Professional Licensure in an Era of Competency-Based Education: Development and Alignment Issues and Challenges in Medicine

• In Event: 28.090 - MTCC Roundtable Session Nine
  In Roundtable Session: 28.090-8 - Challenges to the Development of Assessment Systems for Competency-Based Education in the Health Professions

Abstract

In recent years, many countries have embraced competency-based medical education (CBME). Focused on learners’ time-variant development of competence in a predetermined set of constructs, as opposed to time-dependent program length, CBME integrates curriculum and assessment, includes multiple types and points of assessment and feedback, and stresses achievement of agreed upon educational outcomes. The advent of both milestones and entrustable professional activities offer mechanisms by which to link educational performance outcomes with the core competencies in medicine. But what are the implications of CBME for developing assessment systems for use in medical licensure?

This presentation describes the ways in which assessments for medical licensure in the United States align (and do not align) with the tenants of CBME and the challenges associated with ensuring medical licensing examinations appropriately reflect contemporary medical education and practice. It further raises questions about the degree to which professional licensure examinations more broadly require such alignment, given their primary purpose and the inferences to be made from their scores.

As an assessment system intended to signal readiness for medical licensure, the United States Medical Licensing Examination (USMLE) aligns with aspects of CBME in several ways. USMLE governance adopted the Accreditation Council for Graduate Medical Education (ACGME) competency framework more than 10 years ago. This is reflected in items and cases incorporating certain clinical tasks and behaviors nested within the six core competencies. For example, the inclusion of multimedia item formats focused on patient care and diagnosis on the multiple-choice examinations and improved scoring models and examinee feedback related to communication skills for the clinical skills performance-based assessment reinforce elements of CBME in the assessment system for medical licensure.

USMLE and its uses also diverge from CBME in several ways. Contrary to an emphasis on varied learner trajectories, medical schools’ placement of USMLE in their curricula often serves as a point-in-time progress or promotion examination. Also, USMLE feedback is somewhat limited in frequency and, while it provides learners with individualized performance information, it does so in a standardized way. Lastly, there may be constructs associated with the core competencies that are best measured by assessment approaches not included on the USMLE.

With these connections and divergences in mind, questions arise as to the theoretical and practical implications of fully aligning USMLE with CBME. The following issues will be explored in relation to these questions: all curricular content cannot (and probably should not) be covered on a licensure examination; licensure examination scores can be interpreted as indicating competence or as reflecting the underlying knowledge and skills necessary for achieving competence in practice; by definition the purpose of a licensure examination is to protect the public by restricting entry into practice to only those who demonstrate minimal competence, suggesting a summative model of assessment and feedback. This is not to say that one necessarily needs to choose between competency and licensure orientations when thinking about preparing learners for professional practice. What is needed is a thoughtful and evidence-based evaluation of the most desirable ways to connect the two.

Author

• Monica M. Cuddy, National Board of Medical Examiners