By: Leila Niemi-Murola, MD, PhD, MME; Taina Autti, MD, PhDCurrently, the CBE
In Finland, we now have seven years of experience in implementing CBME. During this time, we have celebrated many successes and learned many lessons along the way.
The reform was initiated in 2015, but the statute launched by the Ministry of Health in February 2020 marked its official starting point. The journey was very interesting for us; some challenges that were difficult for others turned out to be surprisingly easy, while some basic principles proved very challenging in our context.
In Finland, postgraduate medical education is organized by the medical schools but delivered within the healthcare system, coordinated by the Ministry of Health and Social Services. It is essentially a university degree, and there are five autonomous medical schools in our country. Before the reform, we had a traditional, time-based, master–apprentice model. There was little interaction between program directors, professors, and the healthcare system. Training was counted in months and weeks, and one secretary could assist a professor with the relatively small amount of paperwork. Clearly, new structures were needed to support the implementation of CBME (1).
The first new structure was the creation of national curricula for each specialty. The five autonomous universities, encouraged by the statute, required their program directors and professors to negotiate and establish a shared understanding.
The second new structure was the introduction of entrustable professional activities (EPAs)(2), which was a success. Several articles were published in Finnish medical journals to introduce key terms and definitions in our language, helping to build a shared mental model (3-9). The number of EPAs grew rapidly—from 50 in 2020 to 284 in 2022—and currently we have 429 EPAs across 50 medical specialties. However, when we look more closely at the descriptions, the actual process of making entrustment decisions is missing. The assessment scale resembles milestones more than entrustment decisions.
The third new structure was the introduction of specialist education coordinators, who serve a role like Academic Advisors in Canada. To implement CBME, universities need to work closely with the healthcare system. To facilitate this, we introduced coordinators—between 1 and 8 per specialty, depending on the number of residents. They are employed jointly by the university and the healthcare system, and both institutions have been very satisfied with their contribution.
The fourth new element was the successful launch of an electronic assessment system in autumn 2023. All program directors were invited to join, and the number of registered residents increased rapidly. Residents appreciate the system, as it allows them to store all essential documents in one place. However, building the system requires compromise; it is the same for all 50 specialties, despite their different needs and focus areas. The result is a fair, though imperfect, compromise that works for everyone.
The fifth new element was intended to be the introduction of clinical competency committees (CCCs)(10), but this has been the main barrier to reform. Specialties in Finland are autonomous; program directors hold supreme authority in their programs, and a new committee was perceived as a potential threat. According to the literature, CCCs are often institution-wide, placed above program directors. In Finland, the proposed model was to introduce them as a support structure for program directors. Time was another concern—we are all busy, and no one wanted additional meetings. Despite publishing several articles to introduce the principle of CCCs, implementers decided to set the issue aside for now. As a result, many local innovations have emerged to address the need for shared decision-making.
Finland now has ten years of experience with CBME, marked by notable successes, challenges, and lessons learned. Key achievements include the creation of national specialty curricula across five autonomous universities, the rapid expansion of EPAs, the establishment of specialist education coordinators bridging universities and healthcare systems, and the launch of a widely adopted electronic assessment system. Challenges have included the absence of clear entrustment decision-making processes, compromises in the electronic platform’s design, and difficulties in introducing CCCs due to concerns about autonomy and workload. Our next challenge is to establish programmatic assessment. The main obstacle has been that there is no clear term for it in Finnish. We need to begin by introducing the concept, explaining its value, and then writing recommendations.
Overall, Finland’s journey highlights the importance of shared negotiation, integration across institutions, and flexibility in adapting international CBME models to local contexts.
About the Author:
Leila Niemi-Murola, MD, PHD, MME, senior clinical lecturer, works as the national CBME facilitator in Finland. She is a member of the Teacher’s Academy of the University of Helsinki, Finland. She has held many national and international positions of trust related to medical education (ESAIC, AMEE).
Taina Autti, MD, PhD, is the Professor of Radiology with a special interest in postgraduate medical education. She has worked for several years at the Ministry of Health and Social Affairs, and she is currently the Chair of Postgraduate Education at the University of Helsinki, Finland.
References
- Schwitz F, Brodmann Maeder M, Hennel E: Competency-based education – the reform of postgraduate medical training in Switzerland. GMS Journal for Medical Education 2024, Vol. 41(5), ISSN 2366-5017.
- Pinilla S, Bauer W, Breckwoldt J et al. Introducing entrustable professional activities for postgraduate medical training in Switzerland. GMS Journal for Medical Education 2024, Vol. 41(5), ISSN 2366-5017.
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- Cooper D, Holmboe E. Competency-based medical education at the front lines of patient care. NEJM 393;4 nejm.org July 24, 2025
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