R. Englander is associate dean for undergraduate medical education, University of Minnesota Medical School, Minneapolis, Minnesota. C. Carraccio is vice president of competency-based assessment, American Board of Pediatrics, Chapel Hill, North Carolina.
Acad Med. 2018 Mar;93(3S Competency-Based, Time-Variable Education in the Health Professions):S12-S16. doi: 10.1097/ACM.0000000000002071.
The paradigm shift to competency-based medical education (CBME) is under way, but incomplete implementation is blunting the potential impact on learning and patient outcomes. The fundamental principles of CBME call for standardizing outcomes addressing population health needs, then allowing time-variable progression to achieving them. Operationalizing CBME principles requires continuity within and across phases of the education, training, and practice continuum. However, the piecemeal origin of the phases of the "continuum" has resulted in a sequence of undergraduate to graduate medical education to practice that may be continuous temporally but bears none of the integration of a true continuum.With these timed interruptions during phase transitions, learning is not reinforced because of a failure to integrate experiences. Brief block rotations for learners and ever-shorter supervisory assignments for faculty preclude the development of relationships. Without these relationships, feedback falls on deaf ears. Block rotations also disrupt learners' relationships with patients. The harms resulting from such a system include decreases in patient satisfaction with their care and learner satisfaction with their work. Learners in this block system also demonstrate an erosion of empathy compared with those in innovative longitudinal training models. In addition, higher patient mortality during intern transitions has been demonstrated.The current medical education system is violating the first principle of medicine: "Do no harm." Full implementation of competency-based, time-variable education and training, with fixed outcomes aligned with population health needs, continuity in learning and relationships, and support from a developmental program of assessment, holds great potential to stop this harm.
基于能力的医学教育（CBME）范式正在转变，但不完全实施正在削弱其对学习和患者结果的潜在影响。CBME 的基本原则要求标准化解决人口健康需求的结果，然后允许时间变量来实现这些结果。实施 CBME 原则需要在教育、培训和实践连续体的各个阶段保持连续性。然而，“连续体”各阶段的零碎起源导致了从本科到研究生医学教育到实践的一系列顺序，尽管在时间上是连续的，但没有任何真正连续体的整合。由于未能整合经验，在阶段过渡期间的这些定时中断会导致学习无法得到强化。学习者的短暂块旋转和教师的监督任务越来越短，排除了关系的发展。没有这些关系，反馈就无人倾听。块旋转也会破坏学习者与患者的关系。这种系统造成的危害包括患者对护理的满意度下降和学习者对工作的满意度下降。与创新的纵向培训模式相比，在这种块状系统中的学习者也表现出同理心的侵蚀。此外，已经证明在实习生过渡期间患者死亡率更高。目前的医学教育系统违反了医学的首要原则：“不伤害”。全面实施基于能力、时间变量的教育和培训，具有与人口健康需求相一致的固定结果、学习和关系的连续性以及来自发展性评估计划的支持，具有很大的潜力来阻止这种伤害。
