Answering this question has been a major focus for PAEA over the past two years or more, beginning with our work at the 2016 Stakeholder Summit and culminating in the draft Core Competencies for New PA Graduates released in October.
While we elected to postpone a formal membership vote on adopting the new graduate competencies until 2019, these competencies can nevertheless be used as a starting point by programs looking to move toward competency-based medical education (CBME). The new PAEA Digital Learning Hub already contains a number of articles on the competencies, and additional resources will be added soon.
The new graduate competencies are part of a larger body of work that PAEA has been building for the past few years, including Presidents Commission papers on entrustable professional activities (EPAs) and the noncognitive attributes desired of PA students, as well as a task force paper on outcomes-based accreditation.
As PAEA CEO Timi Agar Barwick noted in her Forum address, “The sum total of this work really does change the game. … we are collectively building the intellectual framework for a new approach to PA education in the future — one built on a clear understanding of the knowledge, skills, and attitudes we want our graduates to have.” The Association will be reinforcing this framework, providing resources for programs interested in CBME, including a PAEA Learning workshop in the spring of 2019.
On the CBME Track
For the first time this year, PAEA offered a dedicated CBME track at the Education Forum, with 10 sessions on various aspects of CBME and EPAs in PA education. For those who did not attend, or did but still have questions, we spoke to two presenters of those sessions: Rachel Ditoro of Salus University; and Janelle Bludorn of the University of North Carolina (UNC), Chapel Hill, and offer some of their insights and experiences here.
Why should programs consider offering a CBME curriculum? For Bludorn’s program, the impetus came when they were working on designing clinical assessments for students just about to graduate. “We proposed to give our students a written exam, but asked ourselves if it would really capture what we needed,” said Bludorn. “The answer was ‘No, not really; it mostly covers book smarts. But are these soon-to-graduate PAs actually competent to treat patients?’”
So the UNC program looked to the Competencies for the PA Profession, developed by the four national PA organizations in 2005 and most recently revised in 2012. They realized they were assessing only one of the six competencies – medical knowledge. To assess other competencies, such as professionalism and communication skills, the program developed a three-part clinical summative assessment that included a simulated half-day clinic OSCE, in which students were evaluated on aspects of the competencies across several different touch points.
For Ditoro’s program, the move toward CBME was partly about making it easier to demonstrate compliance with accreditation standards around learning outcomes. “With accreditation, whatever you say you are doing, you have to show how you are doing it,” she said. “[CBME] is a way to prove you are doing that.”
In developing competencies for a program, it’s important to begin with the end in mind, Ditoro added. “We held a faculty retreat and asked the question, ‘What do we want our new graduates to look like?’ Then, we worked backward to look at where we could introduce these concepts in the curriculum, where we could reinforce them, and how we could assess them.” The program also reviewed the competencies for the PA profession and those developed by the Accreditation Council for Graduate Medical Education.
The UNC program uses an assessment framework adapted from the RIME framework developed by the well-known medical educator Louis Pangaro, MD. The Reporter, Interpreter, Manager, Educator framework assesses a student’s ability to gather, interpret, and act on clinical data, with the expectation that students will achieve at least Manager status by graduation. Ditoro’s program uses a model based on required level of supervision, developed by Chen et al., in which students progress through the stages of Novice, Advanced Beginner, Competent, Proficient, and Expert. There are several other similar models available.
Whatever model is used, it is important to give students the opportunity to practice skills many times, and to be assessed across multiple touchpoints, Ditoro said. A CBME model also helps with transparency for students, she noted: “It lets [students] see how it all fits together; they can see the framework of learning. They are assessed across multiple courses, so if we see the same issues come up in different places we know what to remediate.”
Take It One Step at a Time
The biggest lesson about implementing the competencies is to take things slowly and don’t feel like you have to revamp your entire curriculum at once. “It’s not about starting over,” said Ditoro, “It’s about looking at what you have and making intentional changes to what you want your endpoints to be. Don’t be overwhelmed by the huge mountain. Take small steps.”
Introducing CBME is certainly easier in a newer program, though, Bludorn acknowledged. “At UNC we were a newish program, and relatively small, with only 20 students. So when my colleague Meg Beal and I said we want to do it, it was relatively easy.”
Getting the buy-in of faculty and other stakeholders is essential in any program, both educators said. At UNC, the program and department were very supportive, Bludorn noted. But they needed to build support around the whole university — the simulation center had to agree to provide the program dedicated time for assessment, for example.
Developing a competency-based curriculum can involve some additional work up front, Bludorn said, “but once you’ve done the work on developing competencies and how to measure them, it should make things easier moving forward.”
In 2019, PAEA will continue to seek feedback on the first iteration of the new graduate competencies, with a view to bringing a perhaps slightly revised version to the 2019 business meeting for membership action. At the same time, a cross-org task force is currently working to meet its charge to “review and recommend revisions to the PA Professional Competencies to ensure alignment with the Competencies for New PA Graduates.” This work, scheduled to be completed by the end of next year, should provide further clarity to the continuum of competence that PAs should achieve from graduation through increasing experience in practice.
In the meantime, keep an eye on the Digital Learning Hub for more resources on CBME, and engage in dialogue with the more than 700 of your peers who have signed up for the learning hub so far. (If you have not yet signed up, go to the access page, scroll to Request Access, and fill out the short form.)