A “Zombie” Reform: Outcome Based Education (OBE) in Medical Education and K-12 Schools

Outcome Based Education (OBE) rolled through U.S. public schools in the 1980s and 1990s. Yes, OBE (a.k.a “mastery learning,” “competency-based education”) is still around (see here). But the drum-beating policy talk and promises of turning around “failing” U.S. schools, well, those claims have evaporated for K-12 schools.  Except for university medical education. Thus, a “zombie” reform returns.

On the 100th anniversary of the Flexner Report (1910) which did, indeed, alter medical education a century ago, another gaggle of reforms aimed at transforming current medical education has swept across U.S. medical schools in the past decade. I say “another” because like K-12 U.S. schools, university medical education has had cycles of reform aimed at the original Flexnerian model of medical education–two years of basic sciences (e.g., anatomy, biochemistry, genetics) and two years of clinical practice in hospitals and clerkships in various specialties (e.g., surgery, internal medicine, obstetrics).  OBE–sometimes called “Competency-Based  Education” (CBE)–has become the “reform du jour” in this cycle of change in medical education. Yet its shortcomings and missing elements applied to medical education have already been documented fully  (see 2013_OBE).

OBE in either K-12 or medical schools is all about educators identifying concepts, knowledge, and skills that students must have in the “real world,” teaching both, and then measuring  performance to see whether students have acquired the requisite knowledge and skills.

In OBE, how long it takes for each student to master the content and skills is not tied to a prescribed time such as a quarter, semester, or year. Nor is any pedagogy privileged. Moreover, assessment is not only a one-time snapshot, it is ongoing.  Mastery depends upon individual students’ grasp of the material and their demonstration of skills. Thus, in K-12 schools embracing OBE would give up an age-graded system–1-8, 9-12. Students would not be compared to one another. Teachers would be free to use varied pedagogies matched to student differences as each one masters prescribed outcomes. Yet OBE, even with the stamp of Presidential approval (Bill Clinton and George W. Bush) barely made a dent in U.S. schools in the 1980s and 1990s.  It is in the dust-bin reserved for once-hyped school reforms.

For medical education, however, CBE has come back from the dead. As had occurred in K-12 OBE, definitional problems have arisen often. For medical education, a recent definition is:

Competency-based education (CBE) is an approach to preparing physicians for practice that is fundamentally oriented to graduate outcome abilities and organized around competencies derived from an analysis of societal and patient needs. It de-emphasizes time-based training and promises greater accountability, flexibility, and learner-centredness.

Defining what CBE is also means specifying what outcomes have to be mastered before medical students can become doctors. One report summarized the seven roles that physicians must become competent in: “medical expert, communicator, collaborator, manager, health advocate, scholar, professional.” In addition, according to the report, physicians must master 28 general competencies and 154 “enabling and sub-competencies.”

But even definitions and detailed outcomes cannot get around one of the fundamental lapse in K-12 OBE and currently faces those leaders in medical education who seek to implement CBE. And that lapse has haunted not only these reforms but any major change seeking to alter structures and cultures in educational organizations: inattention to the capacities of teachers and, in this instance, medical school professors to both understand the reform and implement it fully. As one report put it, albeit delicately (see: 00001888-201110000-00017-1 )

Faculty in medicine are expected to teach, yet most faculty enter their academic positions underprepared for their roles as medical educators—even when they assume education leadership positions. This lack of formal training in teaching may be due, in part, to a lack of recognition of the complex skills (from techniques in microteaching to metaskills in program evaluation) necessary to succeed as a medical educator. Without formal educational training, most faculty members undergo ad hoc training, selecting from a local/national menu of programs, that they hope will enhance their skills—after they assume their teaching roles. Developing a better understanding of the skills necessary for success as a medical educator would be an important advance for medical education, resulting in the improved quality of teaching and enhanced learner outcomes.

Less delicately, I would say: If those who are expected to put CBE into practice lack the know-how in helping students master the specified outcomes, how in the world can learners become competent in their roles as doctors? Like so many promised reforms in K-12 schooling, teachers have to implement the reform and in doing so acquire the knowledge and skills that will aid students. The same is true for CBE in medical education. Putting an end to “zombie” reforms begins with recognizing that teachers and medical faculty are the gatekeepers to any meaningful classroom change be it OBE or CBE.