Competency-based medical education

Medical education at all levels—undergraduate, graduate and continuing—is shifting away from using time spent in classrooms and clinical experiences as a proxy for learning toward establishing that the necessary knowledge and skills for patient care have indeed been acquired. Competency-based medical education (CBME) focuses on learning outcomes: programmatic assessment informs learning experiences and appropriate progression.

The application of individualized, competency-based pathways creates physicians who continually assess and update their abilities and address any deficiencies throughout their careers (master adaptive learners). CBME drives increased attention to the quality of the assessment system, presenting an opportunity to elevate issues of equity and inclusion and address historical confounders to assessment results.

Medical schools are incorporating programmatic assessment throughout the curriculum of competency milestones and entrustable professional activities (EPAs) to track developmental trajectories and determine the best path for each student to advance. Developmental dashboards and coaching, as well as an organizational culture of growth, are critical to successful implementation of CBME. Collaboration between UME and GME programs will improve the definition and reporting of competencies necessary to support the transition to residency.

The Reimagining Residency grant program is supporting projects that address competency-based medical education assessment across emergency medicine residency programs as well as competency-based time-variable medical education through a sheltered independence model.

In 2023, the American Medical Association placed a new level of strategic focus on four high-priority areas in medical education:

• Competency-based medical education (CBME)
• Transitions across the continuum
• Equity, diversity and belonging
• Precision education

As part of the initial stages of work in these areas, two AMA ChangeMedEd® Innovation Groundwork Teams will be selected in 2023. These teams will develop tools and strategies and pilot innovations at their sites in the areas of health systems science assessment in clinical environments to support the development of CBME and coaching for competency development to support better transitions across the continuum.

Because the competency of any individual is expressed within the context of a complex health system involving others, skills in health systems science are critical to developing and assessing competency. The health systems science in clinical environments Innovation Groundwork Team will advance CBME by defining the contribution of systems thinking and other health systems science skills in competency development and readiness for transitions.

Each Innovation Groundwork Team will consist of eight U.S. medical schools along with select AMA Reimagining Residency initiative projects and subject matter experts. These partners will collectively develop innovations in their subject areas and pilot them at their local institutions over the next two years.

In this manuscript, the authors perform a root-cause analysis to determine the underlying reasons for continued norm-referencing in medical education, which is impeding the movement toward competency-based medical education (CBME). The root-cause analysis consisted of two processes: (1) identification of potential causes and effects organized into a fishbone diagram and (2) identification of the five whys.

The authors argue that, although assessment in UME should be designed to foster readiness for residency, the implicit goal of stratification for residency selection drives undesired behavior that can detract from competency development. Because stratification traditionally involves normative comparison, the appearance of competency becomes valued over transparency in growth. To advance CBME, the authors recommend moving away from global normative rankings to instead inform selection with more nuanced reporting of competency, thereby promoting the continuity of development within programs and across transitions.