My name is Sanjeev Francis, and I'm the Director of the Cardiovascular Fellowship Program at Maine Medical Center and the Director of Education for the Cardiovascular Institute. Today, I'm going to talk about competency-based education, a phrase that has been generating a lot of buzz within graduate medical education. My objectives for this session are to define what is competency-based education in the context of our fellowship programs. Why is it important? What are some easy or relatively easy wins as a program director or associate program director? How do we incorporate a competency-based curriculum into our milestones and entrustable professional activities or EPAs? Finally, I will talk about the challenges and opportunities that we face in our fellowship programs as we embark on this paradigm shift in education and training. Let's get started. In a traditional education system, the unit of progression is time and it is teacher-centered. In a competency-based education system, the unit of progression is mastery of specific knowledge and skills and is learner-centered. This may seem like semantics, but let's look at how we organize things in our fellowships. In the traditional system, if you are like me, you struggle to make the fellowship block schedule. For each fellowship class, every fellow gets the same number of cardiac ICU months, consult months, cath lab EP, you get the point. This is the case at least for the first two years of fellowship. Doesn't matter what the individual fellow's strengths or deficiencies are, it is a one-size-fits-all training program. It is teacher-centered in the sense that we assume that our large and heterogeneous faculty are going to impart the wisdom and skills necessary to become a competent cardiologist to our apprentices by virtue of the amount of time they spend together. Sometimes it feels like we rely on osmosis for this knowledge transfer. In a competency-based system, the focus is on the learner and making sure that the necessary skills and knowledge are obtained during training and not assumed based on the completion of the requisite number of rotations in months. So why is this important? Why should we change a system that has been working for all these years? Here are three reasons why we should all make the shift in how we structure our fellowship training programs. First, we need to be confident in the product of our training. I'm going to go on a little tangent here, but hopefully this will make sense. In the area of quality and safety, many healthcare experts are looking to an industry that has performed extraordinarily well in an equally high stakes environment. I'm talking about the airline industry. Stay with me, this will make sense. When you're boarding a flight to a conference, vacation or whatever, how often do you wonder, where did the pilot of this flight train? If you're like me, this never enters your thoughts because pilots undergo a rigorous competency-based training and evaluation program that is highly standardized. Now, if your family member is hospitalized at a small community hospital, how often will you wonder where did his or her physician go to medical school? Do they residency? Why the difference? We recognize that training in medicine is heterogeneous. Passing the boards is not a great marker for who is a competent physician. A competency-based system will level the playing field so that we can all be confident that a graduate of a fellowship program has the skills and knowledge necessary to be a competent cardiologist. If we design our training programs around competency, then we can remediate earlier. We can identify the struggling fellow, and in particular, the areas that he or she is struggling in. Finally, and most importantly, this is the right thing to do for our patients and our trainees. So if you are a new or relatively new program director, you are now overwhelmed by all of the requirements and governing bodies out there. There is COCATS-4, ACGME and its milestones, subspecialty requirements like the echo and nuclear boards. Your hospital institution also has policies in place for trainees. Your job is to synthesize all of these and somehow preserve enough flexibility to allow you to try something innovative and new, not an enviable task. But have faith, there are some opportunities for an easy win or two. What are some of the low-hanging fruit when contemplating making your program more competency-based? One strategy is to start with a rotation. Pick one that is due for an overhaul. The lowest-rated rotation by your fellows is a good start. We are in the process of looking at our echo rotation in curriculum. We can break it down into the skills that fellows acquire over the course of their training, from transthoracic acquisition to transthoracic interpretation, likewise from TEE acquisition to interpretation, followed by complex cases like VAD assessments, RAMP studies, complex structural heart disease, and so on. We can assess each fellow on the specific knowledge and skills and sign off when a fellow has demonstrated competency. In the case of echocardiography, there are several standardized curricula available, including the ACC and the American Society of Echocardiography Board Review courses. Both of these provide a nice framework for a curriculum, so you don't have to reinvent the wheel here. What does take time is faculty development. We need our faculty to provide quality assessments and feedback to the fellows during their rotations to allow them to continue to improve on their areas of deficiency. Linking this to the EPAs or untrustable professional activities or milestones to put it into ACGME parlance does require a shift to more frequent assessment of skills. Faculty development is critical. I will mention this several times during this presentation. Using objective tools to minimize bias is critical. The halo effect, which many of you may be aware of, involves you enjoy working with a fellow, so you're more likely to evaluate her through a favorable lens. There are different strategies to make our assessments more simple, objective, straightforward, and timely. You can employ a checklist, including the relevant skills, and use the Sim Center to assess these skills. Your clinical competency committee members are key in getting your faculty engaged in this process and helping compile all of the assessments. You then link the relative knowledge and skills to the ACGME milestones for a particular rotation. The advantage of this approach is that it moves away from the one-size-fits-all paradigm and recognizes that each fellow has a different trajectory for mastering the necessary skills to become a competent cardiologist. One fellow may rapidly progress through your echocurriculum and be ready to do transesophageal echocardiography, while another fellow may need to hone his transthoracic skills before he is ready to go on to the next level. So this sounds all well and good, but there are obvious challenges. We have to create an individualized curriculum which still has to fit into a standard block schedule. It is difficult to extend the cardiac intensive care unit rotation for a fellow that needs more time without wreaking havoc on the entire system. There is very little flexibility in our schedules. Though COCATS4 is moving us towards a focus on competency, it still provides a framework that is based on the number of months and number of procedures for certain specialties. Many hospitals and institutions are now requesting procedure logs as part of their accreditation process for our recent graduates. As I mentioned, we need simple standardized tools to assess our learners. We all acknowledge the critical need for faculty development. So we are caught in this transition of sorts. Within this transition, there are real opportunities for us to innovate as educators and leaders. We can develop the assessment tools and validate them. We can and should share our successes and failures to our colleagues at other institutions and across our educational community. Simulation environments can help fellows acquire skills and provide a means for assessment. We can hone in on the specific areas where a fellow may be struggling and address these gaps in a timely manner. Ultimately, this is a more efficient way to train the next generation of cardiovascular specialists. So our charge is to take stock of our present state, where we are limited by the rigid and often inflexible block schedule. For many programs, our fellows are a key part of the clinical services, and it is difficult to uncouple this relationship without disrupting workflow in our divisions. We are asking faculty to participate in a model of education, which is vastly different from the way they were taught and trained. So there is going to be a lot of inertia. Physicians resist change, and cardiologists even more so. From our present state, let's think about how to get to our future state, where a fellow completes their training when they have acquired the necessary skills to be competent and not according to a one-size-fits-all fixed timeline. Already, we are seeing the ABIM Internal Medicine Cardiology Pilot Program, which takes selected residents and short tracks them into cardiovascular fellowship. These flexible training pathways are the future. The lessons we learn from these experiences and others should make us better prepared for the future. Thank you very much for your attention, and I hope you have found this session informative and helpful. Thank you.

competency-based education

fellowship programs

learner-centered

mastery of skills

curriculum overhaul