#39 – How to Jump Start Your PIF in an Era of CBE 

Episode host

Jason Frank Photo E. Cronberg
Jason Frank, Photo E. Cronberg

Episode article

Sternszus, R., Slattery, N. K., Cruess, R. L., Cate, O. ten, Hamstra, S. J., & Steinert, Y. (2023). Contradictions and Opportunities: Reconciling Professional Identity Formation and Competency-Based Medical Education (1). 12(1), Article 1. https://doi.org/10.5334/pme.1027

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Is a competency-based approach to health professions education compatible with professional identity formation? These authors say no and offer some remedies. But is their premise based on misunderstandings?

Background 

This CBME stuff is all crap, you know. Just a return to 1950s objectives by another name…

– A prominent senior scholar in medical education at an AMEE conference

You may have noticed a surge in interest in professional identity formation (PIF) in health professions education (HPE). You see it in papers in major journals and in sessions at conferences. While there are several ways to think about PIF, a working definition is:  

A developmental process through which an individual’s representation of self integrates the norms, values, ways of thinking, and characteristics of their profession.”

The authors of this paper, a think-piece, assert that current competency-based approaches to HPE curricula are inherently behaviourist because they emphasize outcome abilities of graduates. Therefore, they say, competence based medical education (CBME) is incompatible with the fundamentally developmental PIF. Do you agree?

Reminder the van Melle Core Components of CBME (2019) are:

  1. A framework of graduate outcomes expressed as competencies to meet the needs of those served;
  2. Deliberate sequencing of learning from novice towards expertise;
  3. Choice of educational experiences that enable acquisition of abilities;
  4. Tailored teaching to individual learners’ development;
  5. Programmatic assessment.

Purpose

In this paper by an esteemed group of scholars who think about cbme, PIF, and professionalism, the authors say their “aim is to open a conversation that can inform future scholarship and curricular innovation” to integrate PIF into CBE curricula.

Methods

None, commentary article.

Results/Findings

PIF premiseHow CBE is incompatibleProposed solutions
PIF is constructivist and developmental, therefore focused on processesCBE is behaviourist Focused on graduate behavioursFocus on processes that promote PIF (e.g., storytelling, mentorship) Emphasize PIF in developmental CBE stages
PIF learning is everywhereCBE learning is in the workplace—-
PIF emphasizes individualizationCBE emphasizes standardization to meet societal needs (e.g., competency frameworks)Ensure learning environment embraces diversity while learners explore professional norms, values, and expectations through socialization Allow time for reflection Foster longitudinal relationships
PIF assessment is holisticCBE assessment is reductionist, made of observed competenceExplore how learners see themselves as a professional through longitudinal coaching and guided self-assessment Greater emphasis on narrative comments

Conclusions

CBE & PIF can be compatible as long as PIF is explicitly incorporated into teaching, learning, and assessment

Comments

  1. Commentaries in HPE have an important role in dissemination of new ideas, facilitating debates, clarifying our discourses.
  2. Innovations like CBE have a plurality of interpretations once they are disseminated. Attributions are part of those discourses.
  3. We liked some of the authors’ ideas for explicitly incorporating PIF in curriculum design.
  4. We didn’t accept all the arguments and assumptions inherent to the authors’ logic . For example, a curriculum can use a CBE approach and still be developmental. Any curriculum can focus on learning methods and learning environment and PIF. They didn’t convince me CBE & PIF were incompatible.
  5. PIF is an emerging area of scholarship and presents an exciting opportunity to enhance the next generation of training designs and learner experiences.

Word of the day: Shredded

The Last Word –

Comments from the author, Robert Sternszus MDCM,MA (Ed), FRCPC

Hi Linda. Thanks for the heads up on the podcast. I’m truly thrilled that it is being discussed and that really was the whole point (the stated intention of the paper was ‘to start a conversation.’) In case anyone was concerned, I was in no way offended by the critique although I disagreed with much of it.

In particular, the premise of the entire critique implies that the paper was interpreted in a completely opposite way to which I felt it was written. And that, in and of itself , is interesting and important in terms of how we talk about these concepts moving forward.

The ‘blurb for the podcast’ sets it up with: ‘Is a competency-based approach to health professions education compatible with professional identity formation? These authors say no and offer some remedies.’

And yet, the closing sentence of the introduction/purpose statement of the paper explicitly states the opposite:

‘In this paper, we argue that CBME and PIF are not only compatible, they can also both be enhanced by reconciling one with the other.’

The argument line was intended to reflect that the ways in which PIF and CBME have both been described and operationalized, which are sometimes actually at odds with their theoretical underpinnings (as the group highlighted), have made them seem incompatible to many when they in fact are not. The importance of identifying and naming the perceived contradictions lies in being able to debunk them and point to opportunities and solutions Which, I agree with Jason and Linda, is the value of the paper. Ultimately, initiatives explicitly intended to help support reflection and engagement with PIF have not been meaningfully incorporated into many curricula in part because curriculum designers struggle to see how to do that in a curriculum that is entirely centered on EPAs and competencies.

Lastly, I think the discussion around assessment is an important one. Professional identity and professional identity formation are NOT competencies (agree fully!) And, also agree fully that one’s professional identity should not be assessed. However, I think formative guided self-assessment of the process of forming a professional identity can be a powerful trigger for reflection. And, given that CBME implementation has often meant exclusion/minimization of things that cannot be ‘assessed’ (again, not what CBME theory says but what plays out in practice) conceptualizing assessment around the process of PIF is a launch point to help curriculum designers include it meaningfully.

All of that said, it’s been really fun to see the chatter the paper has generated (it was selected as a MedEd must read for February in addition to being in the podcast). And I am grateful for the time and thought that was put in by the Papers Podcast team in reviewing it.

A demain

Robert

References and further reading

Van Melle, E., Frank, J. R., Holmboe, E. S., Dagnone, D., Stockley, D., Sherbino, J., & International Competency-based Medical Education Collaborators (2019). A Core Components Framework for Evaluating Implementation of Competency-Based Medical Education Programs. Academic medicine : journal of the Association of American Medical Colleges, 94(7), 1002–1009. https://doi-org.proxy.kib.ki.se/10.1097/ACM.0000000000002743

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