#4 How CBME makes residents beasts of assessment burden

Host: Lara Varpio

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Episode Article:

Ott, M. C., Pack, R., Cristancho, S., Chin, M., Van Koughnett, J. A., & Ott, M. (2022). “The Most Crushing Thing”: Understanding Resident Assessment Burden in a Competency-Based Curriculum. Journal of Graduate Medical Education, 14(5), 583–592. https://doi.org/10.4300/JGME-D-22-00050.1


The unintended consequence of CBME that this paper addresses is the assessment burden that residents have had to bear with the increase volume of formative assessments.  


The authors engaged in a Constructivist Grounded Theory Study in the context of the departments of surgery and anesthesia in a Canadian teaching hospital. They began by interviewing 11 residents in their local context, analyzing those data and, through that work, they developed a typology of assessment burdens experienced by the residents. The authors questioned if these burdens were specific to the local context or if they were systemic issues associated with CBME. So they sought participation from residents outside of their local context, interviewing 12 participants from Canadian teaching hospitals outside of their local context. Using constant comparison, they found that the typology of assessment burdens experienced by the external residents was consistent with those experienced by local residents, and they found that residents associated their assessment experiences with stress or anxiety. To understand these data more deeply, the research team turned to self-determination theory (SDT).

Results & Discussion

The authors identified 9 assessment burdens, which clustered under each of the three psychological needs presented in self-determination theory (i.e., competence, autonomy, and relatedness).

Autonomy: Learners suffered imposed limitations on their individual ability to peruse meaningful learning opportunities. They described a lack of situational control because they were asked to achieve EPAs when they had not yet even had the chance to do it. Finally, they experienced comparative assessment.

Relatedness: Residents felt unfairly judged by the competence committee resulting in a lack of trust. They described that the need for constant assessment was problematized by a lack of time and energy in the clinical context. Finally, stress was caused by a lack of connection with assessors.

Competence: Residents described the stress of unclear assessments in the way that the EPAs were communicated to them. They also described the burden of unrealistic expectations. Finally, they described that the form itself was limiting their ability to develop competence.

Finally, the authors stress that since these needs are inter-related, a problem in one area had impact on other areas. The authors argue that assessment burdens emerged as unmet psychological needs and acted as threats to the well-being and competence of residents. In one of their closing paragraphs the authors state:

“An approach to entrustment by numbers in CBD [competence by design] has placed undue stress on residents, replacing an ethos of support for the development of competence with a surveillance system based on performative metrics. We must address the challenges of assessment burdens in CBD comprehensively because competence and well-being of learners is at stake.”


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