Challenges to the time-based model. Two fundamental issues arise with the fixed, time-based model. First, the assessment structure of competence and proper entrustment of skills can be challenging, as it lacks the flexibility to meet individual progression toward competence. In time-based models, time is so central to completion that learners may graduate without having properly demonstrated mastery in required competencies. To address this limitation, a system to monitor and provide ongoing feedback for learners to achieve competence within the fixed time interval is needed. However, courses in time-based models are structured into predetermined intervals, making ongoing, individualized feedback structurally difficult; that is, monitoring and providing individualized feedback to learners in time-based models—particularly on achieving competencies—can be limited due to the inherent condition of graduating learners within a fixed time period.
While summative assessments are common in time-based curricular models, they do not necessarily provide information about whether learners have acquired the competencies to perform at work. Implementing workplace-based assessments (WBAs) that allow continuous measurement of skills in the clinical workplace can be difficult in a time-based environment, because of a lack of alignment between instruction in time-based modules and assessment of overall educational outcomes. Most curricular structure is oriented to completing a time-based block rather than aiming toward overarching educational outcomes. Furthermore, individual rates at which learners acquire necessary competencies may not be measured or tracked within the time-based model. This can also deter promoting self-regulated and flexible learning environments for learners (Gruppen et al. 2012). Because learners progress at different rates, some may achieve the required competencies prior to graduation. A one-size-fits all assessment policy rooted in time-based curricula may not be an adequate model for learning in the twenty-first century.
Second, changes or reforms are difficult to implement in a time-based model; altering curriculum often means only making minor adjustments to accommodate change, rather than a wholesale reform driving the curriculum. Within the traditional time-based curricula, proposals to modify the curriculum often take an additive approach, whereby new topics such as ethics or communications are simply added, rather than streamlining or removing existing content. Therefore, with learners’ schedules already fully committed, modifications to curricula may only result in modest changes.
Given these structural issues in the time-based model, ensuring competence development can be problematic. Moreover, in an era when public accountability and societal expectations drive the need for evidence of competence development, the imperative for curricular reform becomes more pressing. Although the time-based model has adequately served the needs of health professionals since Flexner’s era, these concerns have led to a movement toward CBME.
Flexner wrote in his report in 1910:
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A uniform or fixed appointment between various subjects is in schools of the highest grade neither feasible nor desirable. The endeavor to improve medical education through iron-clad prescription of curriculum or hours is a wholly mistaken effort; while mechanical regulation cannot essentially improve poorer schoos, it may very seriously hamper competent institutions. There is no one way to study medicine, still less one way to advance it. If the teaching is in inferior hands, printed directions will not save it. The prescribed curriculum is a staff upon which those lean who have not strength to walk alone.