Challenging assumptions is the only way forward for competency-based training models

By: Shelley Ross, PhD, MCFP (Hon)

There has been a steady increase in publications about competency-based medical education (CBME), to the point where CBME is arguably one of the most prominent topics in the health professions education (HPE) literature. Much of the published literature about CBME is positive and contributes to literary conversations about the value of CBME to improving the training and eventual practice of health professionals (Hamza, et al., 2023). However, there is a growing body of literature that challenges or disputes the value of CBME (Boyd et al 2018; Brydges et al., 2021) and makes arguments for taking a closer look at the underlying assumptions of CBME. It is in the best interests of everyone to embrace different voices about CBME as we move forward, especially when those authors spotlight issues with the assumptions of CBME; it can be argued that these authors are actually highlighting opportunities to improve how we think about and apply the CBME model.

There has been a fascinating evolution of the assumptions of CBME over time. In an attempt to establish a common description of what constitutes the CBME model, a group of HPE researchers from around the world (International Competency-Based Medical Education collaborators – ICBME) initiated a project to rigorously define the core components of CBME. This work was published by Van Melle and colleagues in 2019 (Van Melle et al, 2019) as five core components that form the basis of a multilevel framework that allows for the influence of local context. Each of the core components must be incorporated into all CBME programs, although the specific practices or “surface-level features” can vary from program to program, with the goal that “the use of core components allows for the promotion of local innovation while fidelity is maintained (p. 1007)”.

And yet… in practice, assumptions of CBME – especially as regards assessment – have become quite rigid. Even a cursory examination of the recent literature around assessment in CBME will show that the use of Entrustable Professional Activities (EPAs) has become synonymous with CBME (Hamza et al, 2023), at the cost of a programmatic assessment approach using a variety of assessment tools. This is particularly true in specialty (i.e., non-family physicians) training in Canada, where EPAs are often the only form of assessment in the Competence By Design (CBD) model (Karpinski & Frank, 2021). Recent publications have discussed assessment burden and other challenges of CBD (Ott et al., 2022; Szulewski et al., 2023). Recent changes to CBD include the incorporation of a variety of assessment tools (Cheung et al., 2024), demonstrating a positive response to challenge and critique to improve and build upon an implemented model of CBME. 

Another notable shift in assumptions about the core components of CBME is the principle of context; i.e., that there is no “one size fits all” when it comes to CBME and approaches and processes can vary as long as the core components are incorporated into a program’s CBME model. Despite the explicit emphasis by Van Melle and colleagues on this assumption, there is a narrowing view of what CBME “looks like” in the published literature. There is a sense that development of CBME processes happens among centralized groups, without sufficient engagement with local leaders to allow for adaptation to local contexts (Dagnone et al., 2020). Some authors have discussed difficulties in implementing CBME programs defined by central bodies that are misaligned with local contexts (Birman et al, 2025; Pack et al., 2024). Interestingly, one of the few nationally-implemented CBME programs that has published evaluation evidence emphasizes the value of allowing for variation in processes and approach based on local context (Ross et al., 2023).

Finally, it is important to note that the CBME literature tends to be dominated by a relatively small group of influential authors. There are specific approaches and perceptions that have stifled innovation and model progression by making it difficult to publish anything that does not fit the prevailing assumptions (for example: https://keylimepodcast.libsyn.com/11-challenging-the-status-quo-of-cbme-in-canada). Truly innovative and novel CBME models are presented at conferences or shared in the grey literature, yet are rarely successfully published due to false assumptions by reviewers or editors (e.g., an author shared this reviewer comment: “authors do not use EPAs, so this is not CBME”). Similarly, manuscripts that challenge or question CBME can be difficult to publish despite their value to CBME literary conversations. Challenges to prevailing trends in education are a good thing; they present the opportunity to take a step back and consider the zeitgeist objectively. CBME is doomed to fail if diverse views and voices continue to be stifled and ignored. Just as healthcare itself is not “one size fits all”, CBME needs to make space for a variety of approaches and perspectives that allow for variations in local contexts and community needs. We are beginning to see some evidence of authors embracing critiques as a driver for positive change: de Heer and colleagues used common critiques of CBME as a way to frame the lessons learned from a document analysis of three different iterations of CBME training plans (de Heer et al., 2024). Similarly, ten Cate has multiple recent publications that acknowledge and accept criticisms and challenges to EPAs while using those critiques to clarify where EPAs are useful – and where they are not (ten Cate & Schumacher, 2022; ten Cate et al., 2024). These kinds of balanced and open responses to challenges are the only way to guarantee a future for CBME – a model that I truly believe is an excellent way to think about and design HPE curriculum and assessment.e healthcare field.

About the Author:

Shelley Ross, PhD, is a Professor in the Department of Family Medicine at the University of Alberta (Edmonton, AB, Canada). Her work examines assessment and theories as applied to the design, implementation, and evaluation of CBME programs and innovations.

References

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