Competency-based medical training

Health systems rely on competent workers, s why are the majority of training programmes biased heavily towards knowledge-based assessments?
25 October 2024

Interview with 

Gloria Pedersen, Harvard Medical School

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Health systems rely on competent workers. So why are the majority of training programmes biased heavily towards knowledge-based assessments, rather than tests of actual competency? It sounds obvious when you put it like that doesn’t it, so can we do it better? Gloria Pedersen, from Harvard Medical School, thinks we can, and, as she explains to Chris Smith, she’s been evaluating the effectiveness of a competency-based programme for trainers and supervisors in Nepal, Peru, and Uganda…

Gloria - Globally, there is a growing demand to meet mental health needs and also to improve the quality of healthcare delivery overall. But right now the workforce just really isn't skilled in certain aspects such as foundational helping skills (like effective communication, empathy, promoting hope for change) that really ensure safe and effective service delivery. In fact, 98% of the healthcare workers scored harmfully in these competencies before taking part in our training, suggesting that existing education is falling short either by not covering these skills, or are focusing too heavily on knowledge-based learning rather than practical competency.

Chris - Does this mean then that what we regard as our gold standard curriculum isn't fit for purpose? The way we're currently training people to do this isn't up to scratch?

Gloria - How we're training isn't up to scratch. I think what we're learning is that everything's really being taught more in a knowledge based approach. People are using knowledge multiple choice questions to determine whether or not these skills are set, so I think really this idea of having a more tailored approach rather than a one size fits all training, one that's really interactive (using roleplay, having competency assessments with tailored feedback on how folks are doing) can really elevate the rate at which folks reach competency in these skills as well as the efficiency with which they reach them.

Chris - You're advocating then more for a bit like doing a driving test for this sort of healthcare provision, rather than I demonstrate that I've learned all the things that Freud said and thought, and I can reproduce them in an exam but I've never been near a patient. You are saying we need to make sure that people, when they are going near a patient, not only know all the stuff that Freud said, but also know how to use that information in a way that's meaningful and impactful for the patient.

Gloria - Exactly. Actually, the roleplays do just that where it gives them the opportunity to practise with someone who's pretending to be the patient or the person they're working with, as well as having a tool that specifically lists out behaviours that are describing what we want to see and show when we're having that engagement.

Chris - Just playing devil's advocate for a moment, though, Gloria, how do we know that that's any better and we'll end up with better outcomes than what we've got at the moment?

Gloria - I think that's a really great question and still one that we're investigating in terms of patient outcomes, but what we have seen in most research that's come out is that roleplay based competency assessment, compared to knowledge-based assessment, does predict better outcomes in patients. Ultimately, there is still some work to be done in terms of looking specifically at patient outcomes, but what we can say is that for sure this is a promising route for ensuring a 'do no harm' approach among these providers.

Chris - What about the healthcare workers themselves? If you ask them both before and after when you start working on them in a competency based way, rather than just the 'have you reach the required level of knowledge' way, do they feel more empowered? Do they feel they're doing better by their patients when they're armed with your approach compared to what I'll call the 'traditional' way of doing it?

Gloria - That was one of the most exciting things from this study is that that's exactly what we heard and learned from these folks. The interactive style, particularly due to the roleplay practice and the feedback, really highlighted the difference from what they had learned in their typical training. We heard from an obstetrician who takes a typical mental health training for a suicide assessment as part of their pre-service training leading up to them being an obstetrician. We can compare that to what they learned and how they learned how to practise it in this training, and they let us know a few weeks later that they have now felt more confident to bring it up actively with their patients. They're talking about the topic of suicide. Their patients are opening up more and all because they really didn't even understand that: 'Well, I understand the questions are there, but I didn't know I'm supposed to ask them directly or how I should do that.' We are hearing it from the health workers and, even beyond that, we're hearing overwhelmingly from these health workers that were trained just how excited and impacted they felt based on it. How they can't wait to see what changes this is going to make with their patients. They want to get more feedback on how this might be making them treat overall holistically this person rather than just another checkbox in terms of treatment.

Chris - What about implementation? Because obviously there's practising like this, but then there's teaching people to practise like this, and then there's teaching people to teach how you practise like this. So what do you think the barriers now are to implementing this and how realisable is it?

Gloria - That's a really important question. For one, the manual that we designed actually is specifically for just that: how trainers and supervisors alike can teach these skills using these competency-based approaches like the roleplays and feedback and tools. That being said, our trainers in this study, some were a little bit more experienced, others weren't as much. So, it does take some time. We also learned that, particularly for the trainees who were currently delivering services - they were going to work during the day (like nurses) and then at night take this training - ultimately, to really optimise the tools and the modular approach of this foundational helping skills training, it could be best implemented into a pre-service or into a school setting where a nurse is already there to learn about all of her techniques in addition to the specific style of competency-based training approaches. I would say that there are definitely barriers when it comes to time and resources, but we also learned and are learning currently from some of our partners in Uganda and in Peru ways that this could also be included in a more simple fashion. For example, in this study, we had actually done a full 8 to 10 modules of training in 20 hours, whereas for the manual setup you could just do one module, looking at it sort of as a continuing education, or just embedding it in ongoing monitoring and supervision.

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