Competency-based medical education (CBME) is an outcomes-based approach to the design, implementation, assessment, and evaluation of a medical education program using an organizing framework of competencies. Competence by Design (CBD) is the Royal College’s version of CBME. It is a change initiative designed to enhance CBME in residency training and specialty practice in Canada.
Rationale and Goals: The benefits of focusing on learning instead of time
- Ensures competence, but teaches for excellence.
- Supports physicians’ skills and abilities to evolve throughout practice – enhancing care.
- Responds to changing patient and societal needs.
- Addresses gaps in the current system, like the ‘failure to fail’ culture of resident education.
- Reduces burden on faculties, promoting smoother credentialing and accreditation.
- Increases accountability and promotes transparency in training.
Competency based education introduces a whole new language and set of definitions to medical education. Clear, common definitions are important for key stakeholders to know and understand as this will facilitate communication of these new concepts. Please see below definitions of key CBME terminology.
Competency based medical education (CBME) is an outcomes-based approach to the design, implementation, assessment, and evaluation of a medical education program using an organizing framework of competencies (e.g. CanMEDS 2015). In a CBME system, a curriculum is organized around the outcomes expected of a resident, and that resident’s advancement is dependent on having achieved those expected outcomes.
The Royal College’s Competence Continuum breaks down specialist medical education into a series of integrated stages, from the beginning of residency through practices.
- Transition to Discipline (Stage 1)
This stage emphasizes the orientation and assessment of new trainees arriving from different medical schools and programs.
- Foundations of Discipline (Stage 2)
This stage covers broad-based competencies that every trainee must acquire before moving on to more advanced, discipline-specific competencies. This stage covers the essential competencies that make up the majority of a discipline.
- Core of Discipline (Stage 3)
This stage covers the core competencies that make up the majority of a discipline.
- Transition to Practice (Stage 4)
In this stage, the senior trainee demonstrates readiness for autonomous practice.
Competence is the array of abilities across multiple domains or aspects of physician performance. Competence is both conditional on, and constrained by, each physician’s practice context, is dynamic, and continually changes over time. Competence is the ability to do all of the tasks of practice effectively and consistently, adapting to contextual and situational needs.
Competent means possessing the require abilities in all domains (areas) in a certain context at a defined stage of medical education or practice. A resident’s promotion from one stage to the next in the competence continuum will occur when they are deemed competent in the competencies defined for that stage.
A competency is an observable ability of a health care professional that develops through stages of expertise from novice to master clinician. Competencies are the things an individual needs to learn to do.
A milestone is the expected ability of a health care professional at a stage of expertise. CanMEDS milestones illustrate the expected progression of competence from novice to mastery associated with each enabling CanMEDS competency. Each milestone is an observable marker of a person’s ability along a developmental continuum. In the context of CBD, milestones are used for planning, teaching and assessment.
A key task of a discipline (profession, specialty, or sub-specialty) that an individual can be trusted to perform without direct supervision in a given health care context, once sufficient competence has been demonstrated. In CBD, EPAs are the framework for assessment. A Royal College (RC) EPA is linked to a specific stage of the competence continuum and integrates multiple CanMEDS milestones from various CanMEDS Roles relevant to that stage. As residents progress through the stages, the RC EPAs become progressively more complex, reflecting the resident’s achievement of more complex milestones.
The assessment of trainees and physicians across the continuum of day-to-day competencies and practice in authentic, clinical environments. It enables the evaluation of performance in context.
Training experiences are the mandatory and recommended training activities that support a resident’s acquisition of competence. These activities can include clinical care, such as inpatient care, ambulatory clinics, performing technical procedures, or extra clinical activities, for example simulation exercises, scholarly projects, journal clubs, etc.
A Competence Committee (CC) is responsible for assessing the progress of trainees in achieving the specialty-specific requirements of a program. These requirements are established for each stage of training.