How a Pilot Project Became a National Standard

By: Markku T. Nousiainen

The implementation of competency-based medical education (CBME) in postgraduate medical education in Canada has developed along the “Competence By Design” (CBD) framework of the Royal College of Physicians and Surgeons (RC).  But unique to orthopaedic surgery, the original pilot in CBME was actually initiated at the University of Toronto in the 2009-2010 academic year1.  This Competency-Based Curriculum (CBC) program, one of the first in the world, included:

  1. an optimized curriculum relevant to what an orthopaedic surgery resident would need to know to enter practice;
  2. explicit expectations or milestones;
  3. EPAs (Entrustable Professional Activities), key tasks of the discipline that a resident must be observed to perform competently in order to progress through the training program);
  4. an intensive assessment process of all relevant CanMEDS roles;
  5. the intensive use of simulation to teach and assess trainees;
  6. a modular curriculum wherein a trainee would acquire the necessary competencies in basic rotations before progressing to advanced rotations; and,
  7. attestation of competence once a resident met all objectives1

Early experience with the pilot was positive, and the CBC has been the sole mode of training and assessment in the training program since the 2013-14 academic year2.

Queen’s University in Kingston also adopted a CBME training model for its entire postgraduate medical education (PGME) system in July of 20173. This included:

  1. attestation that all residents met required training experiences;
  2. stage-specific EPAs and corresponding assessment systems;
  3. web-based trainee portfolios that deliver and record assessments; and,
  4. extensive faculty training in the implementation and evaluation of EPAs.

Key to the successes of these programs was the ability for faculty, trainees, and administrative personnel to meet frequently in an open environment to discuss successes and failures as the curricula were implemented.  This iterative process allowed for meaningful feedback to be given to those responsible for managing the new programs so that positive changes could be made to sustain and strengthen the efforts of all stakeholders.

The initial outcomes of the Toronto and Queen’s pilots were positive – so much so that they helped build the momentum for a national CBD movement.  But when it came time for all orthopaedic surgery training programs in Canada to determine how a national CBME curriculum would be developed, the CBD framework would be utilized.

The development of the orthopaedic surgery CBD curriculum was overseen by the Orthopaedic Surgery Specialty Committee (SC) and took place over three, 3-day meetings which were organized and funded by the RC in 2018 and 20194.  It was through these sessions where the specific set of knowledge and skills in which a graduate of an orthopaedic residency training program should be competent were defined; the required training experiences of a resident and the EPAs a resident must perform competently to be considered eligible for certification were defined; the stage of training at which each training experience should be provided and the EPAs that would have to be completed were defined; the required and recommended training experiences and EPAs for each orthopaedic subspecialty were finalized; the method of assessment for each EPA, and the number of observations of acceptable performance was determined; CanMEDS-specific milestones for each EPA were implemented; the required training experiences that are necessary for a program to provide to a trainee were finalized; and what assessment modalities could be used by the training programs were agreed upon4

All training programs accepted the new training format in the spring of 2020.  All programs initiated the CBD curriculum for all incoming residents in July of 2020 with the understanding that they had the flexibility to deliver the curriculum and assessments to meet their local needs.  This flexibility was critical, as it promoted individual program cooperation and acceptance4.  

Despite the promise of CBD, the members of the SC recognized that several challenges in implementation were likely to occur.  These included: educating faculty and residents on the CBD plan (this would be time intensive); training programs being challenged to have the necessary technical and administrative support to implement CBD (particularly with managing all the assessment data); a change in the culture of residency training programs to adopt and embrace the CBD model (this too would be time intensive for leaders of the program); the implementation of the CBD assessment plan by the training programs into their current curricula; and how best to use the assessment data generated by all training programs to provide feedback on how well each individual program is performing in CBD implementation (no system had been set up to do this at the time of CBD initiation)4.   

Until now, no formal feedback process has been organized to assess how the training programs are experiencing the new curriculum and how they have managed the anticipated challenges.  Certainly, positive and negative effects have been experienced by faculty, trainees, and administrative personnel.  But it is only through formal feedback processes that all stakeholders experiencing the change will be able to provide input on how to improvements and adjustments can be made.  Indeed, the success of the pilot programs that started CBME in Canada – the University of Toronto and Queen’s University – was due to the ability for all stakeholders to participate in an open, iterative process of communication.  Having feedback processes will help not only the ongoing national effort in Canada but also help inform others who are interested in implementing CBME into their own jurisdiction.

About the author: Markku T. Nousiainen, B.A.(Hons.), MS, MEd, MD, FRCSC, FAOA, is an Orthopaedic Surgeon. He is Medical Director of the Holland Bone and Joint Program at Sunnybrook Health Sciences Centre, as well as an Associate Professor in the Department of Surgery at the University of Toronto.


1.Alman BA, P Ferguson, W Kraemer, et al. Competency-based education: a new model for teaching orthopaedicsInstr Course Lect. 2013;62:565-9

2. Nousiainen MT, P Mironova, M Hynes, et al. Eight-year outcomes of a competency-based residency training program in orthopedic surgery. Med Teach. 2018;40(10):1042‐54.

3. Queen’s University CBME Role Descriptions: Last accessed March 1 2023.

4. Nousiainen MT, D Bardana, W Gofton, et al. Creating a National Competency-Based Curriculum for Orthopaedic Surgery Residency: the Canadian Experience. JBJS Open Access. 2022;7(1):e21.00131

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