Fairness: the hidden challenge for competency-based postgraduate medical education programs

Abstract

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.

Some assembly required: tracing the interpretative work of Clinical Competency Committees

“…This process relies on the expertise and judgement of committee members and their ability to interpret performance evidence and transform it into a decision about trainee competence. The process of synthesising heterogeneous assessment data is fraught with challenges and the need for efficient, creative strategies to support the complex task of data aggregation has been communicated in the literature …”

“…Given the high‐stakes nature of progression decisions, the decision‐making processes, data review procedures and the operating practices of CCCs have been subject to recent scholarly attention. Concerns around the fairness and transparency of progression decisions have been at the heart of this conversation . The current lack of systematic procedures for evidentiary review, weighting and interpretation and the heterogeneity of practices within committees have been problematised .…”

“Languaging” tacit judgment in formal postgraduate assessment: the documentation of ad hoc and summative entrustment decisions

“…Yet the problem of how best to incorporate judgment in formal assessment in meaningful and defensible ways remains. For, while attempts at exclusively "objective" measurement have been missing the mark (and, worse, have at times contributed to systemic unfairness [5]), professional judgment is also subject to blind spots and, when not guided by and answerable to other stakeholders in assessment, can lend itself to confusion, arbitrariness and discrimination. To help guard against this, formal assessment employs various linguistic artefacts, including standards, scoring rubrics, procedural guidelines, evaluation forms, and more 1 .…”

Perceptions of competency‐based medical education from medical student discussion forums

“…Discussions around avoiding certain residency programmes, because of perceptions of ‘harsh’ methods of ‘due process’, were prevalent in the SDN and could influence trainees’ ultimate decisions when selecting a residency programme. This could be addressed by standardised probation, termination and remediation procedures across institutions …”