플렉스너에서 역량으로: CBME를 향한 여정의 성찰(Acad Med, 2013)
From Flexner to Competencies: Reflections on a Decade and the Journey Ahead
Carol L. Carraccio, MD, and Robert Englander, MD
2002 년 우리와 다른 사람들은 능력 기반의 의학 교육 (CBME)의 역사와 구현에 필요한 단계를 검토 한 "적응 패러다임 : 역량에서 역량으로"라는 제목의 학술 의학 저널을 발표했습니다. 우리는 광범위하게 채택 될 수있는 전환점에 도달하지 못한 과거의 이유에 대해 추측했다.
In 2002, we and others1 published a manuscript in Academic Medicine entitled “Shifting paradigms: From Flexner to competencies” that reviewed the history of competency-based medical education (CBME) and the steps needed for implementation. We speculated on the reasons for past failures to reach the tipping point that would allow widespread adoption.
지난 10 년간의 고찰 : 진보가 항상 쉬운 것은 아닙니다 ...
Reflections on the Past Decade: Progress Is Not Always Easy …
중요한 변화와 마찬가지로 대학원 의학 교육 (ACGME) 및 미국 의학 전문위원회 (ABMS)가 1999 년에 채택한 "ACGME 역량"에 대한 채택에도 큰 저항이 있었다.
As with any important change, great resistance emerged when the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) adopted in 1999 what have become known as “the ACGME competencies.”
... 그러나 우리는 천천히 그리고 꾸준한 진보를 보았습니다.
… But We Have Seen Slow and Steady Progress
반대자들에도 불구하고, 우리는 CBME 운동에서 느리고 꾸준한 진전을 보아왔다. CBME의 가혹한 행진에 기여한 많은 사람들을이 있다.
(1) 도입을 요구하는 규제 기관의 힘
(2) 국제적인 역량 프레임워크의 확장도입
(3) 의사의 책임 성과 진료의 질에 대한 대중의 격렬한 항의
Despite the dissenters, we have seen slow and steady progress in the CBME movement.2 We hypothesize a number of contributors to the relentless march of CBME: (1) the power of regulatory bodies in requiring its implementation, (2) the expanding adoption of the competency framework worldwide, and (3) the outcry from the public about physician accountability and quality of care.
미국에서 CBME를 채택한 배경은 ACGME가 공인 된 모든 레지던트 및 펠로우 교육 프로그램의 역량을 가르치고 평가하기위한 요구 사항을 개발하고 집행 한 것이 었습니다. ACGME의 메시지는 ABMS에 의해 강화되었으며, 각 학회는 역량 프레임 워크를 기반으로하는 구축 된 인증 유지 관리 (MOC) 프로그램에 diplomates를 참여시켜야 했을 뿐만 아니라, 초기 인증을 위해 6 개 영역에서 역량을 문서화해야했습니다.
The sentinel events behind the adoption of CBME in the United States have been the ACGME’s development and enforcement of their requirements for teaching and assessing the competencies for all accredited residency and fellowship training programs. Their message was reinforced by the ABMS, which led to member boards requiring documentation of competence in the six domains for initial certification as well as requiring diplomates to engage in maintenance of certification (MOC) programs built on the competency framework.3
학부 의학 교육 (UME) 수준에서 LCME는 다음을 진술 한 표준 ED-1-A를 채택했습니다.
At the undergraduate medical education (UME) level, the Liaison Committee on Medical Education adopted standard ED-1-A that states:
The objectives of a medical education program must be stated in outcome-based terms that allow assessment of student progress in developing the competencies that the profession and the public expect of a physician.4
However, the shift to CBME in UME has been slow, at least in part because of the absence of standardization of the specific educational outcomes, or competencies, required of the medical school graduate.
International efforts around CBME have also proliferated, helping drive us toward the “tipping point” in the U.S. medical education system. Published frameworks such as the Scottish doctor learning outcomes5 and the CanMEDS roles6 (medical expert, communicator, collaborator, manager, health advocate, scholar, and professional) took hold and continue to evolve. In 2009, the Royal College of Physicians and Surgeons of Canada, led by Jason Frank, MD, convened an international “theory- to-practice consensus conference” to bring thought leaders from around the world together to build consensus regarding definitions and foundational principles of CBME.7
Perhaps the most compelling catalyst for adoption of CBME has been the public indictment of the current health care system and its practitioners. The seminal Institute of Medicine (IOM) publication To Err Is Human—Building a Safer Health Care System9 exposed a vulnerability in patient safety and concern about a breach of the public trust. The resultant focus on the quality of care led the IOM to publish its quality indicators,10 which demand that care be safe, effective, efficient, timely, patient-centered, and equitable. These indicators underscored the gaps in the performance of both individual practitioners and the heath care system.
As a self-regulating profession, the privilege bestowed is matched by the responsibility to address the public needs and the public trust. A hallmark of CBME is that it is driven by the health needs of populations and the health systems that serve those populations.11
현재 의학교육의 상황
Setting the Stage for the Current State of Medical Education
Our prior review of the literature1 on attempts to shift to CBME in the 1970s and 1980s suggested a four-step implementation process: (1) competency identification, (2) determination of competency components and performance levels, (3) competency assessment, and (4) overall evaluation of the process. On the basis of this review, we speculated that the reason for the lack of previous success was the inability to adequately address step 3, competency assessment. Although this has not stopped the rejuvenation of the movement, it remains the major challenge.
The struggle to develop tools to meaningfully assess competencies resulted in a reductionist approach, using behavioral checklists.12 Although checklists serve an important role in determining one’s ability to accomplish steps in task-oriented activities, they fall short of assessing whether a trainee is capable of integrating the requisite behaviors to deliver safe and effective care to patients. This stumbling block has reaffirmed the position of those who believe that CBME is a fad, because assessment has not yielded the large-scale proof that they are demanding—namely, that CBME produces better doctors.
Lessons Learned
10 년 동안 몇 가지 근본적인 교훈이 나타났습니다.
Over the course of the decade, some fundamental lessons have emerged.
(1) 언어 표준화는 중요하지만 아직 완료되지는 않았다.
(2) 학습자에 대한 guided 직접 관찰은 능력을보다 정확하게 평가할 수있는 큰 잠재력을 가지고 있다.
(3) 의미있는 평가를 위해서는 의미있는 척도에 초점을 맞춘 연수생 성과에 대한 panoramic 전망이 필요하다.
(4) 결과는 실제로 교과 과정을 drive한다.
(5) CBME는 학습자의 전문 지식과 숙달에 대한 궤적에 관한 것이며, 성찰은 전문성 개발의 중요한 구성 요소이다.
(6) 우리는 학습에서 학습자의 역할을 표면적으로만 다루었다.
(7) Competent한 개인을 개발하려면 Competent한 시스템에서 훈련해야합니다.
(1) Standardizing language is critical but not yet complete,
(2) guided direct observation of learners has great potential for more accurately assessing competence,
(3) meaningful assessment requires a panoramic view of trainee performance that focuses on meaningful measures,
(4) outcomes really do drive curriculum,
(5) CBME is about learners on a trajectory to expertise and mastery, and reflection is a critical component of the development of expertise,
(6) we have only scratched the surface of exploiting the role of the learner in learning, and
(7) developing competent individuals requires that they train in competent care delivery systems.
언어의 표준화
Standardizing language
Standardization of language is critical to adaptive change.
At the same time that the ACGME was developing the six domains of competence, the Association of American Medical Colleges (AAMC) developed four domains of competence in the Medical School Objectives Project: knowledgeable, skillful, altruistic, and dutiful.13 Although the essences of the two may have been convergent, the divergent language prohibited formation of a shared mental model and may have served to further separate the UME and GME silos, as teachers within those two silos had different images of what they were teaching and assessing.
In addition to the divergence of language around the targeted domains of compe- tence, the education community has struggled with the common definitions of the specific terminology of competence and CBME. Fernandez and colleagues17 found agreement through a search of the literature that competence is composed of “knowledge, skills and other components,” but they were unable to uncover consensus on the components.
We are perhaps closer to a definition of CBME, as Frank et al18 have recommended the following on the basis of an extensive literature search and extraction of themes:
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-centredness.
직접 관찰
Direct observation
The first is that our preconceived notion of what learners are capable of doing may result in a significant gap between expectations and performance. Joorabchi and Devries,19 for example, developed an objective structured clinical examination and worked with faculty members to develop minimum pass levels for residents in each year of training. Their results showed that only 59% of first-year, 45% of second-year, and 4% of third-year residents met the predetermined standard.
- (1) 일반적인 과정 (관찰을 돕기위한 준비, 연습 및 도구)을 개괄하는 행동 관찰 교육,
- (2) 교수진이 평가할 구체적인 행동과 평가 기준을 이해할 수 있도록 성과 차원 교육
- (3) 교수 그룹이 주어진 수준을 구성하는 행동에 대해 의견 일치를 이끄는 기준 프레임 워크 의 성능.
The second point is well articulated by Green and Holmboe,20 who say that “the biggest problem in evaluating competencies is … not the lack of adequate assessment instruments but, rather, the inconsistent use and interpretation of those available by unskilled faculty.” Kogan et al,21 in their qualitative study of the elements that influence faculty ratings of learners, demonstrate the wide variability in expectations and comparison standards. The work of Holmboe22 in direct observation outlines a three-step process to enable faculty to develop a shared mental model of learner performance:
(1) behavioral observation training that outlines the general process (preparation, practice, and tools to aid observation),
(2) performance dimension training to ensure that faculty understand the specific behaviors they are to assess and the criteria for assessing them, and
(3) frame-of-reference training in which a group of faculty come to consensus about what behaviors constitute a given level of performance.
퍼포먼스에 대한 의미있는 척도
Meaningful measures of performance
However, progress toward those meaningful measures remains the Achilles heel of CBME. The complexity of assessing the competencies initially led to the reductionist approach noted above. Educators broke them down into smaller and smaller fragments of behaviors that could be directly observed, and assessed them using a checklist. In trying to make something simple that is inherently complex, our tools allowed us to judge whether learners could perform simple tasks but not whether they were capable of integrating those tasks to care for patients. Van der Vleuten and Schuwirth12 highlight the major pitfall of this approach, saying that “[a] tomisation may lead to trivialization and may threaten validity and, therefore, should be avoided.”
This will require us to accept qualitative as well as quantitative assessments, which compounds concerns about our ability to develop robust tools with acceptable psychometric properties.
Van der Vleuten24 has proposed a “utility model” for judging the value of assessment tools that reaches beyond the traditional psychometric properties. He suggests that the utility of a tool is the product of its reliability, validity, cost, acceptability, and educational impact.
예를 들어, 신뢰성은 도구에 고유한 특성이 아니며, 객관성과 동일하지 않습니다. 실제로 subjective tool도 신뢰성이 높을 수 있습니다 .12 번거롭고 값 비싼 도구가 사용되지 않아 불충분 한 샘플링을 통해 신뢰성에 부정적인 영향을 미칩니다.
For example, reliability is not inherent to a tool, nor does it equate with objectivity; in fact, subjective tools can be reliable.12 Cumbersome and costly tools will not be used and thus negatively influence reliability through insufficient sampling.
Importantly, however, acceptability of a tool has a critical impact on faculty buy-in of workplace-based assessment, particularly as the shift to CBME has expanded the domains of skills to be assessed. Studying the implementation of assessment tools in real-world settings— what works and what doesn’t for the faculty using the tool—thus becomes as critical as demonstrating its reliability and validity.
Finally, we want to underscore the importance of the educational impact to the value of an assessment tool. Tools that may sacrifice a bit on reliability or validity but score high on impact may do more to advance learning. Portfolios have received much criticism because of the difficulty of reliably assessing them. There are ways to address the concerns, however, and one could argue that what is lost in reliability is gained in the educational impact of actively engaging learners in their learning and assessment.26,27 In the words of Friedman Ben-David,28 “The assessment exercise [itself] becomes the teachable moment.”
요약하면, CBME에서의 평가에 대한 도전은 현실이지만, 우리는
(1) 자주 샘플링하여 신뢰성 향상,
(2) 일상 업무에 대한 평가를 구축하고 구현의 문제를 연구함으로써 비용을 줄이고 수용 가능성을 높이는 것,
(3) 평가를 실제 임상 환경으로 가져 와서 측정 한 것을 실제로 하는 것과 일치시킴으로써 타당성을 높인다.
(4) 평가를 학습자와 평가자를 위한 "팀 스포츠"로 만들어 impact를 높인다.
In summary, the challenges to assessment in CBME are real, but we can address them by
(1) improving reliability through frequent sampling,
(2) reducing cost and increasing acceptability by building assessment into our daily work and studying the issues in implementation,
(3) providing validity by bringing those assessments to the authentic clinical environment and aligning what we measure with what we do, and
(4) adding impact by making assessment a “team sport” for learners and their evaluators.
예를 들어 스마트 폰 응용 프로그램을 사용하는 호스피탈리스트가 학습자의 평가를 담당하는 교수팀은 물론 학습자 성과를 실시간으로 직접 평가할 수 있다고 상상해보십시오.
Imagine, for example, a hospitalist with a smartphone application that allows direct and real-time assessment of learner performance that is electronically delivered to that learner as well as to the team of faculty responsible for that learner’s assessment in real time.
성과가 교육과정을 유도한다.
Outcomes drive curriculum
지난 10 년 동안 커리큘럼을 주도할 성과를 정의하는 것이 중요하다는 사실이 강조되었습니다. 한 예로 UME 및 GME 수준에서의 품질 및 안전 교육 과정에서의 역량의 결과로서의 PBLI의 묘사와 MCC에 제 2 부 및 제 4 부의 추가가있다.
The past decade has underscored the importance of defining the outcomes that should drive curriculum. One example is the delineation of PBLI as a domain of competence and the resultant explosion in quality and safety curricula at the UME and GME levels and the addition of Parts 2 and 4 to MOC.3
전문성의 궁극의 목표이며, 성찰적 실천이 필요하다.
Expertise is the ultimate goal of CBME and requires reflective practice
역설적으로 CBME의 목표는 반드시 "역량"그 자체가 아니라 전문 지식이나 숙달에 대한 궤적에 대한 지속적인 추구이며, 역량은 일정 수준의 경험에 대한 기대되는 성과로 정의됩니다.
Paradoxically, the goal of CBME is not necessarily “competence” per se but, rather, the continual pursuit on a trajectory toward expertise or mastery, with competence defined as demonstrating the expected performance for a given level of experience.
개선을 위한 학습에 대한 지속적인 투자는 Epstein31에서 "주의 깊은 연습"으로, Ericsson32는 "고의적 인 연습"으로 설명되었습니다. Reflect in action과 Reflect on action이 없으면 "경험만 갖춘 비 전문가"가 될 것이다. 사람은 자신이 하는 일의 결과에 대한 지속적인 분석을 통해서만 진정한 전문가가 될 수 있습니다.
The continual investment in learning for the sake of improvement has been described by Epstein31 as “mindful practice” and Ericsson32 as “deliberate practice.” If one does not engage in reflection for, in, and on practice, one will become what Bereiter and Scardemalia33 describe as an “experienced non-expert.” Only through continuous analysis of what one does and what happens as a result of the doing can one become a true expert.
학습에서 학습자의 역할을 강조
Exploiting the role of learners in learning
(학습자가) 학습에 능동적으로 참여하는 것은 CBME의 기본 원칙입니다.
Active engagement in learning is a foundational principle of CBME.1
자기 주도 학습의 구성은 교육의 패러다임으로 많은 관심과 논쟁을 불러 일으켰다. 학생이 자기주도적이 될 수 있는지에 대한 많은 논쟁은 (자기주도성의) 기본 요소인 외부 입력에 대한 Knowles의 요구를 무시하고 원래 정의를 좁게 해석한 결과입니다. 외부 입력이 없다면 자신의 학습을 지도 할 수 있는 능력은, 사람이 정확하게 자기 평가를 할 수 있는 능력에 결함이 있는 것과 마찬가지로, 형편 없다.
The construct of self-directed learning has received much attention and debate as the paradigm of education shifts. Much of the debate about whether one can be self-directed results from a narrow interpretation of Knowles’38 original definition, ignoring his call for external input as a fundamental element. Without external input, our capability to direct our own learning is poor as a result of our flawed ability to accurately self-assess.39
학습 이론 자체를 검토하는 것이 우리의 범위를 넘어서는 것이지만, 자기결정이론은 CBME와의 관련성 때문에 간략한 언급을해야합니다. 이 이론은 능력, 자율성, 관련성에 대한 타고난 필요가 학습 욕구를 몰고 간다는 것을 말해줍니다 .35,41이 소망은 교수진과 학습 환경에 의해 점화되거나 좌절 될 수 있습니다. 우리는 배움의 욕구를 불어 넣어 능력, 자율성 및 관련성에 대한 타고난 필요성을 각각
(1) 능력: 학습 역량을 장려하고 역량을 향상시키는 형성적인 피드백을 제공하기 위하여 (간단한 것에서 복잡한 것으로) 학습 활동을 배열하는 것
(2) 자율성: 학습자의 능력의 정도에 따라 감독의 정도를 조정하고, 안전한 치료 보장과 학습자의 전문성 개발 장려라는 이중 역할을 수행하며,
(3) 관련성: 학습자와 환자, 교수 및 전문 직업인 간의 관계 구축.
Although it is beyond our scope to review learning theories per se, self- determination theory warrants brief mention because of its relevance to CBME. This theory speaks to the innate need for competence, autonomy, and relatedness as driving the desire to learn.35,41 This desire can be kindled or thwarted by faculty and the learning environment. We kindle the desire to learn, addressing the innate need for competence, autonomy, and relatedness, respectively, by
(1) sequencing learning activities (simple to complex) to encourage learning capacity and then providing formative feedback that enhances competence,
(2) adjusting the degree of supervision to align with the degree of learner competence, serving the dual role of ensuring safe care and encouraging learners’ professional development, and
(3) building relationships between learners and their patients, faculty, and interprofessional team members.
사람이 가진 관련성에 대한 내재적 요구는 두 번 강조해도 지나치지 않다. 최근의 증거는 전문직 정체성 형성시에 피드백을 받아들이고 통합하는 것이 giver에 대한 receiver의 인식에 달려 있음을 시사한다. 42,43 이는 의대생의 임상실습과 레지던트 교육 프로그램의 전형적인 블록 구조로 인한 관계 분열에 의문을 제기한다. 장기간의 경험을 제공하는 훈련 모델은 학생들이 교수진과 환자들과 1 년의 의미있는 관계를 가질 때 의과 대학 3 학년 동안 발생하는 전형적인 전문직업성의 침식erosion of professionalism이 현저히 감소됨을 보여줍니다.
The innate need for relatedness cannot be overemphasized. Recent evidence suggests that acceptance and incorporation of feedback are dependent on the receiver’s perceptions of the giver’s investment in their professional formation,42,43 calling into question the fragmentation of relationships resulting from the typical block structure of medical school clerkships and residency training programs.44 Training models that provide longitudinal experiences have demonstrated that the typical erosion in professionalism that occurs during the third year of medical school is significantly reduced when students have yearlong meaningful relationships with faculty and patients.45
유능한 시스템이 유능한 의사의 전제조건이다.
Competent systems are a prerequisite for training competent practitioners
ACGME 역량은 context-independent하지만, 역량 기반 교육의 프레임 워크는 교육을받는 임상 마이크로 시스템의 중요성을 포함하여 context의 역할을 강조합니다. Asch 등은 1992 년과 2007 년 사이에 New York과 Florida에서 4,906,169 건의 배달을 후 향적으로 분석했다. 107 건의 미국 교육 프로그램을 대표하는 총 4,124 명의 산과 전문의가 배달을 수행했다. 모성 합병증에 대한 9 가지 측정법을 사용하여, 주요 모성 합병증에 있어서, 하위 20% 프로그램에서 수련을 받은 산과 전문의의 합병증 비율이 상위 20% 프로그램에서 수련을 받은 전문의보다 높다는 것을 발견했습니다.
Although the ACGME competencies are context-independent, the framework of competency-based education underscores the critical role that context plays, including the importance of the clinical microsystem in which one trains. In a seminal study, Asch et al46 retrospectively analyzed the 4,906,169 deliveries in New York and Florida between the years 1992 and 2007. A total of 4,124 obstetricians, representing 107 U.S. training programs, performed the deliveries. Using nine measures of maternal complications, they found that obstetricians from training programs that were in the bottom quintile for risk-standardized major maternal complications had an adjusted complication rate that was one-third higher than those from programs in the top quintile.
이 연구의 결과는 수련을 받는 임상 환경의 "능력"이 연수생의 능력에 영향을 미치고 전문직 형성의 중요한 단계에서 각인에 비유 될 수 있음을 분명히 보여줍니다. Asch와 동료들의 연구는 부적절한 임상 환경이 가장 유능한 역량 기반 교육 시스템에서도 연수생의 전문성 개발을 저해 할 수 있음을 시사합니다.
The outcome of this work clearly demonstrates that the “competence” of the clinical environment in which one trains affects the competence of the trainee and can be likened to imprinting during a critical phase of professional formation. Asch and colleagues’ work suggests that an inadequate clinical environment can thwart the professional development of its trainees even in the most well-fashioned competency-based education systems.
최근의 발전: 마일스톤과 EPA
Recent Advances: The Milestone Project and Entrustable Professional Activities
2009 년 ACGME는 마일스톤 프로젝트를 시작하기 위해 ABMS 회원위원회와 다시 협조했습니다 .47 모든 전문 분야는 2013 년 7 월부터 단계적으로 시작된 "차기 인증 시스템"의 출현으로 연수생의 마일스톤 평가를 시작해야합니다 .48
In 2009, the ACGME again partnered with member boards of the ABMS in initiating the Milestone Project47 All specialties will be required to begin assessing milestones of trainees with the advent of “the next accreditation system,” which began its phase-in effective July 2013.48
우리는 ACGME 도메인 내의 각 역량에 대한 일련의 이정표를 만들었습니다. 최종 제품은 특정 역량을 위해 의학 실습생을 통해 의대생 진입 발달 연속체 전반에 걸친 각 성과 수준 또는 중요 시점에서의 행동을 설명하는 일련의 간략한 서술입니다. 이정표의 가치는
(1) 교수 및 학습자에게 이해할 수 있는 관찰 가능한 행동 측면에서 역량에 대한 설명,
(2) 그들이 훈련생에게 제공하는 학습 로드맵
(3) 형성 피드백과 평가를위한 토대를 만드는 구체적인 내용.
We created a series of milestones for each competency within the ACGME domains, The end product is a series of brief narratives describing behaviors at each performance level or milestone, across the developmental continuum from entering medical student through expert practitioner, for a given competency.49 The value of milestones is related to
(1) the descriptions of the competencies in terms of observable behaviors that make sense to faculty and learners,
(2) the learning road map they provide to trainees, and
(3) the specific content that creates a foundation for formative feedback and assessment.
그러나 마일스톤은 도메인 간 역량의 통합을 다루지 않는다. 아마도 Regehr가 가장 잘 묘사했다.
What the milestones do not address is the integration of competencies across domains, which is requisite for unsupervised care delivery, Perhaps Regehr et al50 state the challenge best:
... 평가 개선에 대한 해결책은 교수진이 관찰하고 문서화하거나 기존 도구 및 척도를 사소하게 수정하는 것이 아닙니다. 오히려 ... 임상 수행능력 측정법을 개선하려면 우리가 사용하고 있는 도구의 구조를 근본적으로 다시 생각해야 하며, 교수가 일상적으로 레지던트의 임상적 능력을 기능적으로 개념화하는 방식을 확실하게 나타낼 수 있도록하는 데 더 많은 이익을 줄 수 있습니다 기초. 현재 필요한 것은 교수진의 주관적 표현이 레지던트의 성과에 대해 어떤 형태의 문서로 원활하게 변환 될 수있게하는 방법의 개발입니다.
… the solution to improving evaluations may not lie in training faculty to observe and document better or to make minor modifications to existing tools and scales. Rather … efforts at improving clinical performance measures might more profitably focus on fundamentally rethinking the structure of the tools we are using, to ensure that the instruments authentically represent the way in which faculty functionally conceptualize their residents’ clinical competence on a day-to-day basis. What is needed now is the development of methods that will allow faculty members’ subjective representations of their residents’ performance to be smoothly translated into some form of documentation.
마일스톤의 사용은 전문가의 판단을 알리기 위해 성능의 공유 정신 모델에 대한 scaffolding을 제공합니다. 마찬가지로, 마일스톤을 의미있는 클러스터에 넣고 임상 적 맥락에 포함시킬 때만, 신뢰할 수있는 전문 활동 (EPA)에서 가능한 것처럼, 53 학습자 평가에 대한 holistic한 관점을 제공 할 수 있다.
the use of milestones provides the scaffolding for a shared mental model of performance to inform expert judgment. Similarly, only when the milestones are put into meaningful clusters and embedded in a clinical context, as is possible with entrustable professional activities (EPAs),53 can they provide a holistic perspective on learner assessment.
Cate와 Scheele에 의해 소개 된 EPAs는 학습자의 holistic 평가에서 임상적 맥락의 중요성을 다루는 하나의 잠재적 인 해결책을 제공한다. EPA는 직업을 정의하고 임상 적 맥락에서 상황에 독립적 인 역량과 이정표를 삽입하는 일상적인 작업 단위이다. 소아과에서의 EPA의 예는 "신생아를 돌보는"일 것이다. 이 경우 위임은 감독없이 효과적인 관행으로 정의됩니다. 표 1에 제시된 바와 같이 일단 매핑이 완료되면 역량 (행으로 표시)과 EPA (열로 표시)를 나란히 배치하여 매트릭스를 작성하면 학습자에 대한 의미있는 평가에 대한 우리의 생각을 향상시키는 데 도움이됩니다.
EPAs, introduced by ten Cate and Scheele,53 provide one potential solution to addressing the importance of clinical context to a holistic assessment of learners. EPAs are the routine units of work that define a profession and thus embed the context-independent competencies and their milestones in a clinical context.53,54 An example EPA in pediatrics would be “care for the well newborn,” which would require an integration of competencies across the ACGME domains.54,55 In this case, entrustment is defined as effective practice without supervision. As presented in Table 1, once mapping is completed, creating a matrix by juxtaposing the competencies (represented by the rows) and the EPAs (represented by the columns) helps to advance our thinking about meaningful assessment of learners.
EPA는 도메인 간 역량을 통합하여 치료를 제공함으로써 학습 목표를 정교하게 평가할 수 있도록 학습자에 대한 전체적인 시각을 제공합니다. 역량 기반 평가에는 두 가지 관점에서 학습자를 보는 것이 중요합니다. 우리는 학습자가 지속적으로 향상 될 수 있도록 통합 된 성과 (EPA)와 성과 곤란의 근본 원인 (역량 및 해당 이정표)을 진단 할 수 있어야합니다.
The EPAs provide a holistic view of learners as they integrate competencies across domains to deliver care and thus complement the granular lens of milestones assessment. Seeing a learner from both vantage points is critical to competency-based assessment. We must be able to both see integrated performance (the EPA) and diagnose the underlying root cause of performance difficulties (the competencies and their respective milestones) to help our learners continually improve.
지평
The Horizon
CBME가 널리 퍼져서 보급되면 무엇이 다를 것인가?
What is and will be different this time in the widespread adoption of CBME?
CBME가 널리 보급 될 가능성을 높이기 위해 여러 가지 요인들이 작용합니다.
첫째, 인정 기관과 인증 기관, 혁신가와 얼리 어답터 인 지도자, 건강 관리의 개선 된 품질에 대한 대중의 요구가 이미 CBME의 20 세기 진보를 넘어 우리를 회귀 시켰습니다.
둘째, 우리는 역량 및 CBME가 GME를 넘어 UME 및 MOC 분야로 확산되고 있음을 널리 알 수 있습니다.
a number of factors serve to improve the likelihood that CBME is on the verge of widespread adoption. First, regulators from accrediting and certifying bodies, leaders that are innovators and early adopters, and public demand for improved quality in health care have already led us far beyond the 20th-century advances in CBME and will not allow us to regress. Second, we are seeing the widespread support of the competencies and CBME spreading beyond GME to the UME and MOC arenas.
우리는 전통적인 사일로를 무너 뜨리기 시작하여 커리큘럼을 전달할 때 효능과 효율성을 모두 해결할 수있었습니다.
셋째, 의사의 바람직한 성과에 대한 더 나은 합의를 통해 GME, UME 및 대학 수준에서 학습자가 원하는 역량을보다 잘 묘사 할 수있는 역방향 비전 프로세스를 시작했습니다.
We have begun to break down the traditional silos, allowing us to address both efficacy and efficiency in delivering curricula. Third, through better agreement on the desired outcomes of the practicing physician, we have begun a process of backwards visioning to better delineate the desired competencies of the learner at the GME, UME, and even college levels.
성공적인 CBME는 어떤 모습일까?
What will successful adoption of CBME look like?
First, we will have standardized the language and the desired outcomes so that we share a clear mental model of the trajectory to becoming the “expert” physician. Training will occur in competent institutions that have high-quality outcomes and the capacity to train competent learners who will continually work to improve the care they deliver to patients. Focused on the desired outcomes of the practicing physician, we will backwards-vision the most effective and efficient path for curriculum and equip ourselves with the evidence-based learning strategies that are emerging to take us where we need to go, each step along the educational trajectory building on the previous one. We will travel with our learners as part of an interprofessional team, with all team members being responsible and accountable for their learning. We will have built in “rest stops” along the way for assessment and guided reflection that will take us all toward expertise and mastery. The assessment tools that we use will embrace the complexity of care delivery and focus on what is meaningful and not just what is easily measurable. These tools will be useful by van der Vleuten’s24 standards, some qualitative and some quantitative, most targeted for formative assessment. The journey will be long so that we will have ample time to directly observe learners. From early in the process, learners will develop relationships with patients, mentors, and health care team members. These relationships will help to thwart the typical erosion of professionalism and personal accountability that occurs when there is no sense of belonging. Everyone will walk this journey at their own pace, some arriving sooner than others. We have to be prepared for and take advantage of this variation among learners, and model how to help them help their colleagues along the way who may be struggling.
이 여정의 mantra는 "환자에게 더 나은 치료를 제공하기 위해 의학 교육을 어떻게 개선 할 것인가?"입니다. 이것이 우리가 묻고 답하는 책임이있는 근본적인 질문이다.
The mantra for the journey will be “How do we improve medical education to provide better care to patients?” This is the fundamental question that we are responsible for asking and answering.
From Flexner to competencies: reflections on a decade and the journey ahead.
Author information
- 1
- American Board of Pediatrics, Chapel Hill, North Carolina 27514, USA. ccarraccio@abpeds.org
Abstract
- PMID:
- 23807096
- DOI:
- 10.1097/ACM.0b013e318299396f
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