By: Karen Hauer, MD, PhD, Mary Ellen J. Goldhamer, MD MPH and Jan Breckwoldt, MD, MME, FERC
Competency-based health professions education (CBHPE) asks a lot of trainees. They are expected to seek feedback, expose gaps in their knowledge and skills, admit uncertainty, and take on progressively greater responsibility. At the same time, they are expected to trust that the educators and educational system assessing them will use that information to support their development while ensuring they are ready to progress. For many trainees, this tension can generate doubt, fear, or mistrust: Who is helping me advance in my career, and who, or what information, carries high stakes and may stand in my way?
The educational alliance (EA) is a promising relationship to foster trainees’ trust in both their educators and the educational system. Originally proposed as a framework for making feedback more meaningful and impactful, the educational alliance centers on three concepts: shared goals, agreement on how to work toward those goals, and a trusting relationship between trainee and supervisor. [1,2]
Shared goals create a common understanding of the purpose of training and align trainee and supervisor around the development of competence for independent practice.
Agreement on tasks establishes how the trainee and supervisor will work toward those goals, aligning activities such as observation, feedback, assessment, reflection, and goal setting with the trainee’s development.
A trusting relationship establishes the interpersonal bond and “terms of engagement” for learning: mutual understanding of roles and expectations, including expectations around competence, assessment, and progression.
In CBHPE, these three concepts scaffold the trainee’s experience and create a partnership between trainee and supervisor. Taken together, the components of the educational alliance enable the entire CBHPE system to succeed.
How does the educational alliance help?
1. The EA can foster trainee trust in supervisors, the clinical learning environment, and the assessment system. [1]
Within a psychologically safe clinical learning environment, trainees can speak up to someone more senior with a question, concern, idea, or proposed plan. [3] They can take learning risks by revealing something they do not know or cannot yet do, asking for help, or trying something new knowing that they may not get it right the first time. Under these conditions, trainees can advance their learning, and team functioning can improve.
CBHPE depends on trainees doing something psychologically difficult: revealing what they cannot yet do in order to advance their developing competence. A trusting relationship with a supervisor can help create the psychological safety needed for trainees to reflect honestly on their strengths and areas for growth, seek feedback, and set meaningful learning goals. The relational bond within the educational alliance therefore provides a foundation not only for trainee–supervisor trust, but also for trainees’ willingness to engage authentically with competency-based learning and assessment.
To cultivate and maintain a robust educational alliance, a formal Educational Agreement may foster understanding of how to establish mutual respect, agreed-upon goals, and the steps to achieve those goals. [2] A trainee and supervisor can use the Educational Agreement [2] as a starting point toward discussing their hopes and preferences for their work together. Revisiting the Educational Agreement periodically is encouraged to update as the trainee progresses through the program and the relationship deepens, or to adjust as needed based on perceived challenges or gaps in the success of the educational alliance. Honest use of such an agreement may help to maintain psychological safety.
2. The educational alliance facilitates achievement of the core components of CBHPE. [2,4]
Placing focus on the trainee’s and supervisor’s shared goals supports the core components of CBHPE that address defined outcome competencies, tailored learning experiences, and competency focused instruction. That is, both trainee and supervisor share understanding of the goals and desired outcomes of training and the path to achieve those outcomes. The task orientation aspect of the educational alliance elevates this relationship beyond general mentoring to focus on the trainee’s specific learning needs and use of assessment data to guide future learning toward achievement of program outcomes. The trusting relationship of the educational alliance enables mutual respect and honest, actionable feedback to support competency-based learning. Within the context of this longitudinal, safe relationship in which the trainee trusts that the supervisor has their achievement as a shared goal, the trainee can engage in honest self-reflection and goal setting necessary to guide future learning.
3. Trust within the educational alliance can contribute to a trustworthy CBHPE system. [1]
Trainees must trust supervisors enough to reveal uncertainty, seek feedback, identify gaps, and acknowledge limitations while progressively taking on greater responsibility. Supervisors, in turn, must be able to trust trainees to engage honestly in this developmental process. By supporting candid conversations about performance and meaningful assessment of developing competence within a trusting relationship, the educational alliance can contribute to better-informed and more trustworthy decisions about progression. Those decisions must serve both purposes of CBHPE: supporting trainees’ development while ensuring that graduates meet the standards required for safe, independent practice.Trusting relationships can support more authentic learning and assessment; more authentic assessment can support trustworthy decisions about progression; and trustworthy progression decisions help health professions education fulfill its obligation to patients and society.
The educational alliance can engage trainees in all aspects of CBHPE. Competency frameworks, workplace-based assessments, performance data, and progression committees provide the structures of competency-based education. The educational alliance facilitates trainees’ willingness to use them fully and ability to maximize the value of feedback conversations for learning. The educational alliance reminds trainees and educators that investing in these relationships is essential to moving from theory to practice and to making CBHPE work.
Refrences:
- Telio S, Ajjawi R, Regehr G. The “educational alliance” as a framework for reconceptualizing feedback in medical education. Acad Med. 2015;90(5):609–614. DOI: https://doi. org/10.1097/ACM.0000000000000560
- Hauer KE, Goldhamer ME, Amiel J, Richardson D, Schwartz A, Marty AP, Molgaard L, Pinilla S, Breckwoldt J. The educational alliance: Essential to implement competency-based health professions education. Perspectives on Medical Education. 2026 Sep 9;15(1):799-813.
- Ahn E, Caverzagie KJ, Damodaran A, Huwendiek S, Lomis K, Marty AP, Turner DA, Turner T, Atkinson A, As members of the International Competency-Based Health Professions Educators Collaborative. No Environment, No Education: Honoring the Clinical Learning Environment as the Engine of Competency Based Education – A Call to Action. Perspectives on Medical Education. 2026; 15(1): 771–782. DOI: https://doi.org/10.5334/ pme.2548.
- 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. Acad Med. 2019;94(7):1002–1009. DOI: https:// doi.org/10.1097/acm.0000000000002743
About the Authors:
Karen Hauer, MD, PhD is Vice Dean for Education and Professor of Medicine at the University of California, San Francisco (UCSF), San Francisco, CA, USA (ORCID 0000-0002-8812-4045)
Mary Ellen J. Goldhamer, MD MPH is Assistant Professor of Medicine, Harvard Medical School, Director of Faculty Continuing Medical Education, Division of General Internal Medicine, Massachusetts General Hospital, and Director of Evaluation, Harvard Kidney Urology Hematology Training Institute, Boston, Massachusetts, USA. (ORCID 0000-0002-2648-9791)
Jan Breckwoldt, MD, MME, FERC is Professor of Anaesthesiology and Medical Education, Institute of Anesthesiology and Perioperative Medicine, Universityhospital Zürich, Zürich, Switzerland (ORCID 0000-0003-1716-1970)
Competing Interests
Dr. Hauer is a member of the Board of Directors of the National Board of Medical Examiners. Dr. Goldhamer receives funding from the American Medical Association Reimagining Residency grant program and from the National Institutes of Health/National Institute of Diabetes and Digestive and Kidney Diseases (NIH/NIDDK). She is a member of the American Board of Medical Specialties Competency-Based Continuing Certification Workgroup. Dr. Breckwoldt is Co-Chair of the Faculty Development Programme of the Swiss Insitute for medical Education (SIWF/ISFM).
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