Never again a botched medical education reform like CBD!
Le Devoir has published the findings of a large-scale study by independent researchers whose conclusions confirm the FMRQ’s worst fears about a pedagogical reform implemented in our medical faculties by the Royal College of Physicians and Surgeons of Canada (RCPSC) starting in 2017. According to these independent researchers, not only was this reform launched on the basis of no evidence from scientific research, but it also raises governance issues for our healthcare system in Quebec.
Competence by Design is an attempted pedagogical revolution whose avowed aim was to customize postgraduate training paths to individuals, aiming to abandon time-based education, where duration of training is based on 13 rotation periods per year for a specific number of years, and replacing it with lists of tasks to be fulfilled—entrustable professional activities (EPAs)—and pedagogical stages to be completed.
The FMRQ has been calling the medical community’s attention since 2018 to the tangible negative impact of this reform, including the substantial administrative overload for resident physicians, which affects their mental health, and its lack of visible pedagogical benefits. But this lack of any improvement in postgraduate education—which indeed was already among the best in the world before the reform—could be attributable to the lack of any scientifically proven basis to that reform, according to the independent researchers.
While prime responsibility for presenting solid evidence in support of this reform lay of course with its enthusiastic creators and promoters at the RCPSC, it remains a matter of grave concern that the Collège des médecins du Québec (CMQ), the college of physicians responsible for ensuring the quality of doctors’ education in Quebec, carried out no checks before CBD was launched and no serious follow-up after its implementation. Indeed, as recently as last week, the CMQ was claiming to Le Devoir reporter, Marco Fortier—apparently based on no scientific evidence and ignoring the existing data pointing to the opposite conclusion—that CBD was an “innovative pedagogical method”. The FMRQ believes it is high time a debate took place on the responsibility of medical education stakeholders, first among them the Collège des médecins du Québec, in this area that concerns both health and higher education, two Quebec jurisdictions.
To the FMRQ’s knowledge, there was no public debate in the late 1990s when the CMQ relinquished important responsibilities concerning medical education bestowed by the provincial government, subcontracting them to pan-Canadian bodies subject to no democratic control, since those bodies answer neither to the Quebec government nor indeed to the CMQ. These bodies were primarily the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada. The CMQ also entrusted part of its responsibilities to the Medical Council of Canada (MCC), albeit to a lesser extent since the FMRQ, and other bodies, successfully obtained the abolition in 2021 of an irrelevant Canada-wide exam that was imposed on resident doctors, but no longer appeared to have any purpose beyond financing the MCC, subsidized by our members. Note that the existence of these pan-Canadian bodies is completely legitimate in itself, and, if over the years they were able to take such a prominent position in an area which none the less should fall under higher education and health, this was because the stakeholders to whom the Quebec government had entrusted these responsibilities had given them free rein.
Was the CMQ thus able to “privatize” part of its responsibilities with respect to medical education in Quebec ? Did it act at the time with the clear blessing of the Quebec government? Is it the Quebec government’s belief today that these actions respect Quebec’s jurisdiction in higher education and health? The FMRQ humbly submits that these questions should be asked, particularly because it can be seen today that a Canadian body, the Royal College, was able in 2017-2018 to begin implementing a pedagogical reform based on no solid scientific evidence in our medical schools in Quebec and across Canada.
Our medical faculties are, moreover, caught between a rock and a hard place in the face of the pan-Canadian bodies with which the Collège has also shared its responsibility for awarding accreditation, an important process whereby our faculties’ medical programs retain, or lose, the privilege of training doctors in Quebec. The consequence of the CMQ’s sharing of this power is that today, the RCPSC can check whether our medical schools’ programs are applying the CBD reform properly, and judge whether they still deserve to continue teaching medicine. So it is no surprise that the faculties are very poorly placed to criticize the controversial CBD created by the Royal College itself. This situation exists only because of institutional choices made by the Collège 20 years ago. The problem is not in itself the RCPSC’s actual power, but rather that such a delegation of authority is tolerated, when the legality of such delegation may even be questionable.
Need for public debate
As we told Quebec’s MNAs and the Minister of Health and Social Services, Christian Dubé, on February 1, 2022, in our brief tabled with the Parliamentary Committee at its hearings on Bill 11:
Our medical faculties are also struggling with the negative impact of CBD. So we must all continue working to improve things. But for the FMRQ, we also have to make sure of something fundamental: that a botched implementation of a radical pedagogical reform such as CBD never occur again. Particularly a reform propelled along ideological lines by a Canada-wide organization whose role is not to decide how to teach in our universities.
The FMRQ has every reason to be proud of having defended its members’ interests in this area, but it is still abnormal that it should have been the only organization in Quebec, and even Canada—aside from the Royal College itself—to have been concerned with monitoring the tangible impact of the implementation of a major pedagogical reform in the medical faculties. The FMRQ should never have had to do so, if all the other stakeholders involved had shouldered their responsibilities.
From 2018 to 2021, the FMRQ has proposed tangible solutions to improve CBD, but to no avail. It is hard to improve a model that is fundamentally flawed. We therefore recently presented a comprehensive solution, to avoid subjecting more resident doctors to a reform with negative impact and no pedagogical benefit. Moreover, we would point out that our studies have clearly shown that resident doctors—and many teaching physicians, including those in charge in our faculties—have exhibited extraordinary resilience since 2017 and have managed to retain a very high level of postgraduate training, despite the implementation of CBD. That is why the FMRQ is demanding the clear, unequivocal retention of what the RCPSC over-simplistically calls the time-based education model—which has nevertheless proven its mettle and is still used. Could some components of the CBD method contribute to improving postgraduate medical education, we believe they could. The important thing would be to determine which components, this time by relying on scientific evidence and not merely on attractive, aunproven, purely theoretical concepts.