The articles included in this review represent a variety of perspectives and approaches to the challenges in implementing CBME within post-graduate medical training programs. Three articles provided a broad systems review8–10. There were surveys looking at perceptions of faculty and residents11, faculty needs assessment12, and program preparedness13. Two studies used qualitative interviews to explore perceptions of residents14 and both residents and faculty15. Finally, there were two case studies of a single program, one in the emergency department16 and one in anesthesiology17. Across these different articles, three important themes emerged: the value of broad stakeholder engagement and leadership, the importance of faculty and resident development, and the development of specific support systems for the educational curriculum.
Stakeholder Engagement And Leadership
Nousiainen et al.10 advocate for a health care curriculum that is integrated with health human resources planning and a need for educational continuity as “policies that support the principles of CBME at all levels of medical education” (p. 594), from the early undergraduate trainee to the continuing professional development of the practicing physician. They argue this requires appropriate leadership to champion the necessary changes, which is echoed by Dagnone et al.9 in calling for program leaders “to engage in a community of shared learning and leadership” (p. e32). Boet et al.15 also express the limitations of literature alone in disseminating knowledge and best practices of CBME, and the advantages of fostering a community of practice to share information both within and between programs.
Another frequently raised concern was commitment and engagement from the faculty and residents directly impacted by CBME14,15,17. Dagnone et al.9 promoted the need for centralized institutional governance and support for CBME, with the appropriate allocation of financial support, time, and educational resources. In their faculty development efforts, Fraser et al.17 noted that financial and other support would have improved engagement and attendance. Focusing specifically on the resident perspective, Mann et al.14 called for increased opportunities for resident engagement and feedback on the implementation of CBME, which were “repeatedly suggested as vital to a successful transition” (p. e37) by their interview participants. This was supported in the systems-based review by Dagnone et al.9, who described the establishment of a resident sub-committee at their center to provide a forum for resident advocacy and discussion.
Ultimately, stakeholder engagement needs to include and be driven by the institutional leadership and priorities, which may be challenging to affect in that they are often external to the program itself 17. Caverzagie et al.8 advocated for clinical program redevelopment to occur in concert with the educational redesign of CBME, requiring the consideration of potential medical regulatory changes and input of those bodies. They also expressed the importance of mutual accountability of the different stakeholders throughout the implementation process. This was validated by Hall et al.16 in their evaluation of CBME implementation in a single emergency medicine program; ongoing efforts at continuous quality improvement led to better investment in the process by the different stakeholders.
Faculty And Resident Development
Fraser et al. 17define faculty development as “any planned activities designed to improve an individual’s knowledge, skills, and attitude in areas related to the roles and responsibilities of a faculty member” (p. 1365), and this definition would apply equally to resident development. Their article provided a review of initiatives undertaken in their anesthesiology program at the University of Ottawa; they initially found a lack of faculty knowledge and skills to shift to CBME, a lack of technological expertise for delivery of CBME curriculum, and a lack of time and ability to provide proper resident assessment. These findings led the authors to develop a variety of faculty development programs, particularly around the curricular format of CBME and the process of workplace-based assessment, which were hindered by the lack of appropriate incentives as presented earlier. Unfortunately, the process of their review was not defined, which impacts the reliability and generalizability of the findings.
In their qualitative interviews of program directors and resident focus group, Boet et al.15 were adversely impacted by poor recruitment and subsequently a lack of saturation of the findings, but they did highlight some important negative elements and concerns of CBME. In particular, they identified the importance of defining the key terminology in CBME, and particularly in relation to assessment criteria and frequency. This was also cited as an important area for consistent definitions by Caverzagie et al.8.
Stefan et al.12 performed a more detailed and structured needs assessment of Canadian emergency medicine program faculty and trainees, and uncovered similar issues. They describe that their faculty generally believe they give good feedback to residents but have a desire to improve. These faculty also identified the time required to deliver workplace-based observations, potentially impacting patient flow and care, and the possible repercussions of delivering negative feedback as barriers to effective assessment. Their survey also uncovered a general lack of familiarity with the details of CBME, which was their explanation for the finding that nearly half of respondents did not anticipate benefits in training or patient care with CBME. Similar concerns were identified in medical oncology programs13.
In their interviews with residents, Mann et al.14 identified the need for appropriate faculty development to create a change in feedback culture, which Caverzagie et al.8 also describe as a requirement for CBME to be successful. This fits well with the observation by Hall et al.16 that similar culture change efforts within the emergency medicine program led to “substantial efforts and adaptations in the form of faculty and resident development activities relating to the provision, documentation, and acceptance of constructive feedback” (p. 790). They describe this as a core component of CBME, requiring iterative cycles of instruction, practice, and feedback to fully develop, consistent with their discussion of the value of continuous quality improvement, as presented in the first theme.
Crawford et al.11 surveyed both residents and program directors regarding perceptions and barriers of CBME, similar to the efforts of Boet et al.15 which were specific to the anesthesiology program. Crawford et al.11 highlight the importance of both resident and faculty development, and in particular the role of the resident in partnering with faculty in their assessments. Their survey found that residents had the least positive opinion of CBME, and noted that residents might not recognize the practical relevance of the EPA, since they are not yet fully versed in the skills of clinical practice. Their call for residents to be engaged in CBME leadership echoes the call in the first theme for communication and engagement with residents throughout the implementation of CBME9,14.
Educational And Technological Support
The resident focused approach to training was highlighted in several articles9,10,13,14,15. Nousiainen et al.10 refer specifically to the use of time as a resource rather than an endpoint in CBME, necessitating the changed approach to health care education as described in the first theme. While recognizing the value of personalizing a resident’s training according to their own developmental needs, Boet et al.15 listed potential adverse impacts, such as a desire to rush through training to enter the workforce at full salary, competition for training experiences and observations, and the administrative challenges of individualized training programs. In their interviews, Mann et al.14 also observed that such practical and logistical challenges were associated with pessimism from the residents on the success of CBME, and they advocated for the possibility of resident input in mitigating them.
In addition to the administrative reorganization of training experiences, appropriate curriculum delivery, assessment, and evaluation will also require educational and technological support10,11. Simulation may be necessary for those EPA that are less frequent9, and Arora et al.13 describe how this might actually create new training opportunities.
These core pedagogical elements require rapid introduction in the early implementation of CBME, to provide appropriate systems, support, and leadership as foundations for the subsequent faculty and resident development16. Solutions to these practical challenges are suggested in the previous two themes, with stakeholder engagement, strong leadership, and faculty and resident development playing important roles.