CBME, by the ICBME Collaborators, Competency-based medical education
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Learner Growth and Support: Focusing on the Primary Role of WBAs in CBHPE

By: Daniel Schumacher, MD, PhD, MEd

Picture source: https://www.britishjournalofnursing.com/content/professional/an-evaluation-of-practice-supervisor-training-for-final-year-healthcare-students

I see an increasing number of articles focused on how work-based assessment (WBA) in competency-based health professions education (CBHPE) has either deleterious effects on trainees or low/no value for trainees. Some of these articles only partially focus on WBA and place equal or greater focus on suboptimal current training environments.1 However, an increasing number focus squarely on WBA. Here are three examples from just the past month:

  • “Even amongst residents expressing views consistent with a growth mindset, the lack of meaningful feedback on EPA [entrustable professional activity] assessments prevented them from being a tool for learning” – Hempel et al2
  • “Residents experienced EPAs as compliance exercises disconnected from meaningful professional development” – Phaneuf et al3
  • Residents and faculty express uncertain educational value, frustration, overwhelm, and fatigue with EPA-based WBAs – Bilgic et al4

In response to confusion around what CBHPE is, I previously coined a two-word definition that has gained traction: CBHPE is patient-focused and learner-centered (https://icenet.blog/2022/01/27/competency-based-medical-education-patient-focused-learner-centered/). The learner-centered piece of this definition means that CBHPE seeks to support trainee growth and development in a manner that focuses on what is best for trainees and for their ongoing development. So, CBHPE, implemented as intended, would not have deleterious effects on trainees. It also would not deliver low or no educational value. This assertion is supported by the fact that 3 of the 5 core components of CBHPE5 (i.e.; necessary elements to say you have implemented CBHPE with sufficient fidelity to call in CBHPE) focus on individualized approaches to trainee development to ensure educational outcomes are met. So, if our current goals for CBHPE and our current delivery of CBHPE are misaligned, what should we do?

We Need to Substantially Shift the Focus of WBA to Formative and Low Stakes

The fourth core component of CBHPE is programmatic assessment. When we discuss this approach to assessment, we most often focus on how assessment efforts should employ a mix of types and sources of data determined by justifications for what is included in the mix and why. To be sure, this is central to programmatic assessment.6 However, another characteristic of programmatic assessment is taking a formative approach with a focus on low stakes that ensures constant reflective dialogue with trainees about their assessment data to support their development. This focus is essential to the “learner-centered” tenet of CBHPE, and was a key focus of Carol Carraccio and colleagues’ seminal paper that details what “learner-centered” means in CBHPE.7

At this point, you may think this sounds good in theory but may be wondering how clinical competency committees (CCCs) will have sufficient data to make summative and higher stakes decisions if WBA is heavily focused on formative and low stakes. I understand this concern. I have chaired and been a member of CCCs and have also extensively studied CCCs. So, I know from practical and research experience8,9 that CCCs often feel they lack desired data to fully inform their decisions. I also fully understand that robust and defensible CCC decisions are central to the “patient-focused” tenet of CBHPE that ensures educational outcomes prepare trainees to meet the needs of patients.10 These points acknowledged, there is no question that contemporary CBHPE advocates, and even demands, that WBA focus on formative and low stakes purposes first. Once this is sufficiently achieved, focus can shift to summative and higher stakes. But only then.

Are you in? Let’s continue this discussion and shift the landscape of WBA literature to success stories that highlight trainee engagement that drives trainee growth and ensures high quality, equitable patient care.

Refrences:

  1. Ott MC, Pack R, Cristancho S, Chin M, Van Koughnett JA, Ott M. “The Most Crushing Thing”: Understanding Resident Assessment Burden in a Competency-Based Curriculum. Journal of Graduate Medical Education 2022;14(5):583-592. doi:10.4300/jgme-d-22-00050.1
  2. Hempel A, Boyle J, de Bruin A, Ginsburg S. ‘Just a checkbox’: Growth mindset and feedback in resident experiences with EPA assessments. Med Educ 2026;doi:10.1111/medu.70234
  3. Phaneuf J-C, Sehlbach C, Gauvin-Morin A, Slimani O, Walsh CM, Heeneman S. When using entrustable professional activities thwarts basic psychological needs: A case study of residents’ experience. Medical Teacher. 2026/05/23 2026:1-13. doi:10.1080/0142159X.2026.2649217
  4. Bilgic EA-O, Chopra S, Dhanoa JA-O, et al. An In-Depth Exploration of the Entrustable Professional Activity Assessment Related Experiences, Perceptions and Associated Emotions of Residents and Faculty. Clinical Teacher  2026; 23(4): 1-10. doi:10.1111/tct.70449
  5. Van Melle E, Frank JR, Holmboe ES, Dagnone D, Stockley D, Sherbino J. A Core Components Framework for Evaluating Implementation of Competency-Based Medical Education Programs. Academic Medicine 2019;94(7):1002-1009. doi:10.1097/ACM.0000000000002743
  6. van der Vleuten CP, Schuwirth LW, Driessen EW, et al. A model for programmatic assessment fit for purpose. Med Teach. 2012;34(3):205-14. doi:10.3109/0142159X.2012.652239
  7. Carraccio C, Wolfsthal SD, Englander R, Ferentz K, Martin C. Academic Medicine. 2002;77(5): 361-267.
  8. Schumacher DJ, Michelson C, Winn AS, Turner DA, Martini A, Kinnear B. A realist synthesis of prospective entrustment decision making by entrustment or clinical competency committees. Med Educ 2023; 58(7):812-824. doi:10.1111/medu.15296
  9. Schumacher DJ, Michelson C, Winn AS, Turner DA, Elshoff E, Kinnear B. Making prospective entrustment decisions: Knowing limits, seeking help and defaulting. Med Educ 2022;56(9):892-900. doi:10.1111/medu.14797
  10. Schumacher DJ, Kinnear B, Burk-Rafel J, Santen SA, Bullock JL. The Next Era of Assessment: Can Ensuring High-Quality, Equitable Patient Care Be the Defining Characteristic? Academic Medicine. 2024;99(4S):S7-S13.

About the Author:

Dr. Dan Schumacher, MD, PhD, MEd, is a tenured professor of pediatrics at Cincinnati Children’s Hospital Medical Center in Cincinnati, Ohio, USA. He had led and studied national competency-based medical education efforts in the United States for two decades.

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