Current Issues in CBME and WBA Relevant to this Thesis

Since this project was conceived and designed, the CBME movement has continued to

grow and develop. In 2017, the ICBME collaborators published another special issue

in Medical Teacher, ten years after the first. Somewhat surprisingly, it bears a strong resemblance to the first in terms of focus and content. It opens with an editorial

highlighting the importance and growth of the CBME movement (Frank et al., 2017).

It contains a series of commentary and perspective pieces prepared by ICBME

collaborators on a number of familiar topics. Holmboe et al. (2017) address some (but

not all) concerns levelled at the CBME movement, again with limited empirical

evidence. In fact, a core argument refuting concerns about CBME is ‘there isn’t much

evidence to support the traditional systems that have been in place for over a century’

(p. 578). Englander et al. (2017) provide a commentary on the importance of

terminology in CBME. Issues of implementation are discussed in other papers

Nousiainen, Caverzagie, Ferguson, & Frank, 2017) as is CBME in continuing

professional development (Lockyer, Bursey, et al., 2017).

There were two papers on assessment and one on research in CBME which are most

relevant to this thesis. Harris et al. (2010, p. 607) conclude with a worryingly familiar

sentiment that ‘many assessment issues related to CBME remain unresolved, and

more data on the effective application of this approach are needed’. A ‘vision for

meaningful assessment’ is described in a second paper, that involves timely, ongoing

assessments with periodic progress reviews, best use of multiple assessors and

assessments, data synthesis and group decisions about competence, faculty

development for all trainees, and ‘optimized relationships’ between givers and

receivers of feedback (Lockyer, Carraccio, et al., 2017). The special issue concludes

with a paper aiming to propose a research agenda for CBME. Gruppen et al. (2017, p.

623) commence their paper by acknowledging that ‘CBME is becoming a pervasive

framework for the design and implementation of educational programmes worldwide,

yet the research and theory that underlie its principles are still very limited’. They go

on to identify several questions that need to be addressed with research including

fundamental and conceptual questions, implementation questions, and methodological

issues for CBME and WBA. Therefore, this thesis that aims to address issues relating

to implementation and practice, as well as theory and methodology so appears to be

well placed to add to the literature on WBA.

While high-profile educators have continued to promote CBME and WBA

implementation, the debate between those who support it and those who are more

cautious persists. This is highlighted in a recent exchange between two high profile

authors. Krupat (2018) wants the CBME movement to slow down and ‘avoid the trap

effort already expended’ (p. 375), and Holmboe (2018) responds (by way of an invited

commentary) to address concerns raised by reiterating the potential value of CBME

and WBA and the limitations of the previous model. Both arguments are still heavily

reliant on theoretical rather than empirical concerns, and neither of them are fully

convincing. Krupat (2018, p. 371) seeks to ‘urge more public debate, to throw light,

not just heat, on the pros and cons of this movement’, highlighting that there has been

reasonably little critique of the movement.

Boyd et al. (2018) use Foucauldian critical discourse analysis to explore the debate in

CBME, tracing recurring arguments in the 49 empirical and 94 non-empirical papers.

They identify a ‘resistance discourse’ from those with concerns about CBME that has

highlighted fundamental conceptual critiques of CBME (epistemological and

behaviourist critiques). They demonstrate that responses from CBME advocates come

in a discursive strategy that minimises critiques and deflects attention from conceptual

issues. They claim conceptual critiques are reframed as less critical matters of

implementation or interpretation. Thus critical voices are silenced and those ‘whose

scholarly opinions align with the dominant discourse are accorded legitimacy,

whereas other voices are suppressed’ (Boyd et al., 2018, p. 53). Through empirically

exploring current practice, the role of technology, and the influence of theory on the

study of WBA in the NPIP, I aim to add to this debate through generating empirical

data through which these issues can be explored.

2.6 Chapter Summary

This chapter aimed to provide context for this research through describing the

development of CBME and WBA in the NPIP, with a particular emphasis on

practice in the health professions education literature, the key literature is reviewed,

and used to analyse the NPIP WBA. Literature of specific relevance to this thesis

relating to WBA and radar graphs is reviewed in more detail. The development of the

research aim and objectives from the specific NPIP context and literature reviewed is

described. The literature review revealed two main issues with the WBA literature to-

date, namely the lack of empirical research (particularly relating to practice) and

prominence of opinion-based publications, and the lack of theory-informed studies.

However, with the call for more empirical research strengthening (Gruppen et al.,

2017; Holmboe, 2018), hopefully this and other studies can allow us to “problematise

unsupported claims” (Boyd et al., 2018, p. 53) and critically analyse the CBME

movement in terms of empirical study of practice. Harden (2007) describes three

patterns of behaviour relating to OBE that is just as relevant for CBME and WBA in

the NPIP, and this research. He describes ‘ostriches’ (who ignore the movement), ‘peacocks’ (who develop and ‘sometimes ostentatiously display a set of outcomes but stop there’) and ‘beavers’ (who actually implement outcomes-based approaches into

their curriculum). Having incorporated the CCF into every aspect of our NPIP

curriculum we seem to be beavers. Morcke et al. (2013) suggest that beavers should ‘draw on theory as well as authority statements to craft and carefully evaluate curriculum revisions’ to advance the field. Therefore, in the following chapters, I

describe how this study was designed to research practice empirically using a