hen I compare my days at Harvard Medical School more than 50 years ago to the experience of medical students today, I’m struck by the tremendous change that has taken place. Today’s students are learning about health care costs and how to work in teams. They are moving away from hospital settings and training in community centers and even in patients’ homes. And they are learning in small groups, viewing their teachers more as coaches than as all-knowing authorities. One thing has remained the same: We still determine the length of education and training by predetermined times. That needs to change.
What we need is a new model of education in which students advance when they master required competencies, not because they’ve passed an exam after a set period of time. This lets students learn at their own pace. For some, that may mean completing medical school in three years. For others it may mean taking longer, giving them more time to spend with family, to pursue research or other extracurricular interests, or earn money — without the stigma currently attached to failing to finish medical school “on time.”
A competency-based, time-variable approach gives faculty members the opportunity to tailor education to the needs of the students and lets students use more or less time in different educational experiences as they achieve predetermined competencies. Viewing time as a variable, rather than as a fixed endpoint, will allow some students to move more quickly from one stage of their education to another, say from medical school to residency, and will allow all students to use their educational time in optimal ways to meet their needs and prepare them for specific career pathways.
A variable-time approach will also begin to blur the artificial distinction we have created between various stages of education, creating smoother transitions to the ultimate goal of creating highly competent independent practitioners.
A number of pilot programs are demonstrating the feasibility and effectiveness of this approach. The Education in Pediatrics Across the Continuum program at the UCSF, Minnesota, Colorado, and Utah medical schools, has tested a competency-based approach for medical students to move into residencies in pediatrics in a time-variable way. The students report that they are much more involved in their own learning and that they actively seek (rather than avoid) constructive feedback. The residency program directors are involved in student education and evaluation much earlier in their journey, making the transitions seamless.
The University of Wisconsin School of Nursing has developed a “Flexible Option” for working nurses with associate degrees to earn bachelors’ degrees in a time-variable, competency-based fashion. This has high learner satisfaction with excellent outcomes — a pathway to increase the number of more highly trained nurses, something the U.S. desperately needs.
Many barriers prevent the expansion of these and other successful pilots into a generalized approach to the education of health professionals. Accrediting bodies will need to be more flexible, and fortunately that is happening. The Liaison Committee on Medical Education, which accredits medical schools, has approved a number of alternative pathways to the medical degree. The Accreditation Council for Graduate Medical Education, which accredits medical residencies, has adopted a competency-based approach with its new accrediting system.
But schools and residency programs have been slow to take advantage of greater flexibility because it requires major changes in scheduling, assessment, and the role of faculty members. The enormous changes going on in the health care delivery system should help to stimulate these changes, but it can also serve as a distraction.
To accelerate a more rapid transition to a competency-based, time-variable education system, the organization that I head, the Josiah Macy Jr. Foundation — the only national foundation solely dedicated to improving health professions education — recently convened leaders in the education and accreditation of health professionals, as well as experts in educational theory and reform, to map a path forward.
In a recently released report, the group outlined strategies in five areas that must be adopted to advance competency-based education for health professionals:
- Systematically redesign curricula, learning environments, and faculty development
- Create a continuum of education, training, and practice that enables learners to seamlessly move from one phase of learning to the next as they master required competencies
- Establish a robust program of assessment that explicitly links a set of competencies to each stage of a health care professional’s education, training, and career
- Leverage new and existing technology to support more complex administrative processes, such as tracking students’ accomplishments, and facilitate new instructional needs, such as continuous learning and just-in-time assessment and feedback
- Develop a rigorous evaluation model that measures the effectiveness of competency-based, time-variable programs for educating health professionals based on outcomes that are important to society, such as improved patient care and improved practitioner performance and satisfaction
A transformation to a competency-based, time-variable education program will take time and won’t be easy. But it’s time to stop tinkering at the edges. We and our patients don’t have another 50 years to wait.
George E. Thibault, M.D., is president of the Josiah Macy Jr. Foundation.