When Implementation Science Meets Democracy in CBME   

By: Fremen Chichen Chou (@FremenChou) and Chien-Yu Jonathan Chen (https://hub.tmu.edu.tw/en/persons/chien-yu-chen)

Competency-Based Medical Education (CBME) is an emerging educational reform that aims to develop healthcare professionals aligned with local healthcare needs. CBME emphasizes patient care and learner development. While CBME research has progressed in the last two decades, translating these advancements into practical education and patient care requires significant changes in both education and clinical settings. This may even involve policy and societal shifts in healthcare systems and professional education. Learning from experiences in public service and management within the healthcare system could offer insights for effective CBME implementation and its impact on healthcare practices.

Bauer and Kirchner (2020) authored a paper titled “Implementation Science: What Is It and Why Should I Care?” in Psychiatry Research, aiming to elucidate the insufficiency of establishing clinical innovation effectiveness alone in guaranteeing its integration into routine practice. They highlighted the role of implementation research. They further explained that transitioning from biomedical research to public health impact, evaluating the potential effect of a clinical innovation (internal validity, efficacy studies), and assessing its applicability in daily practice falls short. The adoption and dissemination of clinical innovation constitute a social process involving contextual factors and evolving individual and societal behaviors.

Implementation science, characterized by systematic research methodologies, addresses the systematic assimilation of research findings. This entails recognizing barriers and facilitators to uptake, and subsequently developing strategies to surmount obstacles or amplify facilitators. This process enhances healthcare service quality and efficacy. Drawing an analogy between clinical innovation and public health impact to understand the translation of CBME innovation into health professional education and healthcare outcomes underscores the paramount importance of implementation science. While the medical domain traditionally emphasizes efficacy studies, public management places greater emphasis on implementation research.

Co-production represents an emerging perspective and methodology within the realm of public management. It encompasses citizen engagement in public services, particularly emphasizing the active involvement of citizens impacted by the service in shaping its design and delivery. “Co-production and Co-creation: Engaging Citizens in Public Services,” a publication by Brandsen, Steen, & Verschuere (2018), systematically elucidates the concept of co-production, its theoretical underpinnings, and empirical validations. Their work emphasizes that co-production inherently embodies democratic principles and delves into the Democratic Quality of Co-production.

This exploration touches upon at least two democratic attributes. Firstly, equity and inclusion necessitate equitable representation of citizens in co-production to enhance the diversity of perspectives contributing to service development. Secondly, Impact and empowerment, a more process-oriented aspect, signifies that involved stakeholders should perceive their influence on decision-making. This extends beyond the right to express opinions, encompassing the ability to impact the nature of the service and its implementation.

While implementation science concentrates on the systematic integration of innovations (such as CBME), democratic co-production offers insights into identifying barriers and facilitators, and devising strategies to overcome challenges or amplify facilitation. An exemplary instance of democratic co-production is evident in the undergraduate medical program at Charité – Universitätsmedizin Berlin 3 . In less than a decade, this institution transitioned from a traditional, discipline-based curriculum to a fully integrated, competency-based program. They effectively applied the wisdom of implementation science through a systemic change management approach. To facilitate this transformation, they organized an interdisciplinary project management team to offer support, leadership, and relief to the faculty. This was achieved through sustained top-down communication with stakeholders and by engaging students and frontline educators in a bottom-up manner. They adopted a systematic, standardized, and transparent eight-step approach to curriculum reform. To assess its efficacy, a tangible longitudinal concept for operationalizing outcomes was collaboratively developed, demonstrating how a challenging curriculum reform objective can be collectively achieved within a democratic framework.

A similar pattern has emerged in Taiwan’s postgraduate specialty training, predominantly within institutions like Taipei Medical University Hospital and China Medical University Hospital. They are comprehensively integrating Milestones (or EPAs) and Clinical Competency Committees into their specialty physician training programs. This systematic adoption of CBME is also unfolding within national emergency medicine and anesthesiology specialty medical associations. The implementation strategies encompass various facets, including the support from national research initiatives, the collective effort of all training institutions, the establishment of long-term faculty development committees within professional associations, consensus-building methods rooted in academic rigor, emphasis on a high degree of autonomy and non-compulsion, respect for diverse opinions, and the facilitation of coordination and compromise processes, all while valuing international collaboration and connectivity. However, areas for improvement lie in the representation of trainees and patients, as well as the yet-to-be-established effectiveness assessment criteria. These aspects are areas where the German model can serve as a learning opportunity.

Taiwan’s remarkable progress in advancing CBME among Asian nations can be attributed to the nation’s nearly 40-year democratic process, which has deeply ingrained a cooperative democracy at every level, including medical education. Amidst the paradigm shift towards CBME, while resource allocation and policy direction certainly wield significant impact, it is the implementation strategies of democratic co-production that hold the key to the success of educational reform.

Fremen Chihchen Chou, MD, PHD, is an Emergency Physician, Assistant Professor in the School of Medicine at China Medical University in Taiwan, and Director of the Center for Faculty Development at its affiliated hospital. Dr. Chou has been instrumental in leading the competency-based training reform for the Taiwan Society of Emergency Medicine since 2011. He actively engages with the international CBME community and holds significant roles such as the International Regional Hub Leader for the Faculty Development Assessment Program in collaboration with ACGME, a faculty member of the International Course: Ins and Outs of Entrustable Professional Activities, and an inaugural member of the executive committee of ICBME collaborators.

Chien-Yu Jonathan Chen, MD, PhD, is an Associate Dean of Academic Affairs and an Associate Professor in Anesthesiology and Medical Humanities at Taipei Medical University (TMU). He has led the implementation of Competency-Based Medical Education (CBME) for 21 physician specialties and 10 allied healthcare professions as the former Director of Education at Taipei Medical University Hospital. He is also the chair of the CBME Committee of the Taiwan Society of Anesthesiologists (TSA) and has developed the milestone-based Entrustable Professional Activities (EPAs) for anesthesiology residency training. He is currently collaborating with the Taiwan Association of Nurse Anesthetists (TANA) to develop an EPA-based curriculum and a faculty development course in Taiwan


  1. Bauer, M. S., & Kirchner, J. (2020). Implementation science: What is it and why should I care?. Psychiatry research, 283, 112376.
  2. Brandsen, T., Steen, T., & Verschuere, B. (2018). Co-production and co-creation: Engaging citizens in public services (p. 244). Taylor & Francis.
  3. Maaz, A., Hitzblech, T., Arends, P., Degel, A., Ludwig, S., Mossakowski, A., … & Peters, H. (2018). Moving a mountain: Practical insights into mastering a major curriculum reform at a large European medical university. Medical Teacher, 40(5), 453-460.

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