MENTORING, EDUCATION, AND TRAINING CORNER John Del Valle, Section Editor
Competency-Based Education, Feedback, and Humility Larry D. Gruppen University of Michigan Medical School, Ann Arbor, Michigan
O
ver the past 2 decades, competency-based education (CBE) has rapidly become the predominant framework for medical education innovation and change. It forms the core of graduate medical education accreditation in North America and much of Europe, and is making inroads into undergraduate education. CBE is an approach to preparing physicians for practice that is fundamentally oriented toward graduate outcomes and organized around competencies derived from an analysis of societal and patient needs. It deemphasizes time-based training and promises greater accountability, flexibility, and learner centeredness.1,2 Although it is based on solid educational principles, CBE is too new to have yet demonstrated efficacy in improving educational or clinical outcomes. Nonetheless, it is a potent tool to reconsider many of the assumptions we have made about medical education. The contrasts between CBE and traditional or “structurebased education” are numerous.3 The most frequently highlighted contrasts include an outcomes focus rather than content focus, a recognition that learners will become competent at variable times rather than on a fixed schedule, and that outcomes assessment must be conducted against a fixed criterion or definition of competence rather than on comparisons with other learners. These contrasts have considerable practical implications for organizing learning programs, scheduling educational events, and structuring assessments. The salience of these particular aspects of CBE tend to overshadow some other important but less discussed contrasts. One of these, on which this commentary will focus, is that CBE is fundamentally learner centered rather than teacher centered.3 The learner must take responsibility for attaining competence, using the learning opportunities and resources available to them, and changing their performance and practice on the basis of formative feedback. Although competence must be defined by the program Gastroenterology 2015;148:4–7
through statements and acceptable forms of evidence, CBE requires learners to actively participate in their individual learning process by setting short-term learning goals and selecting and pursuing learning activities. Learners are also responsible for seeking out feedback and applying it to their own learning. The institutional concerns about offering a feasible and efficient educational program do not always align with this principle of learner centeredness. It is much more efficient for faculty to schedule learning events at set times, which coordinate well with clinic schedules and the faculty members’ other responsibilities. Similarly, assessment, even when intended for formative feedback, often gets hijacked by the program’s need to evaluate learners and assign grades.
Feedback in Competency-Based Education For a specific example of how challenging it can be to align institutional educational practices with CBE goals, we can consider the problem of feedback. To do so, it is helpful to set it in a conceptual framework that helps us to understand the complex dynamics that surround feedback. One of the theoretical underpinnings of CBE is self-regulated learning, and one of the best known theories of self-regulated learning is that developed by Zimmerman.4 Self-regulated learning can be conceptualized as a learning cycle consisting of 4 stages: (1) learning, (2) assessment of the results of the learning (eg, one’s performance), (3) subsequent adjustment of one’s goals or strategies for learning, and (4) planning learning activities and marshaling resources (eg, time).5 Mastery of this learning cycle is part of “learning to learn” and a critical component of lifelong learning. Feedback plays its most important role in the second phase of the cycle, when the learner assesses her or his performance and identifies gaps or deficiencies that need subsequent attention. Such feedback on the quality of one’s performance can come from internal or external sources. Internal feedback typically comes in the form of selfassessment, which is based on a comparison of one’s own
Abbreviations used in this paper: CBE, competency-based education; EPAs, entrustable professional activities. © 2015 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.11.021
MENTORING, EDUCATION, AND TRAINING CORNER performance with one’s understanding of performance standards. If one’s performance meets or exceeds those standards, all is well; if not, the deficit needs to be diagnosed and remedied through subsequent learning. Unfortunately, this apparently simple process is actually very complex and frequently flawed. Research from multiple domains consistently indicates that self-assessment is generally very unreliable as a guide to performance quality.6,7 The inaccuracy of self-assessment is particularly problematic for those who need it the most—the less skilled or experienced, because the knowledge needed to make accurate self-assessments is often the very knowledge that the individual lacks. Selfassessment can also fail through inappropriately high or low internal standards for performance. These internal standards may be biased by one’s experience, critical incidents of success or failure, and by role models—we cannot assume that everyone shares the same standards. External feedback comes from other people, who also make judgments about the quality of a learner’s performance against the judge’s standards. External feedback avoids many of the pitfalls of self-assessment, but has its own limitations. Because it is less subjective than selfassessment, it has the potential for being more accurate. When formatted effectively and delivered by a knowledgeable faculty member, feedback may include valuable guidance for improvement, not just the identification of the deficiency. However, externally generated feedback is much more difficult to obtain than is self-assessment. It is often delayed, often general (“good job”) rather than specific to the performance, and may be based on a limited and biased sample of learner performances. External feedback is where the faculty and the program leadership focus their attention, because it is more or less under their control. It is part of their educational responsibilities and they seek to understand feedback and deliver it effectively. As a result of research, we know of a number of ways to improve feedback: it needs to be delivered frequently; it needs to be linked to behavior and specific parameters, not generalities; it should be formative, directed toward improving performance, not summative (ie, for determining grades or graduation decisions); and it should balance the identification of deficiencies and strengths in performance.8 These are frequently the focus of faculty development workshops and educational policies, yet many faculty and educational leaders are frustrated by a sense of futility that their feedback is being misinterpreted or even willfully ignored.9
Why Feedback Fails Although there is ample evidence that internal feedback is inaccurate (and often fails to identify deficiencies) and that external feedback is delivered poorly, it is important to recognize that feedback is fundamentally a social transaction that takes place in the context of an interpersonal relationship and is modified by the self-image of the learner. Both self-directed learning and faculty development efforts to improve feedback tend to neglect this psychosocial context, seeing the failure of feedback as either a deficiency
in the individual learner or in the faculty member. There is growing evidence, however, that giving and receiving feedback are tied together in intricate ways that influence how feedback translates into behavior change.10–12 There are 3 domains of obstacles that we educators should consider: within people, between people, and in the learning/practice environment.
Within People Learners at all levels want feedback (“How am I doing?”). Often, however, this only amounts to seeking reassurance. They fear disconfirming information, information that does not fit with their self-image. Although disconfirming feedback is likely to be the most useful in terms of making improvements to one’s performance, it is also the most difficult to accept because of the psychological discomfort it creates. There is an intricate interplay between one’s self-image, self-confidence, and feedback. Having self-confidence is not only emotionally positive, but also desirable; confidence fosters action whereas a lack of it leads to inaction and risk avoidance. Individuals need a basic level of self-confidence to even entertain feedback that indicates a gap or deficiency; too little confidence can lead to hesitancy and paralysis. In contrast, too much confidence is likely to lead to ignoring the validity of disconfirming feedback. Confidence is something of a paradox in that it enables learners to ask for and accept feedback but also (inappropriately) buffering them against feedback that might be critical in nature. Thus, the extent to which feedback is deemed valuable is dependent, in part, on the degree to which the feedback can be reconciled with one’s confidence in one’s self-assessments.
Between People Most externally generated feedback comes from people with whom we have a relationship—personal, professional, or both. Feedback affects and is affected by these relationships in several ways. One is the desire to seem competent to others, which makes it difficult to openly acknowledge failures or even uncertainty. The likelihood that external feedback will be utilized depends on the perceived credibility of the source and the perceived accuracy of the feedback. We also tend to support another person’s selfimage by more readily giving praise rather than criticism. Indeed, giving someone corrective feedback places stress on the relationship. Unless the relationship is strong, this stress may damage the relationship, thus producing a reluctance to provide relevant corrective feedback. Providing feedback requires a strong relationship that is characterized by trust and safety. Such relationships are not built quickly, which means either that feedback in new relationships will be shallow, general, and biased toward affirmation, or criticism will be easy because there is no investment in and value placed on the relationship.
In the Learning/Practice Environment The work and learning environments have their own influences. The workplace may have a “feedback culture” or a “blame culture.” There may be few opportunities to be 5
MENTORING, EDUCATION, AND TRAINING CORNER observed and thus receive relevant feedback. There may be little time for learners to reflect on the feedback received so they can interpret it and translate it into action. The stated and the hidden priorities of the institution may clash, as often happens between emphases on clinical productivity and educational excellence. Finally, there may be a greater emphasis on evaluation than on feedback, leaving learners reluctant to expose any ignorance. The complexity of giving, receiving, and using feedback, whether internal or external, is not unique to CBE. However, the reliance of CBE on an active learner who takes responsibility for his own learning and performance improvement places greater importance on how he uses feedback. Given the powerful psychological mechanisms that protect our self-concept from possible injury from negative feedback, even at the expense of our long-term effectiveness, we need a psychological countermeasure to help us honestly consider this feedback. One candidate for this role may be humility.
Humility Humility is a willingness to acknowledge the possibility that you are fallible and may be wrong, that you need guidance or help from others on occasion, that you can benefit from feedback, and that you need to make changes in your performance. Many of us find humility more or less difficult. In North America, we typically practice in an environment that rewards hubris rather than humility. Indeed, striving for excellence motivates people toward achievement and advancement, but it also engenders competition and striving for preeminence. However, the benefits of humility are real. At an institutional level, acknowledging errors and making appropriate apology has been demonstrated to improve patient relations and reduce litigation.13 At a personal level, it makes it easier to recognize the need for continuing improvement, to seek and accept feedback that can foster that improvement, and to make relevant changes. Thus, humility should be treated as a professional and personal value that needs to be learned and constantly practiced.14 Indeed, a commitment to humility is built into modern versions of the Hippocratic Oath (such as the ‘Lasagna Oath’)—“I will not be ashamed to say ‘I know not,’ nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.”15 Instilling humility is not done best by humiliation, but by demonstration. In other words, learners must see humility in their faculty as role models. However, this requires all of us as faculty to come to a healthy appreciation for the pervasive presence of uncertainty, the reality of our own limitations, and a willingness to express these issues more openly with each other. In summary, the adoption of CBE and the explicit definition of competencies, entrustable professional activities (EPAs) and milestones16 has several implications for feedback in medical education. On the one hand, it clarifies what goals faculty members should be addressing when they provide feedback. Explicit milestones and EPAs can provide the specificity that is too often lacking in feedback. It can 6
also foster corrective actions to take in response to feedback. On the other hand, the very centrality of feedback in CBE will likely accentuate the impact of the barriers to delivering and receiving feedback, as described. Overcoming these barriers requires action by faculty, learners, and the organization. Faculty members can take advantage of program milestones and EPAs to not simply evaluate trainees, but to provide a few words of feedback about the individual’s actual performance. Faculty should explicitly identify it as “feedback” so that trainees do not hear it as “evaluation” and neglect opportunities for changing their performance. Faculty also should discuss and model the ways they themselves seek out and use feedback, particularly when it identifies a correction that they need to make. Trainees must recognize that their learning is a life-long process and that they need to acquire the ability to constantly appraise their knowledge, skills, and performance, always seeking ways to improve. They must accept the discomfort inherent to this healthy level of skepticism applied to themselves and take on the work of seeking out feedback rather than avoiding it. The organization needs to work on building an educational culture in which feedback is routine, and takes place in an atmosphere of trust and a sense of safety, so that errors, improvements, and working relationships can be openly discussed. Effective implementation of CBE requires this coordinated effort by all involved to realize the potential of educating physicians who constantly strive to improve themselves and the health care they deliver.
References 1. Frank JR, Mungroo R, Ahmad Y, et al. Toward a definition of competency-based education in medicine: a systematic review of published definitions. Med Teach 2010;32:631–637. 2. tenCate O, Billett S. Competency-based medical education: origins, perspectives and potentialities. Med Educ 2014;48:325–332. 3. Carraccio C, Wolfsthal SD, Englander R, et al. Shifting paradigms: from Flexner to competencies. Acad Med 2002;77:361–367. 4. Zimmerman BJ. Dimensions of academic self-regulation: A conceptual framework for education. In: Schunk DH, Zimmerman BJ, eds. Self-regulation of learning and performance: Issues and educational applications. Hillsdale, NJ: Erlbaum, 1991:3–21. 5. White CB, Gruppen LD, Fantone JC. Self-regulated learning in medical education. In: Swanwick T, editor. Understanding medical education. 2nd ed. Chichester, UK; 2014. pp. 201–212. 6. Kruger J, Dunning D. Unskilled and unaware of it: How difficulties in recognizing one’s own incompetence lead to inflated self-assessments. J Personality Soc Psychol 1999;77:1121–1134. 7. Ward M, Gruppen L, Regehr G. Measuring selfassessment: current state of the art. Adv Health Sci Educ 2002;7:63–80.
MENTORING, EDUCATION, AND TRAINING CORNER 8. Kilminster S, Cottrell D, Grant J, et al. AMEE Guide no. 27: effective educational and clinical supervision. Med Teach 2007;29:2–19. 9. Watling C, Driessen E, van der Vleuten CPM, et al. Understanding responses to feedback: the potential and limitations of regulatory focus theory. Med Educ 2012; 46:593–603. 10. Sargeant J, Eva KW, Armson H, et al. Features of assessment learners use to make informed selfassessments of clinical performance. Med Educ 2011; 45:636–647. 11. Eva KW, Armson H, Holmboe E, et al. Factors influencing responsiveness to feedback: on the interplay between fear, confidence, and reasoning processes. Adv in Health Sci Educ 2011;17:15–26. 12. Mann K, van der Vleuten C, Eva K, et al. Tensions in informed self-assessment: how the desire for feedback and reticence to collect and use it can conflict. Acad Med 2011;86:1120–1127. 13. Boothman RC, Imhoff SJ, Campbell DA Jr. Nurturing a culture of patient safety and achieving lower
malpractice risk through disclosure: lessons learned and future directions. Front Health Serv Manage 2012; 28:13–28. 14. Gruppen LD. Humility and respect: core values in medical education. Med Educ 2013;48(1):53–58. 15. Lasagna L. Hippocratic oath – modern version [Internet]. [cited 2014 Aug 19]. Available from: http://ethics.ucsd. edu/journal/2006/readings/Hippocratic_Oath_Modern_ Version.pdf. 16. Iobst WF, Sherbino J, ten Cate O, et al. Competencybased medical education in postgraduate medical education. Med Teach 2010;32:651–656.
Reprint requests Address requests for reprints to: Larry D. Gruppen, PhD, Department of Medical Education, University of Michigan Medical School, G1111 Towsley Center, Ann Arbor, Michigan 48109-0201. e-mail: [email protected]; fax: (734) 936-1641. Conflicts of interest The author discloses no conflicts.
7
Competency-Based Education, Feedback, and Humility Larry D. Gruppen University of Michigan Medical School, Ann Arbor, Michigan
O
ver the past 2 decades, competency-based education (CBE) has rapidly become the predominant framework for medical education innovation and change. It forms the core of graduate medical education accreditation in North America and much of Europe, and is making inroads into undergraduate education. CBE is an approach to preparing physicians for practice that is fundamentally oriented toward graduate outcomes and organized around competencies derived from an analysis of societal and patient needs. It deemphasizes time-based training and promises greater accountability, flexibility, and learner centeredness.1,2 Although it is based on solid educational principles, CBE is too new to have yet demonstrated efficacy in improving educational or clinical outcomes. Nonetheless, it is a potent tool to reconsider many of the assumptions we have made about medical education. The contrasts between CBE and traditional or “structurebased education” are numerous.3 The most frequently highlighted contrasts include an outcomes focus rather than content focus, a recognition that learners will become competent at variable times rather than on a fixed schedule, and that outcomes assessment must be conducted against a fixed criterion or definition of competence rather than on comparisons with other learners. These contrasts have considerable practical implications for organizing learning programs, scheduling educational events, and structuring assessments. The salience of these particular aspects of CBE tend to overshadow some other important but less discussed contrasts. One of these, on which this commentary will focus, is that CBE is fundamentally learner centered rather than teacher centered.3 The learner must take responsibility for attaining competence, using the learning opportunities and resources available to them, and changing their performance and practice on the basis of formative feedback. Although competence must be defined by the program Gastroenterology 2015;148:4–7
through statements and acceptable forms of evidence, CBE requires learners to actively participate in their individual learning process by setting short-term learning goals and selecting and pursuing learning activities. Learners are also responsible for seeking out feedback and applying it to their own learning. The institutional concerns about offering a feasible and efficient educational program do not always align with this principle of learner centeredness. It is much more efficient for faculty to schedule learning events at set times, which coordinate well with clinic schedules and the faculty members’ other responsibilities. Similarly, assessment, even when intended for formative feedback, often gets hijacked by the program’s need to evaluate learners and assign grades.
Feedback in Competency-Based Education For a specific example of how challenging it can be to align institutional educational practices with CBE goals, we can consider the problem of feedback. To do so, it is helpful to set it in a conceptual framework that helps us to understand the complex dynamics that surround feedback. One of the theoretical underpinnings of CBE is self-regulated learning, and one of the best known theories of self-regulated learning is that developed by Zimmerman.4 Self-regulated learning can be conceptualized as a learning cycle consisting of 4 stages: (1) learning, (2) assessment of the results of the learning (eg, one’s performance), (3) subsequent adjustment of one’s goals or strategies for learning, and (4) planning learning activities and marshaling resources (eg, time).5 Mastery of this learning cycle is part of “learning to learn” and a critical component of lifelong learning. Feedback plays its most important role in the second phase of the cycle, when the learner assesses her or his performance and identifies gaps or deficiencies that need subsequent attention. Such feedback on the quality of one’s performance can come from internal or external sources. Internal feedback typically comes in the form of selfassessment, which is based on a comparison of one’s own
Abbreviations used in this paper: CBE, competency-based education; EPAs, entrustable professional activities. © 2015 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.11.021
MENTORING, EDUCATION, AND TRAINING CORNER performance with one’s understanding of performance standards. If one’s performance meets or exceeds those standards, all is well; if not, the deficit needs to be diagnosed and remedied through subsequent learning. Unfortunately, this apparently simple process is actually very complex and frequently flawed. Research from multiple domains consistently indicates that self-assessment is generally very unreliable as a guide to performance quality.6,7 The inaccuracy of self-assessment is particularly problematic for those who need it the most—the less skilled or experienced, because the knowledge needed to make accurate self-assessments is often the very knowledge that the individual lacks. Selfassessment can also fail through inappropriately high or low internal standards for performance. These internal standards may be biased by one’s experience, critical incidents of success or failure, and by role models—we cannot assume that everyone shares the same standards. External feedback comes from other people, who also make judgments about the quality of a learner’s performance against the judge’s standards. External feedback avoids many of the pitfalls of self-assessment, but has its own limitations. Because it is less subjective than selfassessment, it has the potential for being more accurate. When formatted effectively and delivered by a knowledgeable faculty member, feedback may include valuable guidance for improvement, not just the identification of the deficiency. However, externally generated feedback is much more difficult to obtain than is self-assessment. It is often delayed, often general (“good job”) rather than specific to the performance, and may be based on a limited and biased sample of learner performances. External feedback is where the faculty and the program leadership focus their attention, because it is more or less under their control. It is part of their educational responsibilities and they seek to understand feedback and deliver it effectively. As a result of research, we know of a number of ways to improve feedback: it needs to be delivered frequently; it needs to be linked to behavior and specific parameters, not generalities; it should be formative, directed toward improving performance, not summative (ie, for determining grades or graduation decisions); and it should balance the identification of deficiencies and strengths in performance.8 These are frequently the focus of faculty development workshops and educational policies, yet many faculty and educational leaders are frustrated by a sense of futility that their feedback is being misinterpreted or even willfully ignored.9
Why Feedback Fails Although there is ample evidence that internal feedback is inaccurate (and often fails to identify deficiencies) and that external feedback is delivered poorly, it is important to recognize that feedback is fundamentally a social transaction that takes place in the context of an interpersonal relationship and is modified by the self-image of the learner. Both self-directed learning and faculty development efforts to improve feedback tend to neglect this psychosocial context, seeing the failure of feedback as either a deficiency
in the individual learner or in the faculty member. There is growing evidence, however, that giving and receiving feedback are tied together in intricate ways that influence how feedback translates into behavior change.10–12 There are 3 domains of obstacles that we educators should consider: within people, between people, and in the learning/practice environment.
Within People Learners at all levels want feedback (“How am I doing?”). Often, however, this only amounts to seeking reassurance. They fear disconfirming information, information that does not fit with their self-image. Although disconfirming feedback is likely to be the most useful in terms of making improvements to one’s performance, it is also the most difficult to accept because of the psychological discomfort it creates. There is an intricate interplay between one’s self-image, self-confidence, and feedback. Having self-confidence is not only emotionally positive, but also desirable; confidence fosters action whereas a lack of it leads to inaction and risk avoidance. Individuals need a basic level of self-confidence to even entertain feedback that indicates a gap or deficiency; too little confidence can lead to hesitancy and paralysis. In contrast, too much confidence is likely to lead to ignoring the validity of disconfirming feedback. Confidence is something of a paradox in that it enables learners to ask for and accept feedback but also (inappropriately) buffering them against feedback that might be critical in nature. Thus, the extent to which feedback is deemed valuable is dependent, in part, on the degree to which the feedback can be reconciled with one’s confidence in one’s self-assessments.
Between People Most externally generated feedback comes from people with whom we have a relationship—personal, professional, or both. Feedback affects and is affected by these relationships in several ways. One is the desire to seem competent to others, which makes it difficult to openly acknowledge failures or even uncertainty. The likelihood that external feedback will be utilized depends on the perceived credibility of the source and the perceived accuracy of the feedback. We also tend to support another person’s selfimage by more readily giving praise rather than criticism. Indeed, giving someone corrective feedback places stress on the relationship. Unless the relationship is strong, this stress may damage the relationship, thus producing a reluctance to provide relevant corrective feedback. Providing feedback requires a strong relationship that is characterized by trust and safety. Such relationships are not built quickly, which means either that feedback in new relationships will be shallow, general, and biased toward affirmation, or criticism will be easy because there is no investment in and value placed on the relationship.
In the Learning/Practice Environment The work and learning environments have their own influences. The workplace may have a “feedback culture” or a “blame culture.” There may be few opportunities to be 5
MENTORING, EDUCATION, AND TRAINING CORNER observed and thus receive relevant feedback. There may be little time for learners to reflect on the feedback received so they can interpret it and translate it into action. The stated and the hidden priorities of the institution may clash, as often happens between emphases on clinical productivity and educational excellence. Finally, there may be a greater emphasis on evaluation than on feedback, leaving learners reluctant to expose any ignorance. The complexity of giving, receiving, and using feedback, whether internal or external, is not unique to CBE. However, the reliance of CBE on an active learner who takes responsibility for his own learning and performance improvement places greater importance on how he uses feedback. Given the powerful psychological mechanisms that protect our self-concept from possible injury from negative feedback, even at the expense of our long-term effectiveness, we need a psychological countermeasure to help us honestly consider this feedback. One candidate for this role may be humility.
Humility Humility is a willingness to acknowledge the possibility that you are fallible and may be wrong, that you need guidance or help from others on occasion, that you can benefit from feedback, and that you need to make changes in your performance. Many of us find humility more or less difficult. In North America, we typically practice in an environment that rewards hubris rather than humility. Indeed, striving for excellence motivates people toward achievement and advancement, but it also engenders competition and striving for preeminence. However, the benefits of humility are real. At an institutional level, acknowledging errors and making appropriate apology has been demonstrated to improve patient relations and reduce litigation.13 At a personal level, it makes it easier to recognize the need for continuing improvement, to seek and accept feedback that can foster that improvement, and to make relevant changes. Thus, humility should be treated as a professional and personal value that needs to be learned and constantly practiced.14 Indeed, a commitment to humility is built into modern versions of the Hippocratic Oath (such as the ‘Lasagna Oath’)—“I will not be ashamed to say ‘I know not,’ nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.”15 Instilling humility is not done best by humiliation, but by demonstration. In other words, learners must see humility in their faculty as role models. However, this requires all of us as faculty to come to a healthy appreciation for the pervasive presence of uncertainty, the reality of our own limitations, and a willingness to express these issues more openly with each other. In summary, the adoption of CBE and the explicit definition of competencies, entrustable professional activities (EPAs) and milestones16 has several implications for feedback in medical education. On the one hand, it clarifies what goals faculty members should be addressing when they provide feedback. Explicit milestones and EPAs can provide the specificity that is too often lacking in feedback. It can 6
also foster corrective actions to take in response to feedback. On the other hand, the very centrality of feedback in CBE will likely accentuate the impact of the barriers to delivering and receiving feedback, as described. Overcoming these barriers requires action by faculty, learners, and the organization. Faculty members can take advantage of program milestones and EPAs to not simply evaluate trainees, but to provide a few words of feedback about the individual’s actual performance. Faculty should explicitly identify it as “feedback” so that trainees do not hear it as “evaluation” and neglect opportunities for changing their performance. Faculty also should discuss and model the ways they themselves seek out and use feedback, particularly when it identifies a correction that they need to make. Trainees must recognize that their learning is a life-long process and that they need to acquire the ability to constantly appraise their knowledge, skills, and performance, always seeking ways to improve. They must accept the discomfort inherent to this healthy level of skepticism applied to themselves and take on the work of seeking out feedback rather than avoiding it. The organization needs to work on building an educational culture in which feedback is routine, and takes place in an atmosphere of trust and a sense of safety, so that errors, improvements, and working relationships can be openly discussed. Effective implementation of CBE requires this coordinated effort by all involved to realize the potential of educating physicians who constantly strive to improve themselves and the health care they deliver.
References 1. Frank JR, Mungroo R, Ahmad Y, et al. Toward a definition of competency-based education in medicine: a systematic review of published definitions. Med Teach 2010;32:631–637. 2. tenCate O, Billett S. Competency-based medical education: origins, perspectives and potentialities. Med Educ 2014;48:325–332. 3. Carraccio C, Wolfsthal SD, Englander R, et al. Shifting paradigms: from Flexner to competencies. Acad Med 2002;77:361–367. 4. Zimmerman BJ. Dimensions of academic self-regulation: A conceptual framework for education. In: Schunk DH, Zimmerman BJ, eds. Self-regulation of learning and performance: Issues and educational applications. Hillsdale, NJ: Erlbaum, 1991:3–21. 5. White CB, Gruppen LD, Fantone JC. Self-regulated learning in medical education. In: Swanwick T, editor. Understanding medical education. 2nd ed. Chichester, UK; 2014. pp. 201–212. 6. Kruger J, Dunning D. Unskilled and unaware of it: How difficulties in recognizing one’s own incompetence lead to inflated self-assessments. J Personality Soc Psychol 1999;77:1121–1134. 7. Ward M, Gruppen L, Regehr G. Measuring selfassessment: current state of the art. Adv Health Sci Educ 2002;7:63–80.
MENTORING, EDUCATION, AND TRAINING CORNER 8. Kilminster S, Cottrell D, Grant J, et al. AMEE Guide no. 27: effective educational and clinical supervision. Med Teach 2007;29:2–19. 9. Watling C, Driessen E, van der Vleuten CPM, et al. Understanding responses to feedback: the potential and limitations of regulatory focus theory. Med Educ 2012; 46:593–603. 10. Sargeant J, Eva KW, Armson H, et al. Features of assessment learners use to make informed selfassessments of clinical performance. Med Educ 2011; 45:636–647. 11. Eva KW, Armson H, Holmboe E, et al. Factors influencing responsiveness to feedback: on the interplay between fear, confidence, and reasoning processes. Adv in Health Sci Educ 2011;17:15–26. 12. Mann K, van der Vleuten C, Eva K, et al. Tensions in informed self-assessment: how the desire for feedback and reticence to collect and use it can conflict. Acad Med 2011;86:1120–1127. 13. Boothman RC, Imhoff SJ, Campbell DA Jr. Nurturing a culture of patient safety and achieving lower
malpractice risk through disclosure: lessons learned and future directions. Front Health Serv Manage 2012; 28:13–28. 14. Gruppen LD. Humility and respect: core values in medical education. Med Educ 2013;48(1):53–58. 15. Lasagna L. Hippocratic oath – modern version [Internet]. [cited 2014 Aug 19]. Available from: http://ethics.ucsd. edu/journal/2006/readings/Hippocratic_Oath_Modern_ Version.pdf. 16. Iobst WF, Sherbino J, ten Cate O, et al. Competencybased medical education in postgraduate medical education. Med Teach 2010;32:651–656.
Reprint requests Address requests for reprints to: Larry D. Gruppen, PhD, Department of Medical Education, University of Michigan Medical School, G1111 Towsley Center, Ann Arbor, Michigan 48109-0201. e-mail: [email protected]; fax: (734) 936-1641. Conflicts of interest The author discloses no conflicts.
7
