#KeyLIMEPodcast 66: Competency-based training is a framework for incompetence

As the fall start to the academic year approaches, we have added a new element to the ICE blog. (Editors note: we’re shortening the blog title to ICE as there are plans for an ICE Academy in the near future. Details to come.)

For some readers, the Key Literature in Medical Education podcast is not “new.”  For others, I hope that this serves as an introduction to a valuable resource.

KeyLIME is a bi-weekly podcast produced by the Royal College of Physicians and Surgeons of Canada.  Articles that are important, innovative, or will impact your educational practice are discussed.

How do you keep up-to-date with the medical education literature?  How do you find the important articles, let alone have time to read and critique them?  In emergency medicine, the number-needed-to-read (NNR) is 14. You would need to read 14 articles from one of the top 20 clinical journals to find one methodologically sound, practice changing manuscript! The NNR for medical education has not been calculated, but it’s likely as daunting. With KeyLIME, the number-needed-to-listen is one.

On the ICE blog we will post the abstract that accompanies each podcast.  I would also encourage you to subscribe to the podcast via iTunes or listen to the podcast direct from the KeyLIME site.

Let me know what you think!

– Jonathan (@sherbino)


KeyLIME Session 66 – Article under review:

Listen to the podcast

View/download the abstract here.

Glass JM. Competency based training is a framework for incompetence. BMJ. 2014 Apr 25 (348):g2909


Jason Frank (@drjfrank)


Competency-based medical education (CBME) is an emerging approach to designing training worldwide. Numerous reforms and curriculum changes have been implemented under the banner of “CBME”. Not all of these have been successful or well-received.

In this editorial, which got real estate in the BMJ, Glass from Guy’s & St. Thomas’ laments what he sees as the negative impact of the recent changes to training in the UK. This is part of a small body of literature that takes aim at what are perceived as the negative effects of CBME (see also Talbot, or Norman & Norcini).

Type of paper

Key Points on the Methods
This is pure op-ed that borders on a rant, though parts of it are well written, with some compelling language. There is almost no reference to what CBME is in the literature, or critical appraisal of whether the changes the author dislikes are poor design, poor implementation, nor how it can be improved.

Key Outcomes
Glass makes several complaints about the meded changes he sees, including:
• Excessive reductionism, where training is reduced to being “assessed on a four point scale“. He contrasts this with an artist’s pursuit of mastery.
• Rigidity in training, implying that there are quotas for cases instead of pursuit of competence.
• Resident duty hour regulations are an inappropriate focus.
• Negative impact on trainee development, by discouraging wider exposure.
• Less focus on the patient.

Key Conclusions
Glass ends with a poetic expression of nostalgia for a better era: “We should want to produce masters of art, not technicians; to produce masterpieces, not sketches…Is it not time for a medical education renaissance?” Some of Glass’ issues are legitimate concerns for all of us as educators, such as creating a reductionistic culture, where trainees are more concerned about checklists than becoming an excellent physician. However, the problems described are not necessarily attributable to CBME as an approach. They are symptoms of a variety of curriculum diseases. Furthermore, many of the meded terms are misused and apparently misunderstood.

Spare Keys – other take home points for clinician educators
Editorials are legitimate contributions to the discourse of scholarship. When done well, editorials can provide perspective, summarize current thinking, or provocatively stimulate further discourse. Write effective editorials by avoiding rants and consulting a good editor. For a good reference, see Taylor’s Medical Writing Chapter 7 (Springer, 2011).

If you are going to complain about an aspect of medical education, you should at least do a lit review to ground and validate your perspective.

Avoid rants.. Not all that is labeled CBME is. A poorly implemented meded intervention is poorly done, regardless of the underlying approach.

Access KeyLIME podcast archives here