Competency-Based Otolaryngology Training Is Becoming More of a Fixture, But Needs to Be Fully Developed

Competency-based medical education (CBME), a learning model in which students must demonstrate the required knowledge and skill levels on a task before advancing to the next task, has become a crucial part of assessing the clinical competence of residents and fellows—particularly during and after the COVID-19 pandemic, when more traditional education has suffered (Guidance Statement on Competency-Based Medical Education during COVID-19 Residency and Fellowship Disruptions. Accreditation Council for Graduate Medical Education (ACGME). News Release. Updated January 5, 2022).

In addition, entrustable professional activities (EPAs), a clinical assessment component of CBME, serve as a way to translate the broad concept of competency into everyday practice. EPAs were developed to allow “frequent, time-efficient, feedback-oriented, and workplace- based assessment” in daily clinical practice, according to the American Board of Surgery.

Otolaryngology residents need both competency-based and EPA training to be at their best, but such training in the profession is undefined and not yet fully developed in the United States.

Defining Training

“We need both EPAs and [CBME], as the EPAs guide competency-based medical education,” said Sonya Malekzadeh, MD, residency program director and professor of otolaryngology–head and neck surgery at Georgetown University Medical Center in Washington, D.C. She explained that the current training approach is based on a fixed time for training—a standard number of years—and not competency, but some residents may achieve competency earlier than in the current model of required years of training. “With competency-based training, residents remain in training until they can demonstrate knowledge and skills for their specialty and are able to apply the knowledge and skills independently and competently to individual patients,” Dr. Malekzadeh said.

Another issue, according to Dr. Malekzadeh, is that “current training methods are unstructured and unsystematic and are not based on validated teaching methods. Furthermore, our assessment of knowledge and technical skills and overall competency are not objective but based on subjective observation and logbooks.”

Richard V. Smith, MD, professor and university chair in the department of otorhinolaryngology–head and neck surgery, Montefiore Health System/Albert Einstein College of Medicine in New York City, said that the need for competency-based assessment and training is recognized, but that the best methods to assess learners and ensure that there are safe doctors providing high quality care are still a matter of discussion.

“Competency-based assessment of otolaryngology residents is already in existence, using criteria such as the Clinical Competencies and Milestones [2020 Milestones Guidebook for Residents and Fellows, ACGME], but other methodologies are used, such as case logs, which do not, necessarily, rely upon demonstration of competency. This has become even more critical in the area of surgical volume, which can be affected by pandemics and natural disasters, loss of key faculty, or other factors that may be difficult to control and may not be related to competency.”

With competencybased training, residents remain in training until they can demonstrate knowledge and skills for their specialty and are able to apply the knowledge and skills independently and competently to individual patients. —Sonya Malekzadeh, MD

While case numbers have been a convenient way to measure exposure and function as a surrogate for trainee competency, real-time, case-by-case assessment of competency would be a more representative evaluation, said Dr. Smith. He added that simulation-based learning is an important way to teach and evaluate competency; while it’s present in many programs, it isn’t standardized across all programs. “Faculty evaluations are also competency based, as the faculty are assessing the trainees in situ and evaluating their ability to perform given tasks,” he said.

“The main goal now, from my perspective, is to remove the subjective component of assessment as much as possible and have a clear, transparent, and reproducible way to assess and document competency, which eliminates potential bias,” Dr. Smith said.

Steps to Standardize

Michael J. Brenner, MD, associate professor in the department of otolaryngology– head and neck surgery at the University of Michigan Medical School in Ann Arbor, noted that one potential source of confusion relating to EPAs involves how they are sometimes conflated with competencies and skills. Citing insights from a 2022 article published in Advances in Health Sciences Education (Adv in Health Sci Educ. 2022;27:491– 499), he explained that a person’s ability to perform a task or procedure is a skill, but the EPA is the activity itself.

“Entrustment thus lies at the intersection of a learner’s readiness to perform a task and how that task is executed,” Dr. Brenner said. This means that EPAs aren’t attributes of individuals but of the clinical work that’s being performed. “The implementation of EPAs can be undermined by policies requiring that specific roles be performed by an attending physician, as this can reduce autonomy and entrustment that is accorded a physician in training. The goal is that entrustment decisions are made to support progression through stages,” Dr. Brenner explained.

Some professional publishers are trying to break into the competency-based training business, such as Decker publishing, Memphis, Tenn., which offers an e-learning portal for many specialties, including otolaryngology. Dr. Malekzadeh believes, however, that EPA/CBME content should be developed and implemented by a core group of organizations and societies whose mission centers on residency education and assessment, with input from ACGME, the American Board of Otolaryngology–Head and Neck Surgery, and the American Academy of Otolaryngology–Head and Neck Surgery.

Cristina Cabrera-Muffly, MD, associate professor and residency program director at the department of otolaryngology–head and neck surgery at the University of Colorado Anschutz Medical Campus, noted that one of the goals of the ACGME’s revised Milestones 2.0 is to better define competency within otolaryngology residency training. “There has definitely been a push for medical schools to incorporate EPAs into their curriculum, but specific EPAs haven’t been implemented for our specialty,” she said. Dr. Cabrera-Muffly suggested that the content for competency-based training should be managed by ACGME for residency programs, likely in combination with the Residency Review Committee and the Otolaryngology Program Directors Organization.

Catching Up in the United States

When it comes to otolaryngology, Europe and Canada are further along with EPA/CBME than the United States. Programs in Canada have been performing CBME, usually referred to there as competence by design, for some time.

“This international experience may provide a foundation for ongoing efforts in the U.S. Learning from the experience of international colleagues can not only spare us reinventing the wheel but can afford us opportunities for future collaboration,” said Dr. Brenner. “Although thought leaders in otolaryngology in the U.S. are taking a growing interest in this area, relatively few individuals have built a professional focus around leading change through implementation of EPAs in our field. Our specialty can also learn from translatable experiences in medicine, general surgery, and other fields that are exploring EPAs. In some cases, there may even be significant overlap, as with the examples of endocrine surgery or tracheostomy where resources are already being refined.”

EPAs are currently used in medical school curriculum. “There has been discussion in graduate medical education regarding the need for similar constructs. The impact of COVID-19 on training has expedited and facilitated the conversation,” Dr. Malekzadeh said. In the United States, some specialties are starting to explore and incorporate EPAs into the residency curriculum. The American Board of Surgery has implemented a pilot study to explore how this might look in general surgery. “Simulation is another way to assess competency and is being used for not just residency training but also for board certification in other specialties,” Dr. Malekzadeh explained.

The main goal is to remove the subjective component and have a clear and reproducible way to assess and document competency, which eliminates potential bias. —Richard V. Smith, MD

She also noted that while EPA/CBME isn’t very widespread in the United States currently, it is on the rise. The Society of University Otolaryngologists is exploring a national curriculum that could incorporate the concepts of CBME. “It’s very likely that this type of education will be added to residencies nationwide, as we understand the limitations of the current system,” she said. Dr. Malekzadeh added, however, that it will be an intensive effort for each specialty to develop a knowledge base that allows progressive responsibilities for patients.

As for the cost to residents for this type of education, Dr. Malekzadeh believed that it might ultimately be mandated by overseeing and regulatory organizations. Dr. Smith added that the amount that students and institutions are willing to spend in terms of resources for EPA and CBME is variable and depends upon the assessment method and its level of engagement.

“Residents and fellows are often eager to participate in simulation exercises, which can be incredibly effective at teaching interpersonal skills and teamwork and provide a valuable tool for competency assessments,” said Dr. Smith. “Too often, people focus on the ‘task trainer’ side of simulation, which is very important in teaching particular technical skills. However, situational simulation is also an extremely valuable tool to teach and assess teamwork and interpersonal skills in critical and difficult clinical scenarios, particularly when multiple specialties are involved.” He added that the resources are often related to time—for faculty to teach and assess and for residents and fellows to learn. “It’s generally agreed upon that text-based teaching is less effective than when text is combined with experience, which will prompt the learner to a greater depth of understanding by providing relevance,” he said. “Over time, we have addressed this by extending training duration (including fellowships), to allow for increased clinical exposure and to satisfy numerical constructs for surgical experience, and by expanding faculty numbers to provide more clinical opportunities.

“In my opinion,” Dr. Smith continued, “an optimal resident training program in the future would use simulation and competency-based assessment extensively during the PGY-1 [postgraduate year 1] to ensure equivalent training to all learners of the critical and key facets of otolaryngology practice. Additional simulations and assessment would take place annually to build upon the essentials and ensure equal exposure to all trainees of an agreed-upon curriculum, minimizing the variability based upon which patients present to the practice or the hospital.”

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Katie Robinson is a freelance medical writer based in New York.