In last week’s Practice Perfect, Competency-Based Residency Training Part 1: Volume is Not Equivalent to Competence, we discussed the current state of podiatric residency training focusing more on volume than competency. I called on our profession’s leaders to begin moving our programs toward true competency-based education. But what does competency-based education look like? How is this actually different from programs requiring residents to complete minimum activity volumes and 36 months of training? Let’s take a look at what competency-based residency training might look like.

But before we get to competency-based education, it’s worth commenting a little further on the model we currently use, which is essentially how most sophisticated professional education takes place: the apprenticeship. The phases and structure of an apprenticeship look strikingly familiar to our residency structure¹:

Doesn’t this look a lot like what we do in residency training, along the old adage “see one, do one, teach one”? I don’t know if this system is better or worse than a competency-based model, but it doesn’t seem to be where our educational leaders want us to go.

Competence Versus Competency

The CPME refers to competency throughout the 320 document, and for our purposes, they are essentially synonymous. Of the various definitions I’ve come across, this one seems to be the best

“Those characteristics – knowledge, skills, mindsets, thought patterns, and the like – that when used whether singularly or in various combinations, result in successful performance.”

Consider this definition in relation to residency training. Successful performance in our case might look, for example, like completing a lower extremity surgery or applying a nonsurgical treatment with improved patient pain reduction and functional outcomes. That is what we want our trainees to be able to do after graduating from their training. This view is considered “behavioristic” and focuses on specific skills, in contrast to a “holistic” approach, focusing on broad clusters of abilities necessary for successful performance⁴.

Either way, the largely unanswered question about competency is how it relates to performance. Being able to do a thing competently doesn’t mean I will actually do that thing. Essentially, can doesn’t mean will. For example, if I am assessing a resident on their ability to do a preoperative history and physical, my presence in the room may affect how they handle the encounter in a manner different than if they were alone. This becomes the issue with the validity of assessing competency with our trainees. In what way do we most effectively assess our residents?

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“We need to find the most effective way to transfer our expertise to our trainees, have our trainees perform to the highest standards possible, and then assess our trainees to demonstrate that level of quality to the public.”

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What Competency-Based Training Looks Like

All this brings us finally to what competency-based training might look like. It turns out – somewhat anticlimactically – that it may be impossible to create true competency-based training. Let’s get to the utilitarian bottom line of this, though, since we have to do something. We’re training doctors whose job is to treat disorders affecting the lower extremities. We need to find the most effective way to transfer our expertise to our trainees, have our trainees perform to the highest standards possible, and then assess our trainees to demonstrate that level of quality to the public.

The competency-based residency of the future could look something like this:

As you already noticed, this is a resource heavy method that would require the use of expensive technologies, faculty time, assessor training, and changes to our national accreditation system. Don’t hold your breath for this system to be instituted any time soon.

I’ll end this discussion by summarizing the conclusions from a well-written white paper review covering what we know on the competency assessment subject⁵:

Until changes along these lines occur, we’ll remain in the MAV, activity-based, non-standardized apprenticeship-based residency education model, which is not optimal. One of my Western University partners and I are in the earliest stages of planning a move toward a more competency-based model for the Chino Valley Medical Center residency with future research to demonstrate its effectiveness. I hope to have more to report on this in the future.