Whitney Lowe , LMT , Education Section Editor, IJTMB
Director, OMERI, Sisters, OR, USA.What does it mean to be competent and why is this so important? While there is no generally accepted definition of competency, there are key components that should guide the emerging movement of competency-based education (CBE). In addition, entry-level massage curricula typically run from approximately 500 clock hours to 3000 hours or more. This discrepancy demonstrates markedly divergent opinions on what constitutes the required amount of time (content) for entry-level massage and bodywork curriculum. Some programs have begun using competency models, but there is no broad implementation of CBE. A first step is to come to some agreement on what competencies are actually needed for an entry-level massage therapist. A current effort is underway in the United States that should lay essential groundwork for greater adoption of CBE models
In a popular song by the Indigo Girls, they sing “I spent four years prostrate to the higher mind, got my paper and I was free” (Closer to Fine). The reference to time in English idioms is insightful: you can lose or gain time; you can be ahead of or behind the times; from time to time; you can keep time, beat it, or even make time; and finally, you can pass the time.
The last idiom sums up current markers of educational progress, when the focus is on time spent, as opposed to achieving specific educational goals or outcomes. The time-based structure of our health care educational systems is captured well by Snell and Frank in their reference to the tea bag model of medical education.(1) In this model, the emphasis is on how much time the students spend steeped in particular subject matter.
The emphasis on measuring education by time spent begins at the earliest levels in our school systems. It is emphasized strongly in higher education, with the weight on the credit hour. Ironically, the credit-hour system was never designed to be a measure of educational progress. It was originally developed by the Carnegie Foundation as a means to determine instructor qualifications for pension programs.(2)
However, the system was found to be convenient for classifying and categorizing completion of certain educational modules (classes). For decades, time-based credentialing has been the standard because it provided a common currency and appeared to provide a system that, while not perfect, was working sufficiently. Consequently, there did not seem to be ample reason to challenge the status quo.
In the United States, the U.S. Department of Education previously defined a credit hour for course work to be 1 hour of in class time plus 2 hours out of class work each week for a semester or quarter term. After recognizing the inadequacy of measuring educational progress only by time, the Department of Education has recently updated its definition of a credit hour. In the newer definition, credit can also be earned for an “… equivalent amount of work over a different amount of time”.(2) This revised definition acknowledges a shift in emphasis away from time and toward greater recognition of alternative models of learning, which the Department references as an ‘equivalent amount of work’. There is a growing awareness that it is more appropriate to prove what is accomplished by the student in the learning activity, than how long he or she sat in a seat.(2)
Many instructors and curriculum developers now realize that time spent steeped in content is not the best indicator of producing high-quality health care professionals. You can spend a great deal of time on various subjects but still be unprepared for the real-life demands of clinical practice. In this sense, you haven’t met the criteria of becoming a truly competent practitioner.
Instead of such a high reliance on time in courses, there is growing focus on achieving proficiency in a wide set of knowledge, skills, and behaviors that are specifically defined for each discipline. These specific abilities are referred to as competencies. Noted medical educator, Ronald Harden, described this change in education to focusing on outcomes and competencies as “the most important trend in medical education in the past decade”.(3) I would agree.
So what does it mean to be competent and why is this so important? There is no generally accepted definition of competency, but there are some key components that guide the emerging movement of competency-based education (CBE), also referred to as outcome-based education (OBE). Frank and colleagues performed a systematic review of literature related to CBE and found numerous definitions, but several common themes emerged.(4) There was common agreement that CBE is focused more on the successful achievement of predefined outcomes and competencies that cover a broad range of knowledge, skills, and abilities regardless of how the student gets there. CBE is more learner-centered, and there is a decreased emphasis placed on the time structure of programs. Training time is seen as a resource for instruction, no longer as the organizing framework for the course or curriculum.(4)
Entry-level massage curricula typically run from around 500 clock hours to 3000 or more, which is quite a discrepancy. This difference demonstrates markedly divergent opinions on what constitutes the required amount of time (content) to be covered in an entry-level massage and bodywork curriculum.
A few programs, such as Canada’s Interjurisdictional Competencies Development Project (http://bit.ly/17EpqVg), have begun using competency models, but we are still a long way from seeing broad implementation of CBE. One of the first steps is to come to some agreement on what competencies are actually needed for an entry-level massage therapist. A current effort is underway in the United States with the Entry-Level Analysis Project (ELAP) (http://www.elapmassage.org/) that should lay essential groundwork for greater adoption of CBE models. I hope that we will then see a growth of competency-based programs that will better cultivate the real-life skills and abilities needed by massage and bodywork therapists in the future.
The time is now ripe for this change in our field. Educational strategies that focus on competencies put greater emphasis on subjects and abilities not often stressed in traditional curricula—topics such as communication skills, clinical reasoning, attitudes and emotions, as well as self-reflection.(5) An increasing emphasis on developing more well-rounded practitioners proficient in these competencies will greatly improve the quality of services we offer to the public. However, changing to a completely new format, and one that is not familiar to most educators, can breed fear and resistance, so it is likely to be a slow and gradual movement.
There are several key challenges to surmount in the move to CBE models and it will take concerted effort on the part of faculty, administrators, and students to adjust to these new formats. One of the first challenges is the establishment of core competencies in the various different fields covered in our entry-level education. Before we can design curriculum or classroom activities designed to achieve competence in these different domains we must define what competence looks like in these areas. Unfortunately, due to the diversity of approaches in our profession, we have historically had a difficult time coming to agreement on issues of curriculum content. Developing a set of core competencies and getting agreement on them is likely to prove a substantial challenge.
Once competencies are defined, new challenges with curriculum construction will emerge. CBE focuses less on breaking up subjects into discreet categories (anatomy, physiology, kinesiology, etc.). Instead, there is greater emphasis on how the student integrates content from different areas to produce and demonstrate integrated knowledge and skills. Educational strategies in the classroom will be most effective when they, too, integrate content from different subjects together and emphasize the outcome ability more than time in contact with discreet subjects. Consequently, it will be important to train and develop more well-rounded teachers who can facilitate cross-discipline approaches within their classrooms.
Another challenge will come from shifting the focus of how assessment is used. In the traditional classroom approach, assessment comes at the end of a specific topic segment. Once the assessment is complete, the class moves on. In a CBE model, assessment serves a different purpose. Assessment activities are more frequently woven through the instructional modules and designed to provide continual guidance and improvement toward achieving final competence.(6) Competency-based assessment strategies may also make more use of peer evaluation and self-evaluation methods that help each student become more aware of their own strengths and weaknesses, and direct future learning efforts to address areas of deficiency.(7)
CBE models represent the future of education. These approaches hold great promise for solving many of the training challenges we currently face, as well as helping to produce much better practitioners for the future. Yet, there is no doubt that making a change like this shift to CBE will be a difficult road with a number of hurdles. However, just because something is hard doesn’t mean we shouldn’t do it. It is my hope that educators in our field will rise to this challenge and see the benefits that await us when we stop keeping time and shift our attention to the real question we should be focusing on: What do we want our students to be able to DO after we have finished with them?
1 Snell LS, Frank JR. Competencies, the tea bag model, and the end of time [commentary]. Med Teach. 2010;32(8):629–630.
2 Laitinen A. Cracking the Credit Hour. Washington, DC: New America Foundation; 2012.
3 Harden RM, Laidlaw JM. Essential Skills for a Medical Teacher: an Introduction to Teaching and Learning in Medicine. Edinburgh: Elsevier; 2012.
4 Frank JR, Mungroo R, Ahmad Y, Wang M, De Rossi S, Horsley T. Toward a definition of competency-based education in medicine: a systematic review of published definitions. Med Teach. 2010;32(8):631–637.
5 Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA. 2002;287(2):226–235.
6 Holmboe ES, Sherbino J, Long DM, Swing SR, Frank JR. The role of assessment in competency-based medical education. Med Teach. 2010;32(8):676–82.
7 Campbell C, Silver I, Sherbino J, Ten Cate O, Holmboe ES. Competency-based continuing professional development. Med Teach. 2010;32(8):657–62.
INTERNATIONAL JOURNAL OF THERAPEUTIC MASSAGE AND BODYWORK , VOLUME 6 , NUMBER 4 , 2013 2013