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Competency-based medical education systems allow institutions to individualize teaching practices to meet the needs of diverse learners. Yet, the focus on continuous improvement and individualization of curricula does not exempt programs from treating learners in a fair manner. When learners fail to meet key competencies and are placed on probation or dismissed from training programs, issues of fairness may form the basis of their legal claims. In a literature search, we found no in-depth examination of fairness. In this paper, we utilize a systems lens to examine fairness within postgraduate medical education contexts, focusing on educational opportunities, assessment practices, decision-making processes, fairness from a legal standpoint, and fairness in the context of the learning environment. While we provide examples of fairness issues within US training programs, concerns regarding fairness are relevant in any medical education system which utilizes a competency-based education framework.
Assessment oversight committees and annual programmatic evaluations, while recommended, will not guarantee fairness within postgraduate medical education programs, but they can provide a window into ‘hidden’ threats to fairness, as everything from training experiences to assessment practices may be examined by these committees. One of the first steps programs can take is to recognize that threats to fairness may exist in any educational program, including their own, and begin conversations about how to address these issues.
Ramani S, Post SE, Konings K, Mann K, Katz JT, van der Vleuten C. ‘It’s not just the culture’: a qualitative study exploring residents’ perceptions of the impact of institutional culture on feedback. Teach Learn Med. 2016;21:1–9.
Hawkins RE, Welcher CM, Holmboe ES, et al. Implementation of competency-based medical education: are we addressing the concerns and challenges? Med Educ. 2015;49:1086–102. CrossRef
Chan T, Sherbino J. The McMaster modular assessment program (McMap). A theoretically grounded work-based assessment system for an emergency medicine resident program. Acad Med. 2015;90:900–5. CrossRef
Frank JF, Mungroo R, Ahmad Y, Wang M, De Rossi S, Horsley T. Toward a definition of competency-based education in medicine: a systematic review of published definitions. Med Teach. 2010;32:631–7. CrossRef
Holmboe ES, Sherbino J, Long DM, Swing SR, Frank JR. The role of assessment in competency-based medical education. Med Teach. 2010;32:676–82. CrossRef
Morcke AM, Dornan T, Eika B. Outcome (competency) based education: an exploration of its origins, theoretical basis, and empirical evidence. Adv Health Sci Educ Theory Pract. 2013;18:851–63. CrossRef
Frank JR, Snell LS, Cate OT, et al. Competency-based medical education: theory to practice. Med Teach. 2010;32:638–45. CrossRef
Spady WG. The concept and implications of competency based education. Educ Leadersh. 1978;36:16–22.
Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system – rationale and benefits. N Engl J Med. 2012;366:1051–6. CrossRef
Altahawi F, Sisk B, Poloskey S, Hicks C, Dannefer EF. Student perspectives on assessment: experience in a competency-based portfolio system. Med Teach. 2012;34:221–5. CrossRef
van der Vleuten CP, Dannefer EF. Toward a systems approach to assessment. Med Teach. 2012;34:185–6. CrossRef
Greene J. Resident dismissal: Suing the system. Amednews.com. American Medical News 2000. http://www.amednews.com/article/200000508/profession/305089999/4/ (Created May 2000). Accessed 1 Jun 2016.
Jamieson T, Hemmer P, Pangaro LN. Legal aspects of assigning failing grades. In: Pangaro LN, McGaphie WC, editors. Handbook on medical student evaluation and assessment. Alliance for Clinical Education. North Syracuse: Gegensatz; 2015. pp. 251–62.
Wilkerson JR, Lang WS. Portfolios, the pied piper of teacher certification assessments: legal and psychometric issues. Educ Policy Anal Arch. 2003;11:1–30. CrossRef
Gammell C. Black medical student who claims she was bullied by racists sues for 300,000. The Telegraph 2009. http://www.telegraph.co.uk/news/uknews/4697530/black-medical-student-who-claims-she-was-bullied-by-racists-sues-for-300000.html (Created 29 Feb 2009). Accessed: 12 May 2017
Andolsek K, Padmore J, Hauer KE, Holmboe E. Clinical Competency Committees. A guidebook for programs. Accreditation Council for Graduate Medical Education 2015. https://www.acgme.org/acgmeweb/Portals/0/ACGMEClinicalCompetencyCommitteeGuidebook.pdf (Created January 2015). Accessed 20 May 2016.
Nabors C, Peterson SJ, Forman L, et al. Operationalizing the internal medicine milestones – an early status report. J Grad Med Educ. 2013;5:130–7. CrossRef
Cole NS, Zieky MJ. The new faces of fairness. J Educ Meas. 2001;38:369–82. CrossRef
American Educational Research Association. Standards for educational and psychological testing/American Educational Research Association, American Psychological Association, National Council on Measurement in Education. Washington: American Educational Research Association; 2014.
Bierer SB, Dannefer E. Does students’ gender, citizenship, or verbal ability affect fairness of portfolio-based promotion decisions? Results from one medical school. Acad Med. 2011;86:773–7. CrossRef
Lam TCM. Fairness in performance assessment. ERIC Digest. ED 391982. 1995.
Gipps CV. Beyond testing: towards a theory of educational assessment. London: The Falmer Press; 1994, pp 148–57.
Suskie L. Fair assessment practices: giving students equitable opportunities to demonstrate learning. AAHE Bull. 2000;52:1–6.
Barr KP, Massagli TL. New challenges for the graduate medical educator: implementing the milestones. Am J Phys Med Rehabil. 2014;93:624–31. CrossRef
Armstrong EG, Mackey M, Spear S. Medical education as a process management problem. Acad Med. 2004;79(8):728. CrossRef
Holmboe E. Direct observation of students’ clinical skills. In: Pangaro LN, McGaphie WC, editors. Handbook on medical student evaluation and assessment. Alliance for Clinical Education. North Syracuse: Gegensatz; 2015. pp. 97–112.
French JC, Dannefer EF, Colbert CY. A systematic approach to building a fully operational clinical competency committee. J Surg Educ. 2014;71:e22–e7. CrossRef
Royal College of Physicians and Surgeons of Canada. Competence by Design. Competence committees: A critical component of competency-based assessment. Available at: http://www.royalcollege.ca/rcsite/cbd/competence-committee-e. Accessed: 15 Feb 2017
Kogan JR, Conforti LN, Iobst WF, Holmboe ES. Reconceptualizing variable rater assessments as both an educational and clinical care problem. Acad Med. 2014;89:721–7. CrossRef
Linn RL, Baker EL, Dunbar SB. Complex, performance-based assessment: expectations and validation criteria. Educ Res. 1991;20:15–21. CrossRef
Downing SM. Threats to the validity of clinical teaching assessments: What about rater error? Med Educ. 2005;39:350–5. CrossRef
Pope G, Shepher E, Kleeman J, McNamara B, Phaup J. The legal defensibility of assessments: What you need to know. Questionmark White Paper 2007. http://cedma-europe.org/newsletter%20articles/misc/Legal%20defensibility%20of%20assessments%20-%20What%20you%20need%20to%20know%20(Oct%2007).pdf.
Pedhazur EJ, Schmelkin LP. Construct validation. In: Pedhazur EJ, editor. Measurement, design, and analysis. An integrated approach. Hillsdale: Erlbaum; 1991. pp. 52–80.
Schouten BC, Meeuwesen L. Cultural differences in medical communication: a review of the literature. Patient Educ Couns. 2006;64:21–34. CrossRef
Williams RG, Klamen DA, McGaghie WC. Cognitive, social and environmental sources of bias in clinical performance ratings. Teach Learn Med. 2003;15:270–92. CrossRef
Hays RB, Hamlin G, Crane L. Twelve tips for increasing the defensibility of assessment decisions. Med Teach. 2015;37:433–6. CrossRef
Gingerich A, Regehr G, Eva KW. Rater-based assessments as social judgments: rethinking the etiology of rater errors. Acad Med. 2011;86:S1–S7. CrossRef
Thomas MR, Beckman TJ, Mauck KF, Cha SS, Thomas KG. Group assessments of resident physicians improve reliability and decrease halo error. J Gen Intern Med. 2011;7:759–64. CrossRef
Hodges B. Assessment in the post-psychometric era: learning to love the subjective and collective. Med Teach. 2013;35:564–8. CrossRef
Eva KW, Hodges BD. Scylla or Charybdis? Can we navigate between objectification and judgment in assessment? Med Educ. 2012;46:914–9. CrossRef
Brateanu A, Thomascik J, Koncilja K, Spencer AL, Colbert CY. Using continuous quality improvement techniques to evaluate and enhance an internal medicine residency program’s assessment system. Am J Med. 2017; doi: 10.1016/j.amjmed.2017.02.007.
Hauer KE, Chesluk B, Iobst W, et al. Reviewing residents’ competence: a qualitative study of the role of clinical competency committees in performance assessment. Acad Med. 2015;90:1084–92. CrossRef
Colbert CY, Dannefer EF, French JC. Clinical Competency Committees and assessment: changing the conversation in graduate medical education. J Grad Med Educ. 2015;7:162–5. CrossRef
van der Vleuten CPM, Schuwirth LWT. Assessing professional competence: from methods to programmes. Med Educ. 2005;39:309–17. CrossRef
Univ. of Mich. v. Ewing. 474 U.S. 214, 106 S. Ct. 507, 88 L. Ed. 2d 523 1985. http://supremecourtdatabase.org/analysisCaseDetail.php?cid=1985-018. Accessed 26 May 2016.
Univ. of Missouri v. Horowitz. 435 U.S. 78 (98 S. Ct. 948, 55 L.Ed.2d 124) 1978. https://www.law.cornell.edu/supremecourt/text/435/78. Accessed 26 May 2016.
Nayer M, Glover Takahashi S, Martin D, Probyn L, Gold W. “Supporting residents in difficulty – issues and options.” International conference on residency education. Royal College of Physicians and Surgeons 2014. www.royalcollege.ca/portal/page/portal/rc/common/documents/events/icre/2014proceedings/slides/Physician_Health_and_Wellness/Supporting_residents_in_difficulty_issues_and_options.pdf.
Hernandez v. Overlook Hospital, 149 N.J. 68, 692 A.2d 971 (N.J. S. Ct. 1997).
Wayne SJ, Fortner SA, Kitzes JA, Timm C, Kalishman S. Cause or effect? The relationship between student perception of the medical school learning environment and academic performance on USMLE Step 1. Med Teach. 2013;35:376–80. CrossRef
Bierer SB, Dannefer EF. The learning environment counts: longitudinal qualitative analysis of study strategies adopted by first-year medical students in a competency-based educational program. Acad Med. 2016;91:S44–S52. CrossRef
Genn JM. AMEE Medical Education Guide No. 23 (Part I): Curriculum, environment, climate, quality and change in medical education – a unifying perspective. Med Teach. 2001;23:337–44. CrossRef
London M, Smither JW. Feedback orientation, feedback culture, and the longitudinal performance management process. Hum Resour Manage Rev. 2002;12:81–100. CrossRef
Carmeli A, Brueller D, Dutton JE. Learning behaviours in the workplace: the role of high-quality interpersonal relationships and psychological safety. Syst Res Behav Sci. 2009;26:81–98. CrossRef
Kost A, Combs H, Smith S, et al. A proposed conceptual framework and investigation of upward feedback receptivity in medical education. Teach Learn Med. 2015;27:359–61. CrossRef
Accreditation Council for Graduate Medical Education. Clinical Learning Environment Review. Clinical Pathways to Excellence. Available at: https://www.acgme.org/Portals/0/PDFs/CLER/CLER_Brochure.pdf. Accessed May 26, 2016.
Jennings ML, Slavin SJ. Resident wellness matters: optimizing resident education and wellness through the learning environment. Acad Med. 2015;90:1246–50. CrossRef
Accreditation Council for Graduate Medical Education. ACGME common program requirements 2015. http://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRs_07012015.pdf (Created July 2015). Accessed 26 May 2016.
Royal College of Physicians and Surgeons of Canada. General Standards Applicable to All Residency Programs. B Standards. Standard B3. Structure and Organization of the Program. Available at: http://www.royalcollege.ca/rcsite/education-strategy-accreditation/pgme-training-programs/accreditation-residency-programs-e
Association of American Medical Colleges. Medical School Graduation Questionnaire. 2015 All Schools Summary Report. Available at: https://www.aamc.org/download/440552/data/2015gqallschoolssummaryreport.pdf. Accessed June 2, 2016.
Crutcher RA, Szafran O, Woloschuk W, et al. Family medicine graduates’ perceptions of intimidation, harassment, and discrimination during residency training. BMC Med Educ. 2011;11:1–7. CrossRef
Stratton T, McLaughlin MA, Witte FM, et al. Does students’ exposure to gender discrimination and sexual harassment in medical school affect specialty choice and residency program selection? Acad Med. 2005;80:400–8. CrossRef
Fnais N, Soobiah C, Chen MH, et al. Harassment and discrimination in medical training: a systematic review and meta-analysis. Acad Med. 2014;89:817–27. CrossRef
Lee KP, Kelz RR, Dube B, Morris JB. Attitude and perceptions of the other underrepresented minority in surgery. J Surg Educ. 2014;71:e47–e52. CrossRef
Mansh M, Garcia G, Lunn MR. From patients to providers: changing the culture in medicine toward sexual and gender minorities. Acad Med. 2015;90:574–80. CrossRef
Bowe CM, Armstrong E. Assessment for systems learning: a holistic assessment framework to support decision-making across the medical education continuum. Acad Med. 2016; doi: 10.1097/ACM.0000000000001321.
Desimone LM, LeFloch KC. Are we asking the right questions? Using cognitive interviews to improve surveys in education research. Educ Eval Policy Anal. 2004;26:1–22. CrossRef
Groves RM, Fowler FJ Jr, Couper MP, Lepkowski JM, Singer E, Tourangeau R. Survey Methodology, 2nd ed. Hoboken: John Wiley and Sons; 2009.
Willis GB. Cognitive interviewing. A ‘how to’ guide. Research triangle institute. Presented at the Meeting of the American Statistical Association 1999. http://fog.its.uiowa.edu/~c07b209/interview.pdf.
Presser S, Couper MP, Lessler JT, et al. Methods for testing and evaluating survey questions. Public Opin Q. 2004;68:109–30. CrossRef
Ginsburg S, van der Vleuten C, Eva KW, Lingard L. Hedging to save face: a linguistic analysis of written comments on in-training evaluation reports. Adv Health. Sci Educ. 2016;21:175–88.
Pien L, Taylor CA, Traboulsi E, Nielsen CA. A pilot study of a ‘resident educator and life-long learner’ program: using a faculty train-the-trainer program. J Grad Med Educ. 2011;3:332–6. CrossRef
Hattie J, Temperley H. The power of feedback. Rev Educ Res. 2007;77:81–112. CrossRef
French JC, Colbert CY, Pien LC, et al. Targeted feedback in the milestones era: utilization of the ask-tell-ask feedback model to promote reflection and self-assessment. J Surg Educ. 2015;72:e274–e9. CrossRef
Bierer SB, Dannefer EF, Tetzlaff JE. Time to loosen the apron strings: cohort-based evaluation of a learner driven remediation model at one medical school. J Gen Intern Med. 2015;30:1339–43. CrossRef
- Fairness: the hidden challenge for competency-based postgraduate medical education programs
Colleen Y. Colbert
Judith C. French
Mary Elizabeth Herring
Elaine F. Dannefer
- Bohn Stafleu van Loghum