Keywords
CBME - competency-based education - entrustable professional activities - EPA - medical
education
Introduction
Medical education has undergone profound transformations over the past century, evolving
from unstructured apprenticeships to standardized, competency-based frameworks. This
review explores the development of modern medical education, the shift from time-based
to competency-based models, and the role of entrustable professional activities (EPAs)
and milestones in bridging theoretical competencies to clinical practice. Drawing
on key reforms like the Flexner Report and contemporary frameworks such as the Canadian
Medical Directives for Specialists (CanMEDS) and U.S. Accreditation Council for Graduate
Medical Education (ACGME) milestones, we highlight the advantages, challenges, and
future directions of Competency-Based Medical Education (CBME).
Time-Based Medical Education
Time-Based Medical Education
The American Medical Association established the Council on Medical Education in 1904
to standardize training, culminating in Abraham Flexner's landmark 1910 report. Flexner,
commissioned by the Carnegie Foundation, evaluated medical schools against Johns Hopkins’
rigorous model. Before 1910, medical education in North America was marked by inconsistency
and minimal oversight. The 155 medical schools operating in the United States and
Canada had curricula that varied widely, with most programs lasting only 2 years and
emphasizing memorization over practical skills. Libraries and laboratories were under-resourced,
clinical training was observational, and faculty often comprised part-time local physicians
with no formal pedagogical training.[1]
[2]
Flexner, in his 1910 report, recommended closure of substandard schools, which resulted
in reducing their number from 155 to 31, setting stricter admission requirements and
curriculum reform to include two main stages: a 2-year basic sciences stage and a
2-year clinical rotations stage, with medical schools overseeing hospital-based education.[1] These reforms established the time-based model, where competence was assumed after
fixed training durations, a paradigm that dominated for decades.[3]
The traditional model, while successful in standardizing training, faced criticism
for its rigidity:
-
Fixed-time, variable-outcome: as ten Cate noted, traditional medical education awarded
licenses based on duration of training rather than demonstrated competence.[4] This meant learners could graduate simply by completing a set period, as in a 4-year
medical school, even if their competence varied widely.[4]
[5] Hodges compared this to “tea steeping”—assuming time alone ensures readiness.[6] Without clear competency checks, graduates' abilities could differ significantly,
risking patient care quality.[5] This variability in competence is starkly evident in surgical training. Mattar et
al demonstrated that a “substantial percentage of general surgery residents are not
adequately prepared for the demands of surgical subspecialty fellowships upon completion
of their residency.”[7] Their survey of fellowship program directors revealed significant deficiencies in
preparedness, directly linking the rigid, time-based model of residency to tangible
gaps in trainee readiness. This finding exemplifies the core flaw identified by ten
Cate and Hodges: “graduating based solely on time served fails to ensure all learners
achieve the necessary competence, potentially compromising patient care even at advanced
training stages.”
-
Summative assessment bias: the traditional overreliance on final exams created significant
gaps in evaluating physician development.[8] These end-of-training assessments often provided only a snapshot of performance
rather than measuring progressive skill acquisition. This “all-or-nothing” testing
approach fails to capture the longitudinal development of clinical competencies that
occur throughout training.[5] These high-stakes summative assessments tend to:
-
— Focus on easily measurable knowledge recall rather than complex clinical skills.
-
— Provide limited opportunities for formative feedback and improvement.
-
— May overlook critical competencies like communication and professionalism that develop
gradually.
-
— Create “assessment gaps” where learners may pass exams despite persistent skill
deficiencies.
-
Replacing this outdated model with workplace-based assessment (WBA) systems allows
tracking of competence development over time, offering both trainees and educators
more meaningful data about clinical progression.[6]
-
Lack of individualization: a fundamental limitation of rigid time-based education
systems is their inherent lack of individualization, forcing all learners to progress
uniformly through a predetermined curriculum at the same pace, irrespective of their
actual understanding or mastery.[5] This “lockstep” approach operates on the faulty assumption that all students require
identical instructional time to achieve proficiency in a given topic.[9] Consequently, students who grasp concepts quickly are often held back, leading to
boredom, disengagement, and wasted potential as they wait for peers to catch up. Conversely,
students who need more time or alternative explanations to achieve mastery are inexorably
pushed forward before foundational gaps are adequately addressed.[10] This creates a compounding effect, where initial misunderstandings or incomplete
knowledge snowball into significant learning deficits in subsequent, more complex
topics that build upon these shaky foundations. The system prioritizes covering the
curriculum within the allotted time (e.g., a semester or school year) over ensuring
genuine competency development for each individual learner.[11] As Hattie (2009) emphasizes in his synthesis of educational influences, adapting
teaching to the learner's needs has a significantly positive effect on achievement,
highlighting the opportunity cost of the standardized pace.[12] This factory-model approach fails to accommodate the natural variability in learning
speeds, prior knowledge, and cognitive styles present in any diverse classroom, ultimately
serving the administrative structure of the system better than the developmental needs
of the students within it.
-
These shortcomings catalyzed the shift to CBME in the late 20th century, driven by
demands for accountability and patient safety.[13]
Competency-Based Medical Education: Core Concepts and Frameworks
Competency-Based Medical Education: Core Concepts and Frameworks
CBME emerged in the 1990s, with pioneering work by CanMEDS (1996) and ACGME (2002).[14]
[15] These frameworks redefined competence as “the integrated application of knowledge,
skills, and attitudes in clinical contexts.”[16] This concept was added to the existing time-based medical education by incorporating
the new CanMEDS and ACGME competencies. However, after more than 20 years of trials
in the time-based system with its rigid structure and culture, it was clear that there
is a need for a better system to practically execute these concepts. This led recently
to the implementation of the more advanced CBME system, with its unique EPAs, milestones,
and robust assessment system.
CBME fundamentally reorients the educational paradigm by prioritizing demonstrable
mastery over seat time, addressing the critical shortcomings of rigid time-based systems.
Van Melle et al described five core components of CBME[17]:
-
Outcome-focused design: competency-based education (CBE) begins with clearly defined,
measurable competencies that articulate the essential knowledge, skills, and attitudes
learners must master. These competencies serve as the explicit, transparent goals
for both learners and educators. Examples include frameworks like CanMEDS' seven roles
(Medical Expert, Communicator, Collaborator, Leader, Health Advocate, Scholar, Professional),
which provide a comprehensive blueprint for physician competence.[16]
[18] This specificity ensures learning is targeted and relevant, moving beyond vague
curricular coverage.
-
Sequenced progression of competence: unlike time-based models enforcing uniform pacing,
CBME decouples advancement from calendar constraints. Progression to the next stage
or competency is contingent solely upon the learner demonstrating the required level
of mastery, regardless of the time taken to achieve it.[19] This flexibility accommodates individual learning trajectories, allowing those who
grasp concepts quickly to advance without delay, while providing crucial additional
time and support for those who need it, thereby preventing proficiency gaps from persisting
or widening.[3]
-
Programmatic assessment: assessment in CBME is not merely a summative endpoint but
an integral, ongoing process. It relies heavily on frequent, low-stakes, formative
evaluations designed to provide actionable feedback for growth. It also adopts a concept
of thorough assessment system that involves assessing each competency by multiple
assessors, using multiple assessment tools and in multiple contexts.[20] Methods include direct observation of performance in authentic settings (e.g., clinical
encounters, labs), analysis of portfolios documenting development over time, and simulations
replicating real-world challenges. These rich data inform both learner improvement
and instructional adjustments.[21]
[22]
-
Competency-focused instruction or coaching: a defining feature, particularly in professional
fields, is the principle of entrustment. Supervisors progressively grant learners
greater autonomy and responsibility for tasks or decisions based on direct, observed
evidence of their developing competence and professional judgment. This moves beyond
simple pass/fail grades to a nuanced judgment of readiness for independent practice,
reflecting real-world expectations of trust and accountability.[4]
-
Tailored learning experiences: learning experiences should be designed to meet the
specific needs of individual learners and to prepare them for real-world practice.
This may involve providing diverse learning opportunities and addressing potential
barriers to competency development.
The main functional unit of CBME is EPA, which was conceptualized by Olle ten Cate
in 2005 as a pragmatic solution to the persistent “competency–curriculum gap” between
abstract competency frameworks (e.g., CanMEDS, ACGME Core Competencies) and the tangible
tasks clinicians perform daily. As ten Cate argued, competencies alone lack specificity
for workplace assessment, requiring translation into observable units of work. An
EPA is formally defined as “a unit of professional practice that can be fully entrusted
to a trainee once they have demonstrated the requisite competence to execute this
activity unsupervised.”[4]
[23] Examples include high-stakes tasks like “managing a cardiac arrest” or “performing
a safe discharge for a hospitalized patient.” EPAs serve as the critical “missing
link” between theoretical competencies and clinical responsibilities.
EPAs possess distinct features essential for operationalizing CBME:
-
Task-specificity: EPAs represent discrete, essential activities rather than abstract
attributes. Each EPA integrates multiple underlying competencies (e.g., the EPA “Breaking
bad news” requires medical knowledge, communication skills, empathy, and ethical judgment).[4]
[23]
-
Contextual authenticity: EPAs must be performed in real or simulated clinical settings
where authentic patient care decisions, consequences, and team interactions occur.
This distinguishes them from knowledge-based exams or isolated skill assessments.[24]
-
Developmental entrustment: supervision levels for an EPA evolve based on observed
performance. Frameworks like the Ottawa CAPER or Chen's 5-Level Scale describe progression from direct observation (“Show me”) to reactive supervision
(“Do it - I'll watch”), and to eventual unsupervised practice (“Do it independently”).[25]
[26] Entrustment decisions are inherently dynamic.
There have been major initiatives that have standardized EPA implementation, such
as:
-
AAMC Core EPAs for Entering Residency: this landmark project defined 13 activities
that all medical school graduates must be trusted to perform with indirect supervision
(e.g., “Perform a handoff,” “Collaborate as an interprofessional team member,” “Recognize
a patient requiring urgent care”). It emphasized readiness for residency.[24]
-
Association of Faculties of Medicine of Canada (AFMC) EPA Framework: aligned with
CanMEDS roles, Canada established 12 core EPAs for medical graduates (e.g., “Obtain
a history and perform a physical examination,” “Formulate clinical plans”). This framework
explicitly maps each EPA to relevant CanMEDS competencies, reinforcing integration.[27]
-
CBD (Competence by Design): CBD is simply the Canadian brand of CBME, which was built
on their well-known CanMEDS competencies and incorporated the five core components
of CBME. Features of the CBD framework include its basis in the CanMEDS 2015 competency
framework, a time-variable approach to postgraduate training, sequencing of training
along the four stages of the Competence Continuum, and the use of EPAs specific to
each stage.[28]
-
ACGME CBME: despite the complete reliance on EPAs in the American undergraduate system,
they mainly rely on milestones in the postgraduate system.[29]
[30]
CBME offers significant potential benefits, including:
-
The continuous thorough assessment system allows early identification of trainees'
gaps and this in turn allows more time for interventions and improvements.[31] This system of assessments also provides training program leads with a more objective
and fair assessment of trainees to overcome the well-known Failure to Fail phenomenon
in medical education.[32]
-
Enhanced patient safety: CBME aims to ensure all graduates meet standardized, predefined
performance benchmarks before progressing, theoretically reducing variability in competence
and improving the safety and quality of patient care.[24]
[33]
-
Individualized learning: by decoupling progression from fixed time, CBME accommodates
diverse learner paces and styles. Learners who master competencies quickly can advance
without being held back, while those needing more time receive targeted support, theoretically
optimizing learning efficiency and reducing gaps.[23]
[33]
[34]
[35]
-
Lifelong learning: CBME's emphasis on continuous formative assessment, feedback, and
demonstrable mastery inherently fosters a mindset of ongoing skill refinement and
self-regulated learning beyond initial training, aligning with the need for continuous
professional development.[18]
[33]
[36]
Although CBME offers significant potential benefits, these advantages are often accompanied
by inherent challenges and limitations that require careful consideration:
-
Defining valid benchmarks: establishing truly valid, reliable, and universally accepted
performance benchmarks for complex competencies (especially nontechnical skills like
judgment or leadership) is extremely difficult. Poorly defined or assessed benchmarks
create a false sense of security.[35]
-
Assessment fatigue: the constant cycle of observation, feedback, and documentation
required for continuous assessment can lead to significant assessment fatigue for
both learners and supervisors. These risks diminish engagement and the perceived value
of feedback over time,[37] and potentially could be distracting from direct patient care time and authentic
learning experiences.[35]
-
Stress and gaming: high-stakes competency decisions based on frequent assessments
can increase trainee anxiety and potentially encourage “gaming” the system to meet
specific observed criteria rather than focusing on holistic development.[38]
[39]
-
Resource intensity: providing truly individualized pathways requires substantial resources:
more faculty time for tailored supervision, assessment, and feedback; sophisticated
data management systems to track individual progress; and flexible scheduling for
clinical experiences. This is often unsustainable without significant institutional
investment.[33]
[40]
-
Faculty development needs: effective individualization demands faculty skilled in
diagnosing learning needs, providing nuanced feedback, and making complex entrustment
decisions. Many faculty lack training in these areas, leading to inconsistent implementation.[35]
[41]
-
Logistical complexity and potential stigma: managing learners on different timelines
within the same program creates scheduling complexities for rotations, assessments,
and faculty assignments.[3] Slower progression, despite being competency-focused, can carry unintended stigma
or raise concerns about program efficiency.[42]
-
Defining and assessing “attitudes”: while CBME frameworks include attitudes (e.g.,
professionalism, ethics), these are notoriously difficult to define operationally
and assess reliably and objectively. Assessments are often subjective and prone to
bias, making genuine mastery hard to guarantee.[35]
-
Focus on measurables: the drive to assess competence continuously can inadvertently
prioritize easily measurable tasks and knowledge over more complex, tacit, or holistic
aspects of clinical expertise and professional identity formation, which are crucial
for lifelong learning but harder to quantify.[22]
[43]
The Future of Medical Education
The Future of Medical Education
It has been less than 10 years since the official implementation of CBME as a system
in North America, and therefore, the system is still in its development stages. Nevertheless,
there are still challenges that need to be addressed, and we foresee the future of
medical education focusing on:
-
More investment in faculty development: providing comprehensive, ongoing training for educators in EPA assessment, entrustment
decision-making, and effective feedback within clinical workflows.
-
Optimizing WBA systems: leveraging technology to streamline data capture (e.g., mobile apps, AI-assisted
analytics), enhance rater training, and develop efficient methods for synthesizing
longitudinal assessment data into meaningful entrustment decisions.
-
Promoting collaboration and standardization: fostering inter-institutional collaboration to refine EPA definitions, share best
practices, develop validated assessment tools, and establish clearer benchmarks for
entrustment across the continuum of training.
-
Rigorously safeguarding the EPA concept: maintaining clear criteria for what constitutes
a true EPA to prevent terminological drift and preserve its utility as the operational
unit of CBME.
-
Continuous evaluation: rigorously researching the long-term impact of CBME and EPA implementation on learner
outcomes, patient care quality, and system efficiency.
-
Fostering the development of master adaptive learners.[44]
The evolution from Flexner's time-based standardization to CBME's mastery-focused,
individualized approach represents a profound transformation in preparing physicians
for the complexities of modern health care. EPAs provide the essential mechanism to
bridge the gap between competency frameworks and clinical practice. While substantial
implementation hurdles remain, the trajectory is clear: CBME, underpinned by robust
EPA frameworks and effective WBA, holds the promise of producing physicians who are
not only knowledgeable but demonstrably competent, entrusted, and ready to deliver
high-quality, safe patient care from day one. Successfully navigating the challenges
ahead is paramount to fully realizing this transformative potential.
Conclusion
This review tried to trace the remarkable journey of medical education from its fragmented
pre-Flexner roots, through the standardization revolution driven by the Flexner Report
and its ensuing era of rigid time-based training, to the contemporary paradigm shift
towards CBME. The limitations of the traditional model—particularly its fixed-time,
variable-outcome approach, overreliance on summative assessments, and inherent lack
of individualization—proved increasingly misaligned with the demands for physician
accountability, patient safety, and personalized learning in the 21st century. CBME
emerged as a necessary response, fundamentally reorienting education around the demonstrable
mastery of predefined competencies rather than mere time served.
Core frameworks like CanMEDS and the ACGME Core Competencies/Milestones provided the
essential architecture, defining competence as the integrated application of knowledge,
skills, and attitudes. The core principles of CBME—outcome-focused design, variable-time
progression based on mastery, continuous formative assessment, and graduated entrustment—collectively
address the shortcomings of the past by prioritizing learner readiness and genuine
preparedness for practice. This shift promises significant advantages, including enhanced
patient safety through standardized benchmarks, individualized learning pathways that
accommodate diverse needs and paces, and fostering a culture of lifelong learning
and continuous improvement.
However, the translation of abstract competencies into observable clinical practice
presented a significant challenge. EPAs, conceptualized by ten Cate, serve as the
critical “missing link” in this transition. By defining discrete, essential units
of professional practice that integrate multiple competencies and are performed in
authentic contexts, EPAs became the core component of CBME. National frameworks like
the AAMC Core EPAs for Entering Residency and the AFMC EPA Framework in Canada provide
standardized roadmaps, explicitly linking EPAs to foundational competencies like CanMEDS
roles and emphasizing readiness for the next stage of training through developmental
entrustment.
Despite this conceptual clarity and growing adoption, significant implementation challenges
persist. Faculty resistance due to unfamiliarity and time constraints, the resource
intensity of training assessors and managing robust WBA systems, and inconsistent
operational definitions of EPAs across institutions hinder widespread, uniform implementation.
The inherent complexity of assessment—requiring frequent, direct observation, trained
faculty, reliable tools, and sophisticated data aggregation—remains a major hurdle.
Furthermore, the rising popularity of EPAs risks conceptual dilution if the term is
misapplied to tasks lacking the requisite complexity or entrustability, undermining
its foundational rigor.
In the near future, the medical education society will continue to be busy with overcoming
the current challenges of CBME and work on graduating master adaptive learners.[44]
