners need formative, constructive, and specific performance feedback from patients, other health care professionals, peers, and faculty, requiring collaboration with all stakeholders invested in learner development.

 

학습자를 empowerment해야 할 헌신

Commitment to the empowerment of learners.

 

학습자가 다른 것처럼 그들의 교육적 궤적도 모두 다르다. 이 원칙을 적용하기 위해서 우리는 '학습환경'을 '근무환경'까지 확장시켜서 학습자가 궁극적으로 근무할 곳에서 더 많은 시간을 보내게 해야 한다.

The expectation of CBME is that the teacher, the learner, and the learning environment will foster a learner-centered approach that includes individualized learning experiences, feedback, and guided reflection at every step along the career trajectory.30 As all learners differ, so should their educational trajectories. Applying this principle requires that we extend our notion of the learning environment to apply to the workplace, allowing learners to spend more time in the types of settings in which they will ultimately practice.

평가전략과 도구의 효과성과 효율성을 위한 헌신

Commitment to the effectiveness and efficiency of assessment strategies and tools.

다수의 평가자가 필요하다. 첫째, 다양한 이해관계자가 환자 진료에 관여되며 이들은 모두 서로 다양한 관점에서 중요한 기여를 한다. 둘째, 신뢰도를 높이는데는 샘플링이 많아져야 한다.

Multiple assessors are critical for two major reasons. First, many stakeholders are involved with patient care, and they each bring an important and different perspective. Second, reliability is dependent on broad sampling.32

Crossley and Jolly가 말한 바와 같이, 높은 수준의 평가는 '판단'의 문제이고, 이는 '옳은 질문'을 '옳은 방식'으로, '옳은 것'에 대해서, '옳은 사람'이 했을 때 더 가능하다. 즉, 우리의 평가 전략은 우리가 측정할는 construct와 잘 align되어 있어야 한다. 예컨대 팀워크를 평가하기 위해서 우리는 근무지에서의 협력적 행동을 구체적으로 평가할 수 있는 도구가 있어야 한다. construct alignment가 평가자간 일치도를 향상시키고, 저성과자와 고성과자를 구분하는데 도움이 된다는 근거가 있으며, 신뢰도있는 평가를 위해서 필요한 관측의 숫자도 줄여준다.

As Crossley and Jolly33 state, “Because high-level assessment is a matter of judgment, it works better if the right questions are asked, in the right way, about the right things, of the right people.” In other words, our assessment strategies must be closely aligned with the constructs (i.e., the behaviors in health care) we are attempting to measure. For example, if we want to assess teamwork, we need a tool that specifically addresses collaborative behaviors in the workplace.34 There is some evidence that this quality of construct alignment increases rater agreement around learner performance and the ability to discriminate between low and high performers while reducing the number of observations required for reliable learner assessments.35,36

우리가 사용하는 도구는 구조화된 평가 프로그램의 한 부분이 되어야 하며, 그 '효용성'에 의해서 정해져야 한다. van der Vleuten and Schuwirth32이 말한 바와 같이 “multiplicative product of their reliability, validity, cost-effectiveness, feasibility, and educational impact.”을 고려해야 한다.

The tools that we use should be part of a structured program of assessment37 and be guided by their “utility,” which is defined by van der Vleuten and Schuwirth32 as the “multiplicative product of their reliability, validity, cost-effectiveness, feasibility, and educational impact.”

시간이 아니라 역량에 따라서 이행여부가 결정되어야 할 헌신

Commitment to basing transition decisions on competence rather than time.

 

빠르게 학습하는 학습자는 competent 레벨이 아니라 그보다 더 상위 수준의 역량을 가지고 졸업할 수 있다.

Learners who are progressing quickly can be pushed furtheralong the developmental continuum from novice toward expert by the time of their transition from GME to practice.4 Thus, instead of graduating at a level of performance that is considered competent, they may graduate at a performance level of proficient or beyond in certain areas. 

 

근무지 평가, 프로그램 평가, 연구를 통한 CBME 발전을 이룰 헌신

Commitment to advancing CBME through workplace assessment, program evaluation, and research.

학습자를 개개인 수준에서 평가하는 것은 역량-기반 발달에 필수적이다. 그러나 집단의 역량collective competence가 평가의 중요한 단위로 떠오르고 있으며, '팀'에 대한 연구는 앞으로 이어질 연구에서 매우 중요한 영역이다. 따라서 우리는 CBME의 복잡성을 잡아내기 위하여 다양한 렌즈를 통하여 관점을 확장시켜야 한다. 교육 연구는 기존의 교육이론을 기반으로 해야 하며, 새로운 이론의 발달에 기여해야 하고, 무엇이 성공했으며, 무엇이 그러지 못하였고, 왜 그랬는지를 보여주어야 한다. 이에 따르면 이 연구는 가설 검증에만 집중해서는 안되며 어떻게 CBME가 adopted and adapted했는지에 대한 우리의 이해를 정교화시켜주어야 한다.

Assessment of learners at the individual level is critical to their competency-based advancement. However, collective competence is emerging as a critical unit of assessment, and the study of teams is an increasingly important area of continued research.39 Accordingly, we must expand our view, using a range of lenses—including multisite case studies41 and developmental42 and realist evaluation40—to capture the complexity of CBME. Education research must draw from and build on existing theories of education, as well as contribute to the development of new ones, in illuminatingwhat worked, what did not work, and why. 43 Accordingly, this research should not focus solely on hypothesis testing but should also elaborate our understanding of how CBME is adopted and adapted as an educational innovation over time.44 

교수개발에 대한 헌신

Commitment to faculty development.

최근에 졸업한 교수를 빼면, 다른 교수들은 자신이 배우거나 평가받지 않은 역량을 가르치게끔 요구받는다. 더 문제를 복잡하게 만드는 것은 20세기 모델에 뿌리를 둔 교육과 21세기 의사에게 필요한 역량의 격차이다.

Unless faculty are recent graduates themselves, they are being asked to teach about competencies that were not formally taught or assessed during their own training. Compounding the problem is the gap between practices rooted in 20th- century models and the required abilities of 21st-century physicians;

두 층위에서의 헌신이 필요하다.

Our commitment must be twofold:

(1) to provide faculty development in teaching and assessing the competencies required of learners, and

(2) to work with those responsible to transform care systems to models that align with our teaching about best practices.15,45

협력에 대한 헌신

Commitment to collaboration.

This collaboration should encompass all the international communities interested or involved in implementing CBME.

---

Acad Med. 2016 May;91(5):645-9. doi: 10.1097/ACM.0000000000001048.

Advancing Competency-Based Medical Education: A Charter for Clinician-Educators.

Carraccio C1, Englander R, Van Melle E, Ten Cate O, Lockyer J, Chan MK, Frank JR, Snell LS; International Competency-Based Medical EducationCollaborators.

Author information

• 1C. Carraccio is vice president, Competency-Based Assessment, American Board of Pediatrics, Chapel Hill, North Carolina. R. Englander was senior director of competency-based learning and assessment, Association of American Medical Colleges, Washington, DC, at the time this was written. E. Van Melle is education researcher, Queen's University, Kingston, Ontario, Canada, and education scientist, Royal College of Physicians and Surgeons of Canada, Ottawa, Ontario, Canada. O. ten Cate is professor of medical education and director, Center for Research and Development ofEducation, University Medical Center, Utrecht, the Netherlands. J. Lockyer is senior associate dean-education and professor, Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada. M.-K. Chan is associate professor, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada, and clinician educator, CanMEDS & Faculty Development, Royal College of Physicians and Surgeons of Canada, Ottawa, Ontario, Canada. J.R. Frank is director, Specialty Education, Strategy, and Standards, Office of Specialty Education, Royal College of Physicians and Surgeons of Canada, and director of educational research and development, Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada. L.S. Snell is professor of medicine, Centre forMedical Education, McGill University, Montreal, Quebec, Canada, and senior clinician educator, Royal College of Physicians and Surgeons of Canada, Ottawa, Ontario, Canada.

Abstract

The International Competency-Based Medical Education (ICBME) Collaborators have been working since 2009 to promote understanding ofcompetency-based medical education (CBME) and accelerate its uptake worldwide. This article presents a charter, supported by a literature-based rationale, which is meant to provide a shared mental model of CBME that will serve as a path forward in its widespread implementation.At a 2013 summit, the ICBME Collaborators laid the groundwork for this charter. Here, the fundamental principles of CBME and professional responsibilities ofmedical educators in its implementation process are described. The authors outline three fundamental principles: (1) Medical education must be based on the health needs of the populations served; (2) the primary focus of education and training should be the desired outcomes for learners rather than the structure and process of the educational system; and (3) the formation of a physician should be seamless across the continuum ofeducation, training, and practice.Building on these principles, medical educators must demonstrate commitment to teaching, assessing, and role modeling the range of identified competencies. In the clinical setting, they must provide supervision that balances patient safety with the professional development of learners, being transparent with stakeholders about level of supervision needed. They must use effective and efficient assessment strategies and tools for basing transition decisions on competence rather than time in training, empowering learners to be active participants in their learning and assessment. Finally, advancing CBME requires program evaluation and research, faculty development, and a collaborative approach to realize its full potential.

PMID:

 

26675189

 

[PubMed - in process]