Improving Medical Education in Hematology and Transfusion Medicine in Canada: Standards and Limitations

Figures & data

Table 1 Definition of Terms

Term	Definition
Competence	“Habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values and reflection in daily practice for the benefit of the individual and community being served”^Citation42
Competencies	Elements of competence such as knowledge, technical skills, and reasoning.^Citation43
Entrustable professional activities (EPAs)	A task that can be entrusted to a trainee once they have obtained sufficient competence.^Citation44
Milestones	Observable stages of development with regards to a trainee’s abilities.
Assessment	Examination and judgement of a trainee’s ability.
Portfolio	A dynamic compilation of assessments.^Citation45
Evaluation	Deliberate collection of information about a training program to understand its strengths and weaknesses.
Competence by Design (CBD)	An education model inspired by competency-based medical education (CBME).^Citation46 It is supported by the Royal College of Physicians and Surgeons of Canada. As a hybrid model, it incorporates both time and outcome-based learning. EPAs and milestones form the backbone of learning objectives within CBD.^Citation46

Figure 1 Availability of fellowship opportunities after Hematology training throughout Canada. The red markers denote the location of a Hematology residency program. Image available at https://pixabay.com/illustrations/map-canada-provinces-territories-2088308/. Licenced under the Creative Commons Attribution.

Table 2 Sample of the RCPSC Objectives for the Transfusion Medicine AFC Program

Milestone	Standards of Assessment	Documents to Be Submitted
Manage the appropriate utilization of blood products	A description of a specific blood utilization issue and its current clinical practice guideline for a hospital or a certain patient group, an analysis of the actual blood utilization, and its compliance with the guidelines. The submission must demonstrate understanding of the importance of adequate utilization of blood supplies, attention to safety and quality issues, and adaptation of practice to different clinical contexts in order to meet specific patient needs.	One of the following: ● Audit ● Clinical practice guideline ● Report with a reflective critique

Table 3 Assessment Methods in Hematology with Respect to Miller’s Pyramid

Category	Examples Commonly Seen in Traditional Training Models	Examples Commonly Seen in Competency-Based Models
Does	End of rotation evaluations Multi-source feedback	Direct clinical observation Portfolio (depending on components)** Case log with reflection (eg, bone marrow, lumbar puncture) Clinical notes (eg, consult notes, progress notes)** Logbooks (of clinical encounters)** Lab reports**
Shows How	Objective structured clinical exams Oral case presentations	Simulated cases Case summaries** Order sets** Standardized Operating Procedures (SOPs)**
Knows How	Structured oral examination*	Structured oral examination Teaching logbook**
Knows	Multiple choice or short answer written examination* Written morphology or hematopathology examination*	Knowledge examination

Notes: *these components are current high-stakes methods of assessment found in traditional time-based Hematology training programs (eg, Hematology residency training program). **these components are often found in competency-based portfolios (eg, Adult Thrombosis Medicine or Transfusion Medicine Area of Focused Competence).

Table 4 Practical Challenges to Implementing CBME in Hematology. *Solutions Should Be Adapted to Institutional Resources and Culture

	Challenge	Potential Solutions*
Residency program level	Collecting, storing and interpreting a large amount of educational data	Leverage the use of technology (ie learning analytics system)
	Time and resource investment to creating CBME curriculum	Share the responsibility of creating educational materials across multiple residency programs
	Shift away from time-based curriculum impacting clinical service/workforce planning	Preserve the block rotation schedule to make resident scheduling more predictable
Faculty level	Additional time needed for direct observation	Distribute the responsibility of direct observation across all faculty members Use simulation when appropriate Encourage participation of senior residents, fellows, and Chief Residents when appropriate
	Lack of capacity to take on additional educational roles (eg academic coach)	Incentivize faculty members to take on CBME roles (eg credit toward tenure and promotion, financial remuneration)
	Theoretical criticisms about CBME	Encourage and incentivize participation in high-quality faculty development activities Regular and honest dialogue about pros/cons of CBME and potential solutions
Resident level	Maladaptive assumptions about learning (fixed mindset)	Foster a psychologically safe learning environment Reward effort as well as achievement Establish procedures that place value on feedback at all levels of the organization
	Failure to self-regulate learning	Integrate opportunities for self-directed learning throughout the residency program (eg academic coach, portfolio, reflective writing, etc.)

Figure 2 Workflow of competency-based medical education.

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