Flexibility and Individualized Growth in Competency-Based Education

By: Teri L Turner

What happens when a trainee struggles in a system we labeled as “competency-based,” but that still operates on fixed timelines? Just this past week, I received three separate calls from program leaders, each grappling with the same underlying question: What do we do with a trainee who isn’t on track to progress by the expected time?

What struck me most in these conversations is how often our educational structures — even those branded as competency-based — revert to measuring progress by the calendar. If we truly believe in competency-based education (CBE), how can we build more flexibility into these frameworks? And more importantly, how do we support individualized growth in a system still anchored to time?

The Traditional Model: Reactive and Rigid

The traditional remediation model is inherently reactive and rigid. Learners are expected to follow predefined pathways within set timelines. When someone stumbles, formal remediation plans are triggered. These plans often include repeating rotations, targeted coaching, additional evaluations, and structured faculty oversight. But the underlying message is clear: the learner has fallen behind. Instead of embracing the idea that growth happens at different speeds for different individuals, the system frames any deviation from the timeline as failure, rather than as an opportunity for tailored support.

This rigidity can be demoralizing. By the time a learner is placed on formal remediation, they’ve often already been labeled. The experience can feel punitive instead of supportive, eroding confidence and trust. Rather than focusing on a learner’s strengths and potential, the system focuses on deficits — treating struggle as an exception rather than part of the normal developmental process.

Shifting Toward Proactive Flexibility

How do we introduce real flexibility while honoring the principles of CBE? First, we must move from a deficit-based model to a growth-based model. Every learner will face challenges at some point — and these challenges should be normalized as part of their developmental journey.  One tool for proactive support is the Individualized Learning Plan (ILP).^1,2 Too often, ILPs are seen as reactive documents used only when a problem arises. Instead, they should be standard practice for every learner. ILPs can map out strengths, areas for growth, and specific goals, providing a collaborative space for continuous self-assessment and planning. Used proactively, ILPs can guide learning, prevent surprises, and tailor educational experiences in real time.

Reframing Coaching as Continuous Support

Coaching also needs to be reframed. In many programs, coaching is associated with remediation — a signal that a learner needs help. But this perception misses the true power of coaching. High performers in any field actively seek coaching to refine their skills and stay on a trajectory of continuous improvement.  In a true competency-based system, coaching should be embedded and expected. It should be a resource for every learner, not a marker of deficiency. When coaching becomes part of the educational fabric, it helps learners reflect, recalibrate, and progress at their own pace. It also removes stigma, fostering a culture where asking for guidance is a strength rather than a weakness.

Building Flexibility Into Fixed-Time Programs

Given the realities of service needs, rotation structures, and salary progression, how can we realistically introduce flexibility? One promising approach is to build flexible time into the structure itself. For instance, residency and fellowship programs can incorporate 4–6 months of individualized learning time. High-achieving learners can use this for advanced electives or scholarly projects. Learners who need more time can focus on skill development without feeling they’re falling behind.

We also need to rethink scheduling. Too often, schedules are built around service coverage instead of educational needs. Rebalancing this could create space for electives, targeted growth opportunities, and recovery time. This shift requires cultural change, but it’s essential for tailoring education to individual learners.

Reflecting on my own training, I spent six months in the neonatal intensive care unit — nearly 17% of my residency. While it was educational, I didn’t need that much neonatology to become a competent general pediatrician. That time could have been better spent developing skills in other areas. Programs need to move away from one-size-fits-all models and create pathways that reflect individual learner goals and needs.

Frameworks to Guide Change

To guide this rethinking, we can turn to two key frameworks: Precision Medical Education, which focuses on tailoring educational experiences to the unique needs and trajectories of each learner, and the five core components of CBME outlined by Van Melle and colleagues.^3,4 Together, these concepts emphasize that educational systems should be intentionally designed to support flexibility and growth. These frameworks remind us that building flexibility isn’t just an ideal; it’s an essential feature of any educational system committed to learner-centered growth.

Early and Frequent Competency Check-Ins

Clinical Competency Committees (CCCs) have become an important tool for assessing progress. However, meeting only every six months can delay interventions. Early struggles can go unnoticed until they become crises. Instead, programs should implement more frequent, low-stakes check-ins — particularly in the first year, the final year, and during transitions. These check-ins can help identify patterns early and offer timely support. Combined with ILPs and continuous coaching, they make struggle part of the learning process rather than a trigger for crisis intervention.

Rethinking Remediation in a Competency-Based System

Ultimately, in a true CBE system, the concept of remediation as a separate pathway should disappear. Instead of labeling learners as being on remediation, we should offer individualized support, coaching, and time adjustments as part of the standard developmental process. If formal interventions are needed, they should be framed as part of growth, not failure.

This requires a cultural shift. We must redefine success and rethink how we structure progression. Are we providing frequent feedback outside of formal intervals? Are ILPs proactive tools for all learners? Is coaching embedded and stigma-free? Have we designed curricula with flexibility to accommodate individualized pacing?

Change won’t happen overnight, but small steps — like early check-ins, protected growth time, and normalized coaching — can move us from reactive remediation to proactive, learner-centered support. Supporting multiple paths to mastery shouldn’t be an exception; it should be the expectation.

About the Author:

Teri L. Turner, MD, MPH, MEd, Assistant Dean of Graduate Medical Education, Professor of Pediatrics, Vice Chairman of Education, Martin I. Lorin, M.D., Endowed Chair in Medical Education, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX.

References

1. Challis M. AMEE medical education guide no. 19: personal learning plans. Med Teach. 2000;22(3):225-236.
2. Gifford KA, Thoreson L, Burke AE, et al. Describing Overarching Curricular Goals for Individualized Education. Teach Learn Med. 2021;33(3):282-291. doi:10.1080/10401334.2020.1835665.
3. Triola MM, Burk-Rafel J. Precision Medical Education. Acad Med. 2023;98(7):775-781. doi:10.1097/ACM.0000000000005227.
4. Van Melle E, Frank JR, Holmboe ES, et al. A Core Components Framework for Evaluating Implementation of Competency-Based Medical Education Programs. Acad Med. 2019;94(7):1002-1009. doi:10.1097/ACM.0000000000002743.

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