CBME, by the ICBME Collaborators, Competency-based medical education
by ICE Blog Admin

Time variability in medical training: a Dutch example

By: Olle ten Cate, PhD

Time to start a new, 2025, blog ICBME series, now called ICBHPE, the international competency-based health professions educators collaborative. As a current blog editor, I have the privilege to write this first issue, and welcome you all to enjoy the 2025 series. Later this year Aleda Chen will assume the editor role.

Time variability. In December, I read two commentaries discussing pros and cons of CBME with time variability, ended with opposing admonitions: “Continued advancement of competency-based GME makes sense. [But] we should tap the brakes on time variability and PiP [see below], at least for now”(1)  versus “The time is now for our medical education community to be creative and work together to rise to the challenge of implementation of [time variable] CBME and stop deferring the important work required to overcome its challenges)(2). After reading, it occurred to me that the fierce debate about time variability would not easily be heard in the Netherlands (or in several other countries), which I will explain below. But first, the rationales of the commentaries.

Long & Rose warn for the exploitation of residents who qualify early to do the work of attendings, pressured by hospitals, but remain being paid as residents, and they predict chaos and unintended consequences. Khachadoorian-Elia references international studies and feels the time to be ripe to look at time and training more fundamentally. Both commentaries also refer to the Mass General Brigham health care “Promotion in Place” (PiP) project(3), that allows residents who are deemed ready early, to assume attending roles while still formally in training.

While the option to increase training length for some residents is not discussed in these commentaries, this also deserves attention. The graphic below from a 2013 study by Epstein et al shows how the quartile of OB/Gyn graduates with highest complications rates in child deliveries (Q1) improves substantially in the years after training, in the direction of those with the lowest complication rates around graduation (Q4) (based on 15,673 physician years in cohorts in the States of New York and Florida, 1992-2010).(4) I added a green line and two red circles. The green line is an (arbitrary) level to indicate acceptable performance. If this were true, then two more years in training under supervision to prevent complications might have been wise for Q1 residents.

From: Epstein et al, 2013 [see reference list]

Competency-based education requires individualized curricula, where some can move to unsupervised practice early while others remain in training until they are deemed ready. Impossible? Unfeasible? Every country has their own rules, regulations and culture. While not necessarily an example that is applicable in North America, the Netherlands model of medical training I would qualify as more relaxed and flexible. It may be worth to mention some features, contrasting with American education.

  1.  Undergraduate medical education takes six years (3 years ‘bachelor’; 3 years ‘master’). Only a minority of students finishes in 6 year. The majority takes longer; over 7 years is not uncommon. Graduation takes place several times per year for smaller cohorts of student when the are ready. Students are never pre-qualified as when they should graduate (‘class of 20xx’).
  2. The Netherlands have no licensing examination; society assumes that medical schools all meet sufficient quality to equate the medical school diploma with the medical license and the MD degree.
  3. Most of undergraduate and postgraduate medical education is government paid, and the average debt incurred after UME training is estimated around 35,000 USD.
  4. Application for residency occurs in an open market model, and residencies can commence throughout the year. When a resident finishes, their place is filled with a new resident.
  5. After a mismatch of UME matriculants and residency positions in the 1980s, waiting lists emerged, leading graduates to seek assisting physician jobs in hospitals before residency. Next, those with more clinical experience benefitted at residency selections. Now (2025) the gap between medical school and residency has grown to over 3 years on average, spent on general clinical experience and/or research experience. Some specialties even use a PhD degree as a selection criterion for residency. General clinical experience after UME and before GME is accepted as normal and even valued.
  6. Dutch law allows residents to train part-time (90% or 80%), to allow for family building, research experience or other reasons. The decresed presence is compensated after the formal training period to keep the formal fulltime training time constant.
  7. In 2014 however, legislation abandoned strict formal durations of GME programs, and programs introduced EPAs to create flexibility. This led to an average of ~3 months shortening of training.
  8. At the end of the formal duration, program directors have the authority to make the decision whether to add the compensation time after parttime training or not, based on the resident’s estimated competence, given the avaliable data about the individual.
  9. With ahead-planning, flexibility in moments to accept new residents and the existence of a continuous pool of new applicants, program directors can manage the completion of clinical schedules of residents, to serve continuity in patient care.

More details can be found in recent publications.(5,6)

Ask medical educators in the Netherlands how they manage to organize time-variable training, and they will not even understand that question. The status quo is accepted for granted; educators are more concerned with other issues than creating time-variability.

Individualization is a key feature of competency-based postgraduate training, simply because the educational program is different for every individual, based on supervisors, rotations, exposure to pathology, their own proficiency, motivation, attitude, clinical and research interests, and personal circumstances. Most of those variables do not require adaptations of a program duration, but for some residents adaptation may be critical to have them meet competency standards before graduation.

About the Author:

Olle ten Cate, PhD is emeritus professor of medical education at University Medical Center Utrecht and a 2024-25 visiting professor at the University of California, San Francisco.

References

  1. Rose SH, Long TR. A Perspective on Promotion in Place and Competency-Based, Time-Variable Graduate Medical Education. J Grad Med Educ. 2024 Dec 13;16(6):646–8.
  2. Khachadoorian-Elia HR. Time-based versus competency-based medical education: Opportunities and challenges. Med Educ. 2025 Jan;59(1):14–6.
  3. Goldhamer MEJ, Pusic MV, Nadel ES, Co JPT, Weinstein DF. Promotion in Place: A Model for Competency-Based, Time-Variable Graduate Medical Education. Acad Med. 2024 May 1;99(5):518–23.
  4. Epstein A, Nicholson S, Asch D. The production of and market for new physicians’ skill [Available from: http://www.nber.org/papers/w18678.]. Cambridge, MA: National Bureau of Economic Research; 2013.
  5. de Graaf J, Bolk M, Dijkstra A, van der Horst M, Hoff RG, Ten Cate O. The implementation of entrustable professional activities in postgraduate medical education in The Netherlands: rationale, process, and current status. Acad Med. 2021 Jul 1;96(7S):S29–35.
  6. Hoff RG, Frenkel J, Imhof SM, Ten Cate O. Flexibility in postgraduate medical training in The Netherlands. Acad Med. 2018 Mar;93(3S Competency-Based, Time-Variable Education in the Health Professions):S32–6.

The views and opinions expressed in this post are those of the author(s) and do not necessarily reflect the official policy or position of The University of Ottawa . For more details on our site disclaimers, please see our ‘About’ page