“The Most Crushing Thing”: Understanding Resident Assessment Burden in a Competency-Based Curriculum

Abstract

Background Competency-based medical education (CBME) was expected to increase the workload of assessment for graduate training programs to support the development of competence. Learning conditions were anticipated to improve through the provision of tailored learning experiences and more frequent, low-stakes assessments. Canada has adopted an approach to CBME called Competence by Design (CBD). However, in the process of implementation, learner anxiety and assessment burden have increased unexpectedly. To mitigate this unintended consequence, we need a stronger understanding of how resident assessment burdens emerge and function. Objective This study investigates contextual factors leading to assessment burden on residents within the framework of CBD. Methods Residents were interviewed about their experiences of assessment using constructivist grounded theory. Participants (n=21) were a purposive sample from operative and perioperative training programs, recruited from 6 Canadian medical schools between 2019 and 2020. Self-determination theory was used as a sensitizing concept to categorize findings on types of assessment burden. Results Nine assessment burdens were identified and organized by threats to psychological needs for autonomy, relatedness, and competence. Burdens included: missed opportunities for self-regulated learning, lack of situational control, comparative assessment, lack of trust, constraints on time and resources, disconnects between teachers and learners, lack of clarity, unrealistic expectations, and limitations of assessment forms for providing meaningful feedback. Conclusions This study contributes a contextual understanding of how assessment burdens emerged as unmet psychological needs for autonomy, relatedness, and competence, with unintended consequences for learner well-being and intrinsic motivation.

The Assessment Burden in Competency-Based Medical Education: How Programs Are Adapting

“…These findings are in line with the findings of other work that have identified the unintended burden of assessment within CBME in numerous settings for both faculty and residents. 9 What this work adds to the literature is the identification of both program-specific and cross-program adaptations (proposed and/or enacted) by residency programs related to each of the identified themes. These adaptations were identified by individual programs, factoring in their own contexts and unique characteristics.…”

“…These studies have noted a variety of successes and challenges in implementation, but one of the clearest early struggles has been the identification of a major burden of assessment widely experienced by both residents and faculty. 9 Workplace-based assessment is central to CBME and has 2 main purposes. 10 The first is assessment for learning: low-stakes and formative assessment to support learning, the ongoing development of self-assessment skills, and documentation of low-stakes individual data points.…”

“…Furthermore, the concerns related to assessment in CBME are associated, in theory, with concerns about the deterioration of faculty coaching and feedback efforts and their own burnout as well as with issues related to resident wellness. 9 Despite these significant experienced challenges, there is little in the literature describing potential program-level adaptations that could mitigate these risks.…”

“…These studies have noted a variety of successes and challenges in implementation, but one of the clearest early struggles has been the identification of a major burden of assessment widely experienced by both residents and faculty. 9…”

Catalytic effect of multisource feedback for trauma team captains: a mixed-methods prospective study

“…Recently, CBME and EPAs for medical trainee feedback has been adopted in Canada 36. CBME poses a challenge for MSF due to resident and staff physicians feeling overwhelmed by the burden of increased assessment requirements 37. This was reflected in some study participants sharing that mandatory feedback is becoming more of a burden, and some participants want less formalisation of feedback.…”