Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
Wilson Centre for Research in Education, Toronto, Ontario, Canada.
Med Educ. 2018 Jan;52(1):45-57. doi: 10.1111/medu.13467. Epub 2017 Oct 27.
Over the last two decades, competency-based frameworks have been internationally adopted as the primary educational approach in medicine. Yet competency-based medical education (CBME) remains contested in the academic literature. We look broadly at the nature of this debate to explore how it may shape scholars' understanding of CBME, and its implications for medical education research and practice. In doing so, we deconstruct unarticulated discourses and assumptions embedded in the CBME literature.
We assembled an archive of literature focused on CBME. The archive dates from 1996, the publication year of the first CanMEDS Physician Competency Framework. We then conducted a Foucauldian critical discourse analysis (CDA) to delineate the dominant discourses underpinning the literature. CDA examines the intersections of language, social practices, knowledge and power relations to highlight how entrenched ways of thinking influence what can or cannot be said about a topic.
Detractors of CBME have advanced an array of conceptual critiques. Proponents have often responded with a recurring discursive strategy that minimises these critiques and deflects attention from the underlying concept of the competency-based approach. As part of this process, conceptual concerns are reframed as two practical problems: implementation and interpretation. Yet the assertion that these are the construct's primary concerns was often unsupported by empirical evidence. These practices contribute to a discourse of infallibility of CBME.
In uncovering the discourse of infallibility, we explore how it can silence critical voices and hinder a rigorous examination of the competency-based approach. These discursive practices strengthen CBME by constructing it as infallible in the literature. We propose re-approaching the dialogue surrounding CBME as a starting point for empirical investigation, driven by the aim to broaden scholars' understanding of its design, development and implementation in medical education.
在过去的二十年中，以能力为基础的框架已在国际上被采纳为医学的主要教育方法。然而，基于能力的医学教育（CBME）在学术文献中仍然存在争议。我们广泛地研究了这场争论的性质，以探讨它如何影响学者对 CBME 的理解，以及它对医学教育研究和实践的影响。在这样做的过程中，我们解构了 CBME 文献中隐含的未阐明的话语和假设。
我们收集了一套专注于 CBME 的文献档案。该档案的时间跨度从 1996 年开始，即第一份 CanMEDS 医师能力框架的出版年份。然后，我们进行了福柯式的批判话语分析（CDA），以描绘支撑文献的主要话语。CDA 考察了语言、社会实践、知识和权力关系的交叉点，以突出既定的思维方式如何影响对一个主题的看法。
CBME 的批评者提出了一系列概念上的批评。支持者经常以一种反复出现的话语策略来回应，这种策略最小化了这些批评，并转移了对基于能力方法的基本概念的注意力。作为这个过程的一部分，概念上的担忧被重新定义为两个实际问题：实施和解释。然而，认为这些是该构建的主要关注点的说法往往没有得到实证证据的支持。这些做法促成了 CBME 不可错性的话语。
在揭示不可错性的话语时，我们探讨了它如何使批评者保持沉默，并阻碍对基于能力的方法的严格审查。这些话语实践通过在文献中构建 CBME 不可错性，加强了 CBME。我们提议重新开始围绕 CBME 的对话，作为实证研究的起点，目的是拓宽学者对其在医学教育中的设计、发展和实施的理解。
