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Exploring a Value Proposition for Making Changes

The workshop thus far, said Paniagua, has been about pushing the envelope—looking at innovations and creative solutions from the pandemic to transform health professions education (HPE) moving forward. This session, he said, is where “we turn the envelope over and do the math.” For changes to HPE to be sustainable, they must be financially feasible. While some of the issues discussed in the workshop aren’t financial by nature, they have financial implications, said Paniagua. For example, burnout has large implications for provider and patient well-being and the costs of health care. These issues must be part of the value proposition¹ when considering HPE of the future. In this session, participants heard from three speakers about different models for HPE and the value proposition, which was followed by a response panel discussion.

COMPETENCY-BASED EDUCATION

Even before the pandemic, remarked Kimberly Lomis, American Medical Association, there were concerns about the consistency of readiness among medical school graduates. When the pandemic hit, it became clear that the current education structure was “not at all prepared to handle significant disruption.” A competency-based approach to HPE may provide more agility, in both crisis and non-crisis times, said Lomis. The

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¹ For more information on value propositions, see https://www.nationalacademies.org/our-work/exploring-a-business-case-for-high-value-continuing-professional-development-a-workshop (accessed October 11, 2021).

crux of a competency-based approach is a focus on the learning outcomes that will lead to the competencies needed for the next level of training or responsibility in the clinical system. These outcomes, in turn, determine the appropriate learning activities and assessments. In this model, she pointed out, time becomes a resource for learning rather than a measure of learning outcome. In times of disruption—such as the COVID-19 pandemic—competency-based approaches allow more “agility to find alternate mechanisms and alternate pathways to continue training and education.” There are multiple differences between traditional educational approaches and the competency-based approach, said Lomis (see Table 4-1). One key difference is a less hierarchical structure that requires the learner to be engaged and self-directed; Lomis described health professions students as being “prepared to do this.” Such an approach also requires frequent observation and feedback for assessing where a learner is, and what they need to reach the next level of competency. Lomis noted there is already a tradition of graduated responsibility under supervision in HPE, and that careful observation and tracking of each learner’s progress “allows us to be more efficient [and] hone in on what each learner needs.” The development of competencies is context-dependent, said Lomis; HPE learners are frequently asked to advance from simpler, more controlled environments into more challenging situations. A competency-based approach would help the learner understand that regression in a new setting is a normal part of

TABLE 4-1 Differences Between Traditional and Competency-Based Education

SOURCES: Presented by Kimberly Lomis on April 22, 2021, adapted from Carraccio et al., 2002.

development, and to adopt a perspective of life-long learning and pursuit of mastery throughout one’s career.

A critical piece of the competency-based approach, said Lomis, is to be able to track progress across time and settings. Digital tools, such as a database that tracks each learner’s performances in different contexts and with different assessors, can help with monitoring trends over time rather than making decisions based on isolated incidents (see Figure 4-1). During times of disruption, these data can be particularly powerful because “you can see which learners are … ready for more responsibility” based on their trajectory.

Lomis pointed to a major benefit of competency-based education, which is it results in a “master adaptive learner” who identifies personal learning needs and addresses these needs in an iterative process throughout their career. However, she said implementing a competency-based approach requires a shift from a performance-driven culture to an environment in which the learner can be vulnerable and acknowledge when he or she needs help reaching the next milestone. In order for individuals and systems to reap the benefits of the competency-based approach, there must be a “supportive environment with trust and organizational buy-in.”

The value proposition for this approach varies, depending on whose perspective value is measured. For the learner, the benefits include clear expectations, more frequent feedback, and the opportunity for individualized pathways and “precision education.” The benefits to the health system, said Lomis, include graduates who are “more ready to do the job that they are being asked to do” and who are oriented as master adaptive learners throughout their careers. Patients benefit from practitioners who are prepared to provide high-quality care in a safe environment. There are, of course, costs to implementing a competency-based approach. Learners must be prepared to engage in their education, seek and respond to feedback, and participate in self-assessment. HPE programs must create flexible curricula and assessments to respond to the needs of different learners, and must engage in programmatic assessment and faculty development. Health systems need to support learners at all levels through a culture and environment that facilitates self-directed assessment and learning.

Implementing competency-based approaches is resource intensive, but Lomis argued, should result in more purposeful and precise use of those resources to align ongoing education with needs of patients, communities, and the health system. The current cost of variability in provider readiness is hidden within health system outcomes, particularly during periods of transition in responsibilities. Despite the investment and commitment required to implement a competency-based approach, Lomis argued, “the return on the investment could be quite significant,” particularly during a time of disruption.

ADDRESSING BARRIERS TO EDUCATION

In the ideal world, said Richard Berman, University of South Florida, all populations would be served by the health system, the health professions would be inclusive and representative of the populations they serve, and HPE and practice settings would work collaboratively with diverse communities. However, there are many barriers that keep this vision from becoming reality. Berman continued, two major barriers that prevent some learners from being able to pursue a career in the health professions are cost and access. The costs of HPE include those associated with applying, tuition, and living expenses. Many of these costs are incurred up front, and the costs may be disproportionate to the anticipated income, said Berman. Many would-be learners are not able to give up a steady income to go to school. Some students may not be able to access educational opportunities, due to location, conflicts with work or family responsibilities, or issues involving language or culture (e.g., religious restrictions on travel).

To address these issues and create a truly diverse health professions workforce, said Berman, “we need to think outside the box” about how HPE is delivered. While approaches such as competency-based education, interprofessional education, and investments in technology have their place, they “will not significantly change the demographics of health professions.” Berman said “we need to think about changing when and where we go” to recruit students and teachers, and for clinical learning experiences. One potential solution is population-based engagement sites where health professions students can learn and work together. For example, said Berman, community colleges are less expensive, more accessible, and serve a broader, more diverse student population. Furthermore, there are opportunities at community colleges to create experiential learning encounters in student health services, day care centers, and athletic and recreation programs.

COMMUNITY COLLEGES

Community colleges present a strong value proposition for increasing the diversity of the health professions, said Clese Erikson, The George Washington University. Community colleges play an important role in HPE. For example, 28 percent of medical students have a community college background, while three out of four physician assistant students have attended a community college. There is more racial, ethnic, and socioeconomic diversity among students with a community college background, and these students are more likely to be interested in working with underserved populations, said Erikson. Community colleges serve as an important entry point to higher education in general: approximately half of Black, Hispanic,

and rural students begin their higher education in a community college, and half of community college students are from low-income families.

To leverage the potential of community colleges to diversify the health professions workforce, faculty could seek ways to engage with students at local colleges. Representatives from the health professions could hold brown bag lunches or guest lectures, network with and mentoring students, and provide job opportunities. In addition, faculty could guide students in the application process and help them become strong applicants for HPE programs. Many community college students are the first in their families to attend college; mentorship and guidance may be essential to facilitate these students’ entrance into the health professions. Formal programs, such as the Medical School Preparatory Education Program at the University of California, Davis, can also help disadvantaged students be more successful in their educational pursuits. Finally, said Erikson, HPE programs can implement a holistic admissions process in order to remove unintended barriers and to recognize the contributions and potential of students from diverse backgrounds.

DISCUSSION

After the presentations, Paniagua led participants in a structured discussion with a roundtable of invited respondents. Paniagua asked the three respondents to comment on how innovations in HPE during the pandemic have “moved learners, educators, and institutions in and out of the margins.”

Toyese Oyeyemi, Jr., The George Washington University, replied how the pandemic has highlighted access issues. Virtual platforms have made learning easier for some people. The example he offered was virtual conferences, which opened the door for attendees who otherwise would not have been able to travel. This allowed a wider audience to gain valuable skills, training, and continuing education. Oyeyemi said his sister, who is a charge nurse in New Mexico, has been able “to attend more professional development conferences in the past 6 months than she had in the previous 6 years.” At the same time, many educational institutions remained inaccessible to some individuals, even those individuals who are from the communities these institutions are tasked to serve. Oyeyemi noted that in contrast to these institutions, community colleges serve as an important port of entry to higher education, particularly for students of color, those from lower socioeconomic backgrounds, and those from rural communities. Community colleges are a resource that needs “to be tapped into.” Oyeyemi commented on how educational institutions and academic health centers should consider partnering more closely with community colleges to reach communities of color, rural populations, and “others who are on

the margins of HPE traditionally.” Melissa Trego, Pennsylvania College of Optometry, added that her program looks for opportunities for students to provide care in their own communities, in part to improve accessibility to education for potential students and in part to improve accessibility to care for these communities.

During the pandemic, said Casey Shillam, University of Portland School of Nursing, clinical practice partners were not able to accommodate learners, which created a “tremendous impact” on the ability to educate and train students. The Oregon State Board of Nursing recognized the challenge and made the decision to waive the hours requirement. This change presents an opportunity to shift away from a requirement of an “arbitrary number of hours” and toward measuring competency.

Shillam shared a success story from her university, and noted how the faculty have embraced the shift toward a competency-based approach. The illustration involves Shillam’s efforts to implement palliative care into the nurse-run primary care clinic, which utilized a simulation with a standardized patient actor during the pandemic. The junior nursing students, said Shillam, engaged with the actor and “developed therapeutic communication and connection and truly got to the patient’s goals of care much quicker and much more effectively” than she had seen before. Her students reported the robust development of this competency was “far and away” due to the telehealth simulations they conducted the previous semester, in which the focus was entirely on communication. That experience, said Shillam, led to “incredible competency” in skills. Such competencies would have been difficult to develop and evaluate in a traditional clinical environment. Shillam added that incorporating frequent simulation activities into nursing education helps to remove the fear and stress students may feel when simulations are used only for evaluation. Some students, she said, may feel anxious because they are “unable to actually demonstrate the competency they have.” Implementing a simulation program focused on creating a safe environment to allow students to leverage the full potential of these learning opportunities.

Lomis remarked that “if done well, competency-based approaches could support better diversity and inclusion” in HPE. She further commented on how early evidence suggests that taking a broader view of what “good performance” is across multiple domains increases the likelihood that each individual can see excellence in themselves and in their natural skill set. This can help highlight things individuals are doing well, in addition to identifying areas or skills needing greater attention.

The field of optometry, said Trego, tends to take a “traditional approach to many things,” and one of the challenges is allowing faculty, students, and accreditors to think outside the box. The Pennsylvania College of Optometry has a unique accelerated program, she said, while it is primarily

time-based, it also incorporates some competency-based aspects. For example, the clinical skills course allows students to choose when they are ready to be assessed on competencies and move into the clinic. Trego noted how this structure requires “a little bit more hand holding,” and that students have to be motivated and willing to ask for help, to assess their readiness, and to put themselves in uncomfortable situations. Students sometimes need to be reminded that asking for help is “not a character flaw,” she said. Erikson added to the conversation saying there is a long history and ingrained culture in medicine discouraging people from acknowledging mistakes or the need for improvement. Although admitting problems is the first step in identifying solutions, she also noted “it will be a challenging thing” to change the culture whereby students feel comfortable acknowledging when they don’t know something.

During this discussion, virtual workshop participants used the chat feature to share their thoughts and ask questions. Frost summarized the comments, noting most of the remarks focused on three general areas. First, several participants remarked about competency-based education and the benefits it offers, such as increased value and the ability to utilize students during a crisis by assessing where they can be trusted. Second, were observations about holistic admissions as one approach to improving access and equity in HPE, but that it is also critical to creating an inclusive and supportive environment. Third, involved chats about collaborations between community colleges and HPE programs as a way of providing a pathway into HPE that not only limits student debt but can increase student diversity of programs.

REFERENCES