Building capability of meso-level leaders for CBME implementation: a mixed-methods evaluation of a faculty development programme

Imagine the world of medical training as a massive, intricate video game. At the very top, the "Macro" level, are the game designers and rule-makers who decide what skills a player needs to master to become a champion. They write the rulebook: "To win, you must be able to heal a specific type of wound within ten minutes." But the rulebook doesn't tell the players how to do it on the ground. That's where the "Meso" level comes in. Think of this as the level of the "Guild Masters" or "Team Captains"—the experienced doctors who run the local training hospitals. Their job is to take those big, abstract rules from the top and turn them into daily practice for the new recruits (the trainees).

The problem is, these Guild Masters are usually chosen because they are the best fighters (clinicians) in the game, not because they are the best teachers. They might know exactly how to heal the wound, but they haven't been taught how to explain it, how to grade a student's attempt, or how to help a student who is struggling to keep up. This creates a "capability gap." The new players get confused, the rules aren't followed correctly, and the game gets messy. This paper asks a simple but crucial question: If we give these Guild Masters a special "Coach's Training Course," will they get better at translating the rules into real-world success? The study suggests that yes, a structured course can turn a confused captain into a confident leader, but it also hints that one captain can't fix the whole game alone.

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The Mission: Training the Trainers

In the high-stakes world of postgraduate medical education in Hong Kong, there is a shift happening. The system is moving from "Competency-Based Medical Education" (CBME). In plain English, this means the focus is shifting from "how many hours did you sit in a chair?" to "can you actually do the job?" It's the difference between saying, "I've driven for 500 hours," and "I can parallel park perfectly."

To make this shift work, the system relies on "Supervisors of Training" (SOTs). These are the meso-level leaders—the department heads and senior doctors who are supposed to guide the trainees. However, a recent check-up revealed a glitch: most SOTs were hired for their medical skills, not their teaching skills. They were trying to teach a complex new game without a rulebook or a strategy guide.

To fix this, the researchers designed a 12-week "Coach's Training Course." It wasn't just a boring lecture; it was a blended mix of online videos, homework, and a big face-to-face workshop. The course focused on four main super-skills:

1. Facilitating Learning: How to help trainees actually learn the new competency-based style.
2. Fostering Environments: How to make the hospital a safe, supportive place to learn (and stop bullying).
3. Conducting Assessments: How to grade trainees in a way that helps them grow, not just to tick a box.
4. Supporting Struggling Trainees: How to spot a player who is stuck and help them get back on track.

The Results: From "I Think I Can" to "I Know How"

The researchers tested this course with 15 supervisors who completed the full program. They used a mix of surveys (before and after) and focus group chats to see what changed.

The Confidence Boost
The most striking result was a massive jump in confidence. Before the course, many supervisors felt unsure about how to handle specific tasks. After the course, their self-belief skyrocketed.

• For facilitating learning, their confidence jumped by a huge margin (a statistical "effect size" of 0.96).
• For assessing trainees, confidence rose by 0.86.
• For helping struggling trainees, it went up by 0.83.

In the world of statistics, anything over 0.8 is considered a "large" effect. This suggests the course didn't just give them a little nudge; it gave them a giant leap.

The "Social Norm" Shift
Interestingly, the course also changed how the supervisors viewed their peers. Before the training, they felt a bit isolated, unsure if their colleagues were on the same page. After the course, they felt a strong sense of shared purpose. The "social influence" score jumped by 1.04 for assessments and 0.84 for helping struggling trainees. It's as if the course turned a group of solo players into a coordinated team that agreed on the rules of the game.

The "Ceiling" Effect
There was one area where the scores didn't move much: creating a supportive environment. Why? Because the supervisors already felt very confident about this before the course started. They were already high-fiving themselves on a scale of 1 to 7, scoring around 6.6. The course didn't make them feel more confident, but the interviews revealed something deeper: they didn't just feel confident; they suddenly understood the details. They realized that "supportive" isn't just about being nice; it's about spotting subtle bullying and psychological safety issues they hadn't noticed before. The survey couldn't measure this new depth of understanding, but the participants could talk about it.

The "Aha!" Moments: What the Supervisors Said

The numbers tell part of the story, but the focus groups told the real tale. The supervisors described a shift in their brains:

• From "Filling Forms" to "Building a Picture": Before, they saw assessments (like the In-Training Assessment or ITA) as just paperwork—filling out a form to pass a student. After the course, they started seeing it as a "diagnostic tool." One supervisor used a brilliant metaphor: they realized an assessment is like collecting "pixels" over time. One pixel doesn't show the picture, but hundreds of them build a clear image of how the trainee is growing.
• From "It's the Student's Fault" to "It's the System": When a trainee was struggling, the old mindset was, "This student is lazy or bad at medicine." The new mindset was, "Maybe the training environment is broken, or maybe our teaching method is wrong." They realized that if they couldn't fix the system, just diagnosing the student's problem was useless.
• The Need for a "Critical Mass": The supervisors realized that training just the "Guild Masters" wasn't enough. To truly change the culture of the hospital, everyone—from the newest intern to the most senior professor—needed to understand these new rules. One participant noted, "Changing culture involves people at different levels... all need to understand what we learned today."

The Catch: It's Not a Magic Wand

The paper is careful not to call this a "solved problem." While the supervisors felt more capable and confident, the researchers point out a few hurdles:

• The Workload Clash: The online part of the course was self-paced, but the doctors were so busy with real patients that they often rushed through the homework. By the time they got to the face-to-face workshop, they had forgotten the videos. The course design didn't quite match the chaotic rhythm of a hospital.
• The Power Gap: The supervisors realized they had the knowledge to fix things, but they didn't always have the power to change the hospital's rules or culture. As one put it, "If we are not empowered to make any improvements, diagnosing is useless."
• The Unknown Future: The study measured how the supervisors felt right after the course. It doesn't yet know if they will actually do things differently six months from now, or if their trainees will actually become better doctors because of it.

The Bottom Line

This paper suggests that the "capability gap" in medical training isn't because supervisors don't want to do a good job—they already care deeply. The problem is that they didn't have the tools or the framework to do it. A structured, hands-on training course can turn a well-meaning but confused supervisor into a confident, skilled leader.

However, the authors warn that you can't just train a few captains and expect the whole army to win. For this new way of teaching to stick, the whole system needs to align. The rule-makers (Macro), the captains (Meso), and the players (Micro) all need to be on the same page. The course was a successful first step, a way to build the muscle of the leaders, but the real victory will depend on whether the whole hospital ecosystem supports them as they try to use those new muscles.