Carol Carraccio

Although competency-based medical education (CBME) has attracted renewed interest in recent years among educators and policy-makers in the health care professions, there is little agreement on many aspects of this paradigm. We convened a unique partnership - the International CBME Collaborators - to examine conceptual issues and current debates in CBME. We engaged in a multi-stage group process and held a consensus conference with the aim of reviewing the scholarly literature of competency-based medical education, identifying controversies in need of clarification, proposing definitions and concepts that could be useful to educators across many jurisdictions, and exploring future directions for this approach to preparing health professionals. In this paper, we describe the evolution of CBME from the outcomes movement in the 20th century to a renewed approach that, focused on accountability and curricular outcomes and organized around competencies, promotes greater learner-centredness and de-emphasizes time-based curricular design. In this paradigm, competence and related terms are redefined to emphasize their multi-dimensional, dynamic, developmental, and contextual nature. CBME therefore has significant implications for the planning of medical curricula and will have an important impact in reshaping the enterprise of medical education. We elaborate on this emerging CBME approach and its related concepts, and invite medical educators everywhere to enter into further dialogue about the promise and the potential perils of competency-based medical curricula for the 21st century.

Realizing medical education is on the brink of a major paradigm shift from structure- and process-based to competency-based education and measurement of outcomes, the authors reviewed the existing medical literature to provide practical insight into how to accomplish full implementation and evaluation of this new paradigm. They searched Medline and the Educational Resource Information Clearinghouse from the 1960s until the present, reviewed the titles and abstracts of the 469 articles the search produced, and chose 68 relevant articles for full review. The authors found that in the 1970s and 1980s much attention was given to the need for and the development of professional competencies for many medical disciplines. Little attention, however, was devoted to defining the benchmarks of specific competencies, how to attain them, or the evaluation of competence. Lack of evaluation strategies was likely one of the forces responsible for the three-decade lag between initiation of the movement and wide-spread adoption. Lessons learned from past experiences include the importance of strategic planning and faculty and learner buy-in for defining competencies. In addition, the benchmarks for defining competency and the thresholds for attaining competence must be clearly delineated. The development of appropriate assessment tools to measure competence remains the challenge of this decade, and educators must be responsible for studying the impact of this paradigm shift to determine whether its ultimate effect is the production of more competent physicians.

The meaningful assessment of competence is critical for the implementation of effective competency-based medical education (CBME). Timely ongoing assessments are needed along with comprehensive periodic reviews to ensure that trainees continue to progress. New approaches are needed to optimize the use of multiple assessors and assessments; to synthesize the data collected from multiple assessors and multiple types of assessments; to develop faculty competence in assessment; and to ensure that relationships between the givers and receivers of feedback are appropriate. This paper describes the core principles of assessment for learning and assessment of learning. It addresses several ways to ensure the effectiveness of assessment programs, including using the right combination of assessment methods and conducting careful assessor selection and training. It provides a reconceptualization of the role of psychometrics and articulates the importance of a group process in determining trainees' progress. In addition, it notes that, to reach its potential as a driver in trainee development, quality care, and patient safety, CBME requires effective information management and documentation as well as ongoing consideration of ways to improve the assessment system.

The International Competency-Based Medical Education (ICBME) Collaborators have been working since 2009 to promote understanding of competency-based medical education (CBME) and accelerate its uptake worldwide. This article presents a charter, supported by a literature-based rationale, which is meant to provide a shared mental model of CBME that will serve as a path forward in its widespread implementation.At a 2013 summit, the ICBME Collaborators laid the groundwork for this charter. Here, the fundamental principles of CBME and professional responsibilities of medical educators in its implementation process are described. The authors outline three fundamental principles: (1) Medical education must be based on the health needs of the populations served; (2) the primary focus of education and training should be the desired outcomes for learners rather than the structure and process of the educational system; and (3) the formation of a physician should be seamless across the continuum of education, training, and practice.Building on these principles, medical educators must demonstrate commitment to teaching, assessing, and role modeling the range of identified competencies. In the clinical setting, they must provide supervision that balances patient safety with the professional development of learners, being transparent with stakeholders about level of supervision needed. They must use effective and efficient assessment strategies and tools for basing transition decisions on competence rather than time in training, empowering learners to be active participants in their learning and assessment. Finally, advancing CBME requires program evaluation and research, faculty development, and a collaborative approach to realize its full potential.

Competency-based education in the health care professions has become a prominent approach to postgraduate training in Canada, the Netherlands, the United Kingdom, the United States, and many other countries. Competency frameworks devised at national and international levels have been well received, and in many cases mandated, by governing bodies. However, the teaching and assessment of competencies pose questions of practicality, validity, and reliability. In this article we propose that competence and competencies be approached in the context of the particular clinical environment, such that the assessment of competence is tied to a trainee's performance of essential clinical activities that define the profession. Competence is implicit in the eventual entrustment of trainees to perform these professional activities. Competencies and "entrustable professional activities" (EPAs) relate to each other as two dimensions of a grid in which each EPA can be mapped back to a number of competencies. This backward visioning from EPAs to competencies is proposed as a guide to curriculum planning and assessment. The authors discuss experiences with this conceptual model in research, curriculum development and learner assessment.