What is Competency-Based Medical Education?

Competency-based medical education (CBME) is a framework that emphasizes achieving specific, measurable, pre-defined educational outcomes. Rather than relying on process outcomes like time in training, CBME requires educators to clearly define desired programmatic outcomes, design curricula that facilitate the attainment of those outcomes, and establish programs of assessment to measure the extent to which those outcomes have been achieved. The CBME movement has been driven by a desire for greater public accountability and learner-centeredness, as well as a growing recognition that time-based training does not always yield competent physicians. However, it is important to note that while time alone does not ensure attainment of competencies, CBME can and has been implemented within the current time-based training system, and there are obvious logistical benefits of this approach.

Underlying Principles of CBME 

Education Must Be Based on Population Health Needs

Aligning medical education with the needs of patients and communities is critical to assuring the success of future physicians in meeting those needs. CBME ensures that medical trainees have the abilities necessary to address real-world health challenges. Not only does CBME ensure that physicians in training master specific essential competencies, but it also fosters motivation and self-direction, helping physicians to become lifelong learners who are able to meet the ever-changing demands of medical practice.

The primary focus of education should be on achieving desired learning outcomes, not the structure of training programs: Time in training does not guarantee competency. Learners achieve desired educational outcomes at different rates, and the decision to advance them from one stage of training to the next should be based on measured mastery of these outcomes rather than how long they’ve spent in the program. For some learners, this will occur in less time than the usual program duration. While early graduation may not be practical, these learners can complete the duration of their training with reduced supervision or more advanced learning goals. For others, mastery of learning outcomes may require more time. In current educational models, there are already provisions for learners who require additional time in training to meet minimum standards. These provisions can and should be used to ensure that all trainees achieve the needed competencies for independent practice. The ultimate goal is consistent programmatic assessment of competency, with sufficient flexibility to ensure that all graduates meet competency standards.

The Educational Process Should Be Seamless Across the Continuum of Training

CBME should be integrated across undergraduate medical education (UME), graduate medical education (GME), postgraduate fellowship training, and clinical practice, creating a continuum of learning and assessment. This will ensure that competencies developed during UME are built upon and refined during GME, postgraduate, and professional practice. 

Measures of Competency

The CBME movement relies on conceptual frameworks that describe desired educational outcomes, including competencies, milestones, and entrustable professional activities (EPAs), which are defined below.

Competencies

These are broad categories describing general areas in which physicians must develop and integrate appropriate knowledge, skills, and attitudes. Competencies are complex constructs, and, as such, are difficult to assess directly. For example, “patient care” is a competency. The Accreditation Council for GME has defined 6 core competencies of residents: patient care, medical knowledge, interpersonal and communication skills, professionalism, practice based learning and improvement, and systems based practice. 

Subcompetencies

These refer to the knowledge, skills, and abilities that are required to attain a broader competency. For example, the competency of “interpersonal and communication skills” includes subcompetencies such as rapport-building (needed to engender patient confidence), active listening (needed to ensure effective understanding of patient responses), and clinical reasoning (needed to ensure that the right information is gathered).

Milestones

These serve as a “developmental roadmap” for attaining competencies. Milestones provide behavioral descriptions of the knowledge, skills, and attitudes needed for achieving sub-competencies within the broader competency framework. Milestones represent a logical progression of steps over time as the learner develops from novice to expert. For example, “General approach to procedures” t is a subcompetency of “patient care” and the level 1 milestone includes “Performs basic therapeutic procedures (e.g., suturing, splinting).”

Entrustable Professional Activities (EPAs)

These have also been described as “everyday physician activities, and are observable units of work that describe important routine activities in physicians' daily practice. They are termed “professional activities” because they are essential to the profession of medicine. Entrustability refers to the ability of a learner to perform the professional activity safely and effectively at different levels of supervision, with the goal of independent practice. At the national level, EPAs have been defined for medical students, as well as for residents and fellows in several specialties. For example, “Perform basic procedures of a physician” is an EPA related to the competency of “patient care.” 

The Relationship Between Competencies, Milestones, and EPAs

It is important to recognize that competencies and milestones are descriptions of physicians, whereas EPAs are descriptions of work. EPAs represent the day-to-day work of physicians, while milestones represent the developmental trajectory of learners’ abilities across various competencies.

EPAs typically require holistic integration of multiple competencies or milestones. For example, “Perform basic procedures of a physician” requires the medical knowledge to recognize indications and contraindications for the procedure, the patient care skill to perform the procedure, and the interpersonal ability to explain the procedure to the patient and gain their cooperation. Milestones and competencies represent the building blocks of EPAs, and thus, the frameworks, while different, are intimately related.

EPAs lend themselves to direct observation and measurement of competency, as they describe specific behaviors needed to safely and effectively complete the task at hand. “Entrustment” scales have been proposed for measuring EPA performance, meaning that ratings are based on the expected level of supervision needed for safe and effective completion of the EPA in the future. In the example above, a supervisor may choose to provide direct supervision to an early learner performing a procedure, with the “elbow level” ability to prevent them from making dangerous errors. For a more experienced learner, the supervisor may feel comfortable simply being present in the room or even more distantly available, based on their assessment of the learner’s competency to perform the procedure in question. These are all levels of entrustment - the extent to which the supervisor “trusts” the learner to safely complete the task.

Because EPAs require the integration of multiple competencies, inadequate performance of a given EPA could be related to knowledge, skill, or attitude deficits in several different competencies or milestones. For example, a procedure could go poorly because a contraindication was not heeded (medical knowledge), the learner used incorrect technique (patient care), or the learner failed to adequately convey instructions to the patient (communication). The competencies and milestones provide a useful framework for understanding and diagnosing issues with EPA performance. Residency programs that use EPAs rely on them as the basis for the Clinical Competency Committee to assign milestones ratings to submit to the ACGME.