Defining competencies for training in obstetric medicine

The recognition of Obstetric Medicine as a subspecialty of Internal Medicine is being pursued in a number of countries. In Canada, this has involved moving from the standard concept of curricula-based learning to development of a competency-based approach. Competency-based models are being increasingly used in the corporate world.1 Competency-based models have replaced task-based model in job analysis and are thought to be able to distinguish top performers from average performers. Organizations view workers as a whole, with an emphasis on their observable behaviours and measurable capabilities as indicators of the individual’s potential. Conventional measures of intelligence and abilities are no longer thought to be able to predict job performance or success in life. The Royal College of Physicians and Surgeons of Canada has started a multi-year initiative to implement competency-based medical education. Several specialty training programs are currently revising the standardized training objectives into competencies. According to Allen et al.,2 a competency should include the following: Focus on the performance of the end product or goal of instruction. Reflect expectations that apply what is learned in the immediate instructional program. Be expressed in a measurable behaviour. Use a standard for judging competence that is not dependent on the performance of other learners. Inform learners, as well as other stakeholders, of what is expected of them. Competency-based learning is focused on the learner, who can acquire the individual skills they find challenging at a slower pace, and move to other skills that they are more able at, more rapidly. The instructor serves the role of the facilitator. Learners are evaluated on an individual competency and only once they have displayed the measurable behaviours or actions towards a specific outcome do they move on to a larger learning goal. This is in contrast to a didactic course or module where all learners in the course/module are expected to learn at the same speed. The emphasis in the competency-based learning is on performing rather than just knowing. The Canadian Working Group on Obstetric Medicine fellowship training was established in the fall of 2012. The aim of the Working Group is to obtain the Area of Focused Competence (AFC) or diploma recognition of Obstetric Medicine from the Royal College of Physicians and Surgeons of Canada (RCPSC). The AFC or diploma program was established by RCPSC in 2011. In order for the application to be successful, several key elements are required, including: defining the scope of practice of Obstetric Medicine (in terms of how it is different from General Internal Medicine (GIM) or Maternal Fetal Medicine), projecting workforce requirement of Obstetric Internists in Canada, obtaining application funding of $14,000, and writing the Obstetric Medicine training curriculum into competencies. The AFC or diploma training programs are generally one-year in duration; however, the application will likely be stronger in the current climate if defined by competency-, rather than time-based. The Working Group will adopt Cumyn’s Canadian curriculum in Obstetric Medicine (CanCOM).3 The CanCOM curriculum was created based on (a) document analysis of RV Lee’s textbook Medical Care of the Pregnant Patient, (b) review of available curricula including the Brown University and ISOM curricula and (c) triangulation with cases seen over a six-month period in a busy Canadian Mother–Child University Teaching Hospital. The 420 content items were then validated by Delphi survey methodology by 25 Canadian physicians who practice Obstetric Medicine. The curriculum which includes the seven CanMEDS domains, namely medical expert, communicator, collaborator, leader (formerly manager), health advocate, scholar and professional, will be written as competencies that are “active abilities required, rather than knowledge or comprehension of those abilities; thus, verbs such as “identify,” “analyze,” “engage in,” or “demonstrate” are preferred over “describe” or “explain”.”4 For instance, under Chronic Hypertension and Evaluation, the learner should: Identify baseline investigations to be done prior to or at the onset of pregnancy in a woman with hypertension. Perform work-up of secondary causes of hypertension, as it pertains to pregnancy. Analyze physiologic changes to blood pressure in pregnancy. Demonstrate the proper techniques of blood pressure measurement in pregnant women. Since several objectives in Obstetric Medicine are also present in the GIM subspecialty training objectives, the Obstetric Medicine Working Group will work with the Canadian GIM group in their pilot project to further clarify the scope of similar competencies. For instance, for the management of a hypertensive pregnant woman, how much is expected of a General Internist versus an Obstetric Internist. We are optimistic that competency-based training model in Obstetric Medicine will enhance our diploma application and that Obstetric Medicine can be formally recognized as a RCPSC AFC in Canada. We expect that this collective effort will serve as a model for programs worldwide who are also aiming to develop high-quality Obstetric Medicine Training.

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