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A Lack of Continuity in Education, Training, and Practice Violates the "Do No Harm" Principle

Englander R, Carraccio C
Pub Med #: 

The paradigm shift to competency-based medical education (CBME) is under way, but incomplete implementation is blunting the potential impact on learning and patient outcomes. The fundamental principles of CBME call for standardizing outcomes addressing population health needs, then allowing time-variable progression to achieving them. Operationalizing CBME principles requires continuity within and across phases of the education, training, and practice continuum. However, the piecemeal origin of the phases of the "continuum" has resulted in a sequence of undergraduate to graduate medical education to practice that may be continuous temporally but bears none of the integration of a true continuum.With these timed interruptions during phase transitions, learning is not reinforced because of a failure to integrate experiences. Brief block rotations for learners and ever-shorter supervisory assignments for faculty preclude the development of relationships. Without these relationships, feedback falls on deaf ears. Block rotations also disrupt learners' relationships with patients. The harms resulting from such a system include decreases in patient satisfaction with their care and learner satisfaction with their work. Learners in this block system also demonstrate an erosion of empathy compared with those in innovative longitudinal training models. In addition, higher patient mortality during intern transitions has been demonstrated.The current medical education system is violating the first principle of medicine: "Do no harm." Full implementation of competency-based, time-variable education and training, with fixed outcomes aligned with population health needs, continuity in learning and relationships, and support from a developmental program of assessment, holds great potential to stop this harm.