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You hit every number: top grades, top test scores, top patients-per-hour. So why does practicing medicine feel hollow? Ben Reinking, a board-certified pediatric cardiologist, medical educator, and certified physician development coach, argues that the same metric-driven mindset that carries pre-meds into medical school is the one leaving attendings disconnected from why they practice. This episode is based on his article “How competency-based education is driving medical education reform,” published on KevinMD. You will hear why a 15-minute billing slot frustrates both patient and physician, how competency-based education and entrustable professional activities shift the question from “did you meet the number” to “do we trust you in the system,” and why admitting “I don’t know, but let me figure it out” gets discouraged when learners are judged only by scores. If you have ever sensed the gap between your scorecard and your purpose, this conversation names what you have been feeling.
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Ben Reinking. He is a pediatric cardiologist, medical educator, and physician development coach. Today’s KevinMD article is “How competency-based education is driving medical education reform.” Ben, welcome back to the show.
Ben Reinking: Thanks, Kevin. It’s great to be back.
Kevin Pho: All right, tell us what this latest article is about.
Ben Reinking: Yeah, you know, I have the unique perspective, I think, of interviewing premedical students. I work in a learning community with medical students and meet them on their first day of orientation, and then when they prepare for their fourth year, you know, dean’s letter and things. And then now being a division director, I see the full spectrum of development and recognizing that we have had a metric-based mindset for a long time.
And that metric-based mindset has really driven how we start acting in the system as pre-med students, and that carries forward all the way into our attending life. And trying to transition to, you know, why we do what we do and how we do it, rather than the scores we get out of our views that we generate, is important. And I think solving some of the system issues that we have.
Kevin Pho: So when you talk about metrics-based mindset, of course you’re talking about things like a focus on MCAT scores, GPA, and all the test scores that physicians aim to strive for as they’re progressing through medical education, right? Yeah, so tell us how that progresses to when you’re attending. Just give more detail about that connection.
Ben Reinking: Yeah, yeah. So as an attending, we focus on our productivity, or we’re told to focus on our productivity, right? So turnover times in the operating room, number of patients we see in clinic. And that focus on what we do rather than why we do it really leads to people just being unhappy in their jobs. Right. So you’re disconnected from the reasons that you went into this for the first place.
Kevin Pho: When it comes to patient care, how does that metrics-based environment affect patient care? Because if you look at the perspective for the administrators, they’re going to say the metrics improve patient care. But when you’re face to face with a patient, sometimes that’s not always the case, right?
Ben Reinking: Oh yeah. I mean, I’m not a primary care provider, but I talk to lots of primary care providers, and so they may be sitting in a room with a patient who comes in for a well visit and they have multiple other problems. And so if you were the patient, or your family member was the patient, you would love to have as much taken care of in that visit as possible. But that’s not how we bill for our services, right? And that doesn’t fit into a 15 minute time slot that might take 30 minutes or an hour. And that model is frustrating, I think, for the providers as well as for the patient. But it’s adopted by the administrators, and so that’s what drives revenue right now.
Kevin Pho: Yeah. So this metrics-based or merit-based selection, when it comes to selecting who gets into medical school, what does it get wrong about future physician potential?
Ben Reinking: Yeah. You know, I think it’s really unfortunate. First of all, I think metrics are important. So we need to have the knowledge base that we have, you know, in order to do our jobs, and we need to be held accountable to continue learning and to strive for a higher standard. And so it is important that we have some sort of benchmark that we’re judged by, and that we strive for.
But I think what it gets wrong is that it takes the focus actually away from learning, from sort of becoming and growing, and places it on the outcome. And I think as we all know, as we move along, there’s really not a finish line into our careers or what we learn. But the metrics-based method kind of acts like there is one.
Kevin Pho: Yeah. So you make a suggestion for what’s called competency-based education as a potential path out of this. So talk to us more about what that means.
Ben Reinking: Yeah, so when I was in training, it was how many patients that you saw, how many procedures that you did, and how long you were there. And when you fulfilled those metrics, you were done, right? And so for some people, like in pediatrics, one of the procedures that we did when I was in training was LPs. For some people, you could do one LP and you were good at LPs for the rest of your training, right? Yeah, yeah. For others, maybe that took forever. And so really what a competency-based education is, is looking at how you act within the system, and sort of, it’s more about your ability and what you can do, as well as how you’re doing it.
Kevin Pho: So during medical school, as medical students progress through their preclinical clinical years, how would that model, what would that model look like for them?
Ben Reinking: You know, honestly, I think it’ll be really hard to implement, right? So it’s hard from a structural standpoint to think about. Yeah. But it may be that we take focus off of the amount of time spent doing something and look at what they’re doing within that time.
So, I think the best example that I can have, in thinking about competency and milestones and entrustable professional activities, is actually outside of the clinical sphere. So I used to be a lifeguard, and one of the common requirements when you go to a pool, if you want to go for the diving board, is, can you swim across the width of the pool? Right? And so you may have two people that come in. One’s a new swimmer who makes it across the pool but has to stop and lift their head up and get through. And then at the same time, maybe have a college swimmer who runs across the pool deck, dives in, dives over a couple people, swims across, and jumps out. So they both technically met the metric, but the question at the end is, how much do you trust them in your pool? Right? Yeah. And so the new swimmer, you might trust to get across, but worry about their ability to make it from the diving board to the wall. The swimmer who ran on the deck and jumped over people and got out, maybe, you know, had a beautiful stroke and did what they technically was great, but you might not trust them in the system very well, or in the pool very well, because they’re a danger to other people. And so it’s taking that kind of mindset and applying it to medical education.
Kevin Pho: So give us an example of some of the skills that medical students and early career physicians would learn if they place less focus on the metrics. What are some examples of skills that you would like to see them learn?
Ben Reinking: Yeah, so I think one of the things that this model allows is the ability to say, “I don’t know, but let me figure it out.” Right? Yeah. So there’s some discomfort in not admitting that you know something when you’re judged on your performance. Yep. Yeah. So there’s a lot of things that medical students should learn outside of a typical multiple choice test.
Kevin Pho: It’s been a while since I’ve been to medical school, so what’s it like now? Are they moving more away from just metrics-based measures into something more qualitative?
Ben Reinking: Yeah. You know, it’s interesting. We have case-based learning and sort of team-based learning and assessments of that sort. And so that’s there. But it’s interesting that students don’t perceive it as a growth opportunity, right? So, for example, the evaluations that I fill out are milestones based. They say developing, you know, needs to work on this, or expert level, let’s say. Well, the students still break that down into a score of one to five, and so they: “You only gave me a three at the end of this evaluation,” and nowhere on the evaluation does it have a numerical score. Yeah. But that’s how they interpret it. So it’s still a difficult switch to make for the students, as well as, I think, the educators, because it’s such a big leap.
Kevin Pho: Now, you said that it’s very difficult to move away from metrics getting into medical school and while you’re in medical school. Why, what will it take to change, and why is it so difficult?
Ben Reinking: Yeah, that’s a great question. I think it’s so ingrained, right? Yeah. The metrics probably start even when we just start grade school. And so it’s hard to move away from that. And that culture persists within medicine as well as outside of it.
Kevin Pho: Yeah. And I’m sure a lot of the students who get in, right, they’re playing this metrics-based game even during high school, pre-medical school years, and it’s almost like hardwired in them.
Ben Reinking: Absolutely. Yeah. I do think that the shift from, you know, sort of honors pass fail to just sort of a pass fail system is helpful. So taking some of that emphasis off. I know the USMLE, you know, Step 1 went from graded to pass fail. And so, you know, there’s good data to say that it’s not the score that you get on your board scores, it’s actually whether you pass it that matters in many instances. And so that sort of shift, I think, will change the culture gradually.
Kevin Pho: Now, give us a success story. You’ve been involved with medical education for a while now, so what would be an example of a success story where perhaps what was something metrics-based in the past moved away from that and led to positive outcomes in the education of a medical student or early career physician?
Ben Reinking: Gosh, that’s a great question. I think it’s easiest for me to think about that in terms of people who grow their careers outside of the clinical sphere. So someone jumping into a leadership position and getting into a spot where they’re uncomfortable at a time in their career when they’re otherwise very competent at their clinical job and successful on paper. So having the self-awareness to be able to jump from one type of work to another type of work and view that as a growth opportunity, and kind of be able to sit in that “I don’t know what I’m doing” kind of uncomfortable space that happens when you make those jumps.
Kevin Pho: So what do you envision to be the future of medical education? What would you like to see? What would be a successful transition as we move forward?
Ben Reinking: Yeah, I think one that’s sort of a low hanging fruit is to be able to connect to the different layers of careers in education. So having some way for medical schools to have a bit of a handoff to residency programs, and residency programs to fellowship. And similarly, where this idea of ongoing growth and areas for opportunity are shared in a way that is transparent for the, I suppose, educator or employer as well as the learner and the person who’s growing throughout their career.
Kevin Pho: We’re talking to Ben Reinking. He’s a medical educator and a pediatric cardiologist. Today’s KevinMD article is “How competency-based education is driving medical education reform.” Ben, let’s have some take home messages they want to leave with the KevinMD audience.
Ben Reinking: Yeah, I think my take home is, you know, as a pediatrician, we focus on development, and development doesn’t stop no matter how old you are. And so if we take that developmental mindset into our lives and into our careers, I think many people will be happier in what they’re doing.
Kevin Pho: Ben, as always, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.
Ben Reinking: Yeah, thanks, Kevin.
