의학교육의 변화: CBME가 옳은 접근법인가? (Acad Med, 2016)

의학교육의 변화: CBME가 옳은 접근법인가? (Acad Med, 2016)

Transforming Medical Education: Is Competency-Based Medical Education the Right Approach?

Michael E. Whitcomb, MD

지난 15년간 미국 뿐 아니라 전 세계의 대학의학 커뮤니티의 많은 사람들이 CBME를 지지해왔다. 이 움직임은 1999년 ACGME가 새로운 GME프로그램 개발/시행/평가를 위한 여섯 개의 general competencies를 제안하면서 시작되었다.

During the past 15 years, various individuals within the academic medicine community have advocated for the development of a competency-based approach for reforming medical education in the United States, and around the world. The movement had its formal beginning in 1999 when the Accreditation Council for Graduate Medical Education proposed a set of six general competencies that were to be used in establishing a new framework for designing, conducting, and evaluating graduate medical education programs.1

동시에, 의학교육계의 여러 사람들이 CBME는 ill-conceived하며 의학교육의 질을 저하시킨다고 주장했다.

At the same time, other members of the medical education community have argued that the CBME movement is ill conceived and actually threatens to undermine the quality of medical education.2

이번 호에서 ICBME Collaborators는 헌장charter를 제안하며 "CBME가 널리 도입되고 전세계 의학교육계가 이 여정과 함께할 수 있는 길을 구축하는 데" 도움이 되기를 바란다고 하였다.

In an article appearing in this month’s issue of the journal, a group of International Competency-Based Medical Education (ICBME) Collaborators have proposed a charter that they hope will help them “forge a path toward the goal of widespread implementation of CBME and to invite the worldwide medical education community to travel with [them] on this journey.”3

의학교육에서 CBME란 무엇인가?

What Does This Mean for Medical Education?

우선, 나는 의학교육을 변화시켜야 할 강력한 요구가 존재함에 동의한다.

To begin, I agree that there is a compelling need to transform medical education in this country to better prepare new physicians for the practice of medicine.

의학교육프로그램은 새롭게 양성되는 의사들이 진료를 시작했을 때 임상적 역량을 갖추었을 수 있게 설계되어야 한다고 믿는다. CBME를 도입하는 rationale이 "새롭게 양성되는 의사들이 진료practice에 준비될 수 있게 한다"라는 점은 말이 된다.

I believe that medical education programs should be designed and conducted in ways that aim to ensure that new physicians are clinically competent whenthey enter practice. Thus, the rationale for employing CBME in preparing new doctors for practice makes good sense.

내 관점에서, 의학교육계는 CBME지지자들이 말하는 것, 즉 임상역량의 결정은 졸업이나 수련을 마칠 당시에 한 차례의 총괄평가에만 기반해서는 안 되며, 각각의 역량 영역 - milestone - 에 대한 발전과정을 지속적으로 평가해야 한다는 것, 을 반드시 address해야 한다. 이러한 권고가 특히 문제가 있는 지점은, 각각의 역량을 individually 평가할 수 있다는 확실한 근거가 없다는 데 있다.

From my perspective, the medical education community must address the position advanced by CBME advocates that the determination of clinical competence may not be based solely on a summative assessment of a trainee’s ability to provide high-quality care at the time the trainee completes his/her training, but that indicators of progress in each of the competency domains—the milestones—must be continuously evaluated as the trainee progresses through each stage of the educational process. The approach recommended is particularly problematic because there is no convincing evidence that it is possible to assess each of the competencies individually.4

최소한, 스탶 의사들은 전공의들이 다양한 임상을 로테이션 하면서 수행능력 기준을 만족시키는지 평가하기 위해 더 많은 시간과 노력을 들여야 한다. CBME를 도입하는 과정에서 각 기관들이 해결해야 하는 과제는 어떤 기관들에게는 지나친 부담이 될 수 있다.

At the very least, staff physicians will have to commit more time and effort to assess whether residents have met the performance standards required for each of the milestones while rotating through various clinical services. The challenges that institutions will have to address in responding to the implementation of such a CBME framework may be overwhelming for some institutions.

CBME가 완전히 도입된다고 했을 때 생길 문제도 있다. 실제로 2010년 ICBME Collaborators는 CBME 시스템을 도입하기 위해서 극복되어야 할 "CBME의 일곱개의 주요 위험과 과제"를 제시한 바 있다. 이들은 의학교육계가 이 문제를 슬기롭게 해결하기 위한 노력에 동참해주기를 요청했다. 5년 이상이 지났지만, 여전히 그 문제는 해결되지 않고 있으며, 심지어 ICBME Collaborators는 이번 문헌에서 CBME가 더 나은 의사를 양성한다는 근거가 하직까지 없음을 명확히 밝히고 있다.

The reality that institutions will face a major challenge if a CBME system is fully adopted is well recognized. In fact, in 2010, the ICBME Collaborators presented a list of seven major “potential perils and challenges of CBME” that would have to be overcome to implement a CBME system, and they called on the medical education community to engage in efforts to determine how best to resolve the issues of concern.5 Now, more than five years later, those issues have not been resolved, and even more important, the Collaborators state clearly in their current article that there is currently no proof that the implementation of CBME would produce better doctors.

 

CBME를 지지하는 사람들의 주장의 타당성을 검증하는 것이 규제기구와 전문직기구가 CBME system의 도입을 강제하기 전에 이루어져야 한다. 왜냐하면 이를 위해서 엄청난 자원이 요구사항을 맞추기 위해서 투입될 것이기 때문이다. 그러나 현실에서 CBME시스템 도입을 지지하는 사람들의 입장은 theoretical construct에 머물고 있다.

I believe the claims being made by CBME advocates should be verified before steps are taken by regulatory and professional bodies to mandate the implementation of a CBME system that will require that substantial resources be committed to implement and conduct the system requirements. In reality, the position taken by those advocating for the implementation of a CBME system is so far based solely on a theoretical construct.

CBME가 더 나은 의사를 양성한다는 것을 보여줄 수 있는더 자세한 연구 아젠다가 필요하다.

A detailed research agenda that will provide a clear understanding of the value of CBME in producing better doctors is clearly needed.6

진정한 도전

The Real Challenge

나는 의료의 퀄리티가 낮은 것은 현재 진료중인 의사가 임상역량을 유지하는데 실패해서 생기는 경우가 더 흔하며, 학생이나 전공의가 그들의 교육과 수련을 마칠 때 임상적으로 충분한 역량을 갖추지 못했기 때문이라고 생각하지 않는다. 현재 진료중인 의사들의 의료행태를 모니터링하는 접근법은 매우 부족하다. certification과 relicensure에 필요한 프로세스는 의료의 질에 대한 진정으로 유의미한 그 어떤 척도도 포함하지 않고 있다.

I believe that medical care that is of poor quality is more often caused by practicing physicians who have failed to maintain their clinical competence, rather than by physicians who were not clinically competent when they completed their residency training and entered practice. The fact is that the approaches now in place for monitoring physicians’ practice behaviors are grossly inadequate. The fact is that the processes employed to grant maintenance of certification and relicensure do not include any truly meaningful measures of the quality of care being provided by physicians.7 At

4 Lurie SJ, Mooney CJ, Lyness JM. Commentary: Pitfalls in assessment of competency-based educational objectives. Acad Med. 2011;86:412–414.

5 Frank JR, Snell LS, Cate OT, et al. Competency-based medical education: Theory to practice. Med Teach. 2010;32:638–645.

6 Holmboe ES, Sherbino J, Long DM, Swing SR, Frank JR. The role of assessment in competency-based medical education. Med Teach. 2010;32:676–682.

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Acad Med. 2016 May;91(5):618-20. doi: 10.1097/ACM.0000000000001049.

Transforming Medical Education: Is Competency-Based Medical Education the Right Approach?

Whitcomb ME1.

Author information

• 1M.E. Whitcomb is a medical education consultant, Phoenix, Arizona.

Abstract

There is growing recognition within the medical education community that medical education in this country needs to be changed to better prepare doctors for the challenges they will face in providing their patients high-quality medical care. A competency-based medical education (CBME)approach was endorsed by the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties approximately 15 years ago, and a self-designated group-the International Competency-Based Medical Education (ICBME) Collaborators-is now calling on members of the medical education community to join them in their effort to establish CBME as the approach to be used in transforming medical education, not only in the United States but also around the world.In response to an article in this issue by a group of ICBME Collaborators, the author argues that more evidence about the effectiveness of CBME is needed before a global shift to this approach is undertaken. It is time for major organizations and foundations that are committed to improving medical education to step forward and take the lead in partnering with the medical education community to conduct a critical evaluation of CBME. In addition, maintenance of certification, relicensure, and continuing medical education programs should be evaluated for their effectiveness in ensuring that physicians are clinically competent not only at the beginning of their career but also until the end.

PMID:

 

26675191

 

[PubMed - in process]