Dr. Janice Chisholm, former program director of Dalhousie Medical School’s anesthesia residency training program, has stepped into the new role of CBME (competency based medical education) lead. In this capacity, Dr. Chisholm will oversee and facilitate the transition of the medical school’s specialty residency training programs to a CBME model known as Competence By Design, developed by the Royal College of Physicians and Surgeons of Canada. 

Dr. Chisholm has first-hand experience with CBME, having led a Royal College-sanctioned demonstration project in Dalhousie’s Department of Anesthesia, Pain Management & Perioperative Medicine known as FIRE (Fundamental Innovations in Resident Education). She is an associate professor in this department as well as the Department of Critical Care, with a strong interest and track record in medical education. She has won numerous teaching awards, including the 2017 Faculty of Medicine Excellence in Education Award, the 2016 Program Director of the Year Award for Innovation, 2013 Resident Mentor of the Year, and Critical Care Educator of the Year in 2010 and 2007.

Dr. Chisholm feels strongly that CBME will provide residents with more personalized outcome-driven training that will ultimately improve the quality of patient care.   

Q. What are the advantages of CBME over traditional residency training programs?

A. CBME offers several distinct advantages. Unlike traditional residency training programs, which are based on the amount of time spent in the learning environment, CBME is based on the demonstration of competency. The required competencies, or learning outcomes, are clearly defined at the outset of each program, in a stage-by-stage progression from novice to professional levels of competency. This clarity ensures learners and teachers know exactly what’s expected of them and empowers residents to stay on top of their learning in a proactive way. 

At the same time, CBME residents receive frequent—even daily—feedback on their performance through low-stakes evaluations. This allows them to correct course and improve proficiency faster than they can in traditional programs, which provide less frequent feedback. If there are certain skills they’ve gained faster, they can “check the box” and re-focus their attention on areas they find more challenging. This is a lot more flexible than traditional programs. 

Another advantage is that the decision to promote residents from one stage to the next in CBME is made by a competence committee rather than an individual supervisor. This makes the process more transparent and less prone to bias. As an added benefit, CBME casts supervisors in the role of coach more so than evaluator. We believe this will foster a more open learning environment where ongoing feedback and continuous improvement are the norm.

Q. What is Competence by Design and what is its advantage compared to other CBME approaches? 

A. CBME is a generic term, while CBD (Competence by Design) is the specific initiative the Royal College of Physicians and Surgeons of Canada’s is rolling out to implement CBME in all of Canada’s specialty residency training programs. 

The main difference between CBD and most other countries’ CBME programs is that, in Canada, we require residents to demonstrate proficiency in a pre-defined set of tasks, called “entrustable professional activities,” or EPAs, at each of four stages of their training. They can’t progress to the next stage until they’ve mastered these skills. Other countries are not looking for all of the EPAs to be demonstrated until the end of their training program. The Canadian approach breaks the tasks of the job down into what we feel are more manageable pieces and guarantees that residents have truly mastered everything they need to know at each stage. This ensures they have all the foundational skills in place before moving on to more complex tasks.

Q. You led a demonstration program called FIRE when you were residency program director in the Department of Anesthesia. What are the most important lessons learned from the FIRE experience? 

A. We learned that there’s no limit to how much education you can provide to your faculty members, and your residents, about this approach to residency training. It requires shifts in thinking as well as new daily habits—and we all know that habits and thought patterns are often very entrenched and can be difficult to change. It’s an iterative process, as well—we received a lot of feedback from faculty and residents as we rolled out our CBME model through FIRE and went through several rounds of adjustments to come up with a system that worked really well. I should add that this process is far from complete—the program is continuing to evolve as it implements and adapts to the CBD model.

Q. What is your advice to Dalhousie’s specialty programs as they prepare to adopt CBD?

A. Start early. That is the Number One most important thing to do. Get the faculty development ball rolling at your earliest possible opportunity and keep it going from there. 

It also helps to recognize that every step of your rollout and every aspect of your CBD program does not have to be perfect. Start from where you are and assess the strengths and weaknesses of your program. If your program is already really strong overall, you don’t need to change everything—strategic adjustments may be all you need. 

In terms of rolling out your program, focus on your approach to generating and tracking good quality feedback for your residents. Keep in mind that “tick box” forms provide only limited guidance—narrative feedback is essential to inform residents of specific weaknesses and ways they can address them, and also to highlight strengths they can build upon. 

Q. What is your role as CBME lead?

A. As CBME lead, I’m essentially a consultant and facilitator. My role is to work with programs and program directors to make sure they have all the tools, information and support they need to prepare for and implement CBD. I also need to ensure they are well-versed in the guiding principles of CBD assessment. 

Q. What are the guiding principles of assessment in Competence By Design? 

A. There are six principles programs must embed in their CBD assessment protocols. First, residents must demonstrate competence in the tasks of their discipline—the EPAs I mentioned before. (I should note that, for every EPA, there is a series of milestones that marks residents’ progression on the way to the EPA. And, in addition to discipline-specific competencies, the residents must demonstrate the CanMEDS competencies of medical expert, communicator, collaborator, professional, advocate, scholar, and leader). 

The other guiding principles are: an increased emphasis on direct and indirect observation of residents’ performance; frequent low-stakes feedback; timely, actionable and concrete narrative feedback; group decisions on residents’ progress; and progression of increasing entrustment in clearly defined stages. 

Q. In what specific ways is the PGME Office supporting programs to transition to CBD? 

A. The CBME Office is part of the Postgraduate Medical Education Office. We are providing faculty development sessions, one-on-one and group sessions for program directors customized specifically to their needs, and town hall meetings for residents. We’re also making a wide range of tools available to programs to help them prepare and roll out their programs. We’ve just launched our new website, as well, which provides access to a lot of resources that have been developed by the Royal College, and are always more than happy to answer questions!

Q. How will the residency experience differ for residents, with the transition to CBD? 

A. The residency experience will definitely be different. In CBME in general, and CBD in particular, residents are really in the driver’s seat of their own learning journey. They will no longer be passive recipients of a learning experience that’s provided to them. They have to track what they’ve learned against their objectives and proactively seek the experiences that will allow them to gain the skills they need to master to progress through their program. It’s a lot of work to constantly reflect on what’s been learned and what’s yet to learn, but it solidifies the learning and gives them ownership of it on a whole new level. I think residents will find this very empowering.