Medical education has recently undergone a transformation from process-oriented measures of success to more outcomes-oriented assessments that gauge what a learner can actually do and not only to what they have been exposed. Although the notion of competencies is not new, more recent conceptualizations move far beyond simple listings of skills and include multidimensional, dynamic, contextual, and developmental elements. This movement has been particularly transformative in the realm of graduate medical education (GME) with the advent of the Accreditation Council for Graduate Medical Education (ACGME) competencies and has become increasingly common as medical schools begin to embrace competency-based medical education (CBME) and translate the GME competencies for medical students “further upstream.” Learning objectives and related competencies are now more frequently articulated and tend to be more commonly linked to specific assessment tools that measure achievement of that specific competency. However, the practice of medicine is inherently complex and often requires subtle, nuanced skills that are both difficult to teach and challenging to quantify. In particular, competencies that fall within the realm of the Behavioral and Social Sciences (BSS) have proven particularly difficult to articulate, teach, and assess.

This chapter will first provide a brief overview of CBME that articulates common advantages and limitations of this approach. We then offer an update on the status of BSS curricular thinking within medical education, including the recent work of the Association of American Medical Colleges (AAMC) BSS Expert Panel, the BSS Curriculum Consortium (funded by National Institutes of Health [NIH]), and the behavioral science subcommittee of the MCAT 5th Revision (MR5) Committee (charged with creating the 5th version of the Medical College Admissions Test). This chapter presents a careful melding of the concepts and processes of CBME with the content of BSS by offering a synthesis of the innovative work emerging on both undergraduate medical education (UME) and GME levels. Specific assessment methods and evaluation tools for BSS competencies are described in Chapter 43.

Pedagogical Building Blocks for CBME

The Royal College of Physicians and Surgeons of Canada define competency-based education and training (CBET) as “an outcomes-based approach to the design, implementation, assessment and evaluation of an education program using an organizing framework of competencies.” CBET and CBME are intended to focus on outcomes, emphasize abilities, de-emphasize time-based training, and promote greater learner-centeredness. Epstein defines professional competence as “the habitual and judicious use of knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served”. More simply, Ten Cate defines competence as “the threshold level in the development of expertise that permits unsupervised practice”.

A number of classical pedagogical and learning theories have helped medical education move from an expert-centric, apprenticeship model to a more evolved, evidence-based approach emphasizing adult learning and professional development. Medicine is perhaps unique in the number of disciplines, the quantity of knowledge, and the integrative capacity required to achieve even minimal competence. Miller’s Pyramid offers a useful rubric in considering the progression of skill acquisition moving from Knows to Knows How to Shows How to Does in a passing resemblance to the classic See One, Do One, Teach One. Dreyfus and Dreyfus present a continuum ranging from novice at one end, then progressing to advanced, competent, proficient, and expert. It is notable that in the Dreyfus model “competent” does not lie at the end of the continuum but precedes proficient and expert implying that competence is a stage, an important benchmark, on the way to becoming an expert.

In each of these important models and definitions it is clear that competence is thought to progress in a developmental fashion in response to direct (and indirect) intervention from the educational system and the learning environment. Recognizing this developmental aspect to competence, an international group developed a set of definitions to help clarify the confusion often engendered by the terms competencies, competence, and competent. Competencies are best viewed as “abilities.” Competence and competent represent states of being that can be further subdivided into three categories:

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  Competent: Possessing the required abilities in all domains at a specified stage of medical education or practice.

  
  
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  Dyscompetent: Relatively lacking in one or more domains of required abilities at a specified stage of medical education or practice.

  
  
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  Incompetent: Lacking the required abilities in all domains in a certain context at a defined state of medical education or practice.

Competence is acquired by the learner and not necessarily imparted by the faculty. Peers, patients, allied health professionals, the learner himself or herself, and others may be considered teachers capable of assisting a learner in acquiring competence. Once competent, learning and growth continue well into the professional years and perhaps for the rest of one’s career. Competence is multidimensional and includes knowledge, procedural skills, metacognition, emotional management, social relationships, and communication. To best grasp how such breadth can be meaningfully captured and assessed to assist the faculty and learner in our opening vignette, it is helpful to review the history and evolution of CBME.

History of CBET and CBME

Competency-based medical education is not a new concept and represents an amalgam of educational theories, with origins in the work of Thorndike and Dewey. The earliest conception of competency-based training actually arose in the United States during the 1920s as educational reform became linked to industrial and business models of work that centered on clear specification of outcomes. However, the more recent conception of CBME had much of its genesis in the teacher education reform movement of the 1960s. This interest was spurred by a US Office of Education National Center for Education research grant program in 1968 to 10 universities to develop and implement new teacher training models that focused on student achievement (outcomes). Elam laid down a series of principles and characteristics of CBET in 1971 (see Table 41-1). In 2002, Carraccio and colleagues noted that some sectors in medical education explored competency-based models in the 1970s, but except for one study, no comparisons between competency-based and the traditional structure/process-based curricula were undertaken. The World Health Organization (WHO) commissioned a paper published in 1978 that strongly recommended the adoption of competency-based educational models for medical education, noting, “The intended output of a competency-based programme is a health professional who can practise medicine at a defined level of proficiency, in accord with local conditions, to meet local needs.”

In the few studies within medical fields that have investigated competency-based models, there appear to be some benefits to trainees in the CBET model. For example, Johns Hopkins has employed competency-based approaches in its neurosurgery program, with success in accelerating competency in specific surgeries.

In 2002, the ACGME Outcome Project changed the accreditation focus from a program’s process and structure (e.g., rotations, written curricula) to actual learner/program outcomes. Programs had to objectively document that their residents achieved competence in six general dimensions of practice—Medical Knowledge, Patient Care, Communication and Interpersonal Skills, Professionalism, Practice-Based Learning and Improvement, and Systems-Based Practice. In phase 1 of the Outcome Project, programs defined objectives to demonstrate learning in the competencies. In phase 2, they integrated the competencies into their curricula and expanded their evaluation systems to assess actual performance. In phase 3, programs are required to use aggregate performance data for curriculum reform—that is, examine important linkages between quality of patient care and education in the competencies. Phase 4 began in July 2011 and focuses on identification of benchmark programs and dissemination/adoption of emerging models of educational excellence. Each of the ACGME competencies are listed in Table 41-2 and paired with recommended assessment tools. Given the broad nature of these competencies, a substantial burden was placed on programs to define objectives and develop curricula.

In addition to the ACGME, a number of international competency frameworks have been developed to guide UME and GME curricula and assessment. Each provides a useful contrast to the ACGME approach, but like ACGME, is not specific to the social and behavioral sciences. Table 41-3 provides a side-by-side comparison of these different competency frameworks. Competencies have been grouped by their approximate equivalence to the ACGME categories.