CBME, EPAs, and Task-Centred Learning
In the beginning of the 21st century, health professions education became heavily affected by a movement that became known as Competency-Based Medical Education (CBME). It was a reaction on fragmented curricula and training programs that were driven by long lists of learning objectives, often focusing on pieces of knowledge and subskills that in the perception of learners had little relation to clinical practice.
In CBME, learners don’t just acquire knowledge that they must spit back at a final exam but they develop competencies that can be assessed in meaningful real-life situations. The general approach of CBME is to identify desired outcomes as to-be-acquired competences, then define the minimum level of performance for each competency, develop a framework for assessing the competencies, and finally evaluate the program on a continuous basis to be sure that the desired outcomes are being achieved. The ACGME and CANMEDS competencies became widely used across the world, with roles such as medical expert, communicator, collaborator, manager, scholar, professionalism, and health advocate (where the latter is only present in CANMEDS, not in ACGME). Furthermore, so-called milestones were developed to operationalize and implement the competencies; they describe the skills, knowledge, and attitudes that learners are expected to demonstrate at several performance levels, such as novice, advanced beginner, competent individual, proficient individual, and expert physician.
CBME has been successful in refocussing health professions education from fragmented knowledge and skills to meaningful competencies. But it also has its weaknesses, of which the most important one is probably the unclear link between competencies on the one hand, and professional tasks on the other hand. This triggered a new counter-movement that is currently known as Entrustable Professional Activities (EPAs). Workplace supervisors traditionally judge the maturity of learners by their ability to bear responsibility and to safely perform particular professional tasks without supervision. These tasks are called Entrustable Professional Activities (EPAs) and are defined as responsibilities entrusted to a learner to execute, unsupervised, once s/he has obtained adequate competence. In contrast to CBME, where learners' growth is typically described on a continuum from novice to expert physician, EPA models typically describe growth in terms of graded workplace supervision, from observing the activity performed by others, through acting with direct supervision available in the room and by acting with direct supervision available in a few minutes, to acting without any supervision.
The new SHE research program is called task-centred learning environments in the health professions. Well-designed task-centred learning environments relay on both CBME and EPAs, giving equal weight to tasks on the one hand, and the competencies required to perform these tasks on the other hand. A model like four-component instructional design (4C/ID), for example, starts the design of a learning environment with the specification of professional tasks that can serve as a basis for designing learning tasks, and the tasks are ordered in simple-to-complex task classes. EPAs closely resemble those task classes. The main difference is that task classes define a set of learning tasks at a particular level of complexity that must help the learners to develop particular competencies, while EPAs define a set of professional tasks at a particular level of complexity for which the learners have already developed these competencies – as determined through summative assessment. Second, both professional tasks and learning tasks are explicitly linked to the competencies necessary to perform those tasks up to the standards. A matrix with tasks at one dimension, and competencies or standards at the other dimension, is thus always at the hearth of task-centred learning environments. I hope that our new research program will so contribute to bringing CBME and EPA models closer together.
Jeroen van Merrienboer
Get involved in task-centred learning environments: A new online SHE research course is called: Critical Appraisal of Task-centred Learning Environments. Starting date: 8 April 2019