The History of Competency-Based Medical Education
Competency-based education has been in existence for decades in medical education and one can trace its roots to the 1970s (ten Cate & Billett, 2014). Over the past 15 years, it has become more consistently present in undergraduate and graduate medical curricula. The increase in competency-based education likely stems from increased accreditation requirements in undergraduate medical education and in residency training programs to assess learners’ skills, increasing quality measures in physician performance, and trends to increase health system accountability (Carraccio & Englander, 2013). In addition, demands for improved safety in patient care drives the need for improved training and skills’ assessment to foster consistent care (Nasca, Philibert, Brigham & Flynn, 2012). Evidence also exists to show that standardized resident training drives future clinical performance (Asch 2009; Chen 2014). The core competencies began to take shape after the Accreditation Council for Graduate Medical Education (ACGME) delineated the six core competencies in 1998 defined by the six domains of clinical competence: Patient Care, Medical Knowledge, Practice-based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, and Systems-Based Practice (Swing, 2007). Development of the core competencies were an important step to help standardize the competency-based teaching and assessment movement.
Figure 1.
Similarly, Canada introduced the CanMEDS framework that defines seven roles: medical expert, communicator, collaborator, manager, health advocate, scholar, and professional. Competency-based medical education (CBME) focuses on abilities, outcomes, and centers on the learner so that competency is determined by standards of performance instead of time-based training.
Figure 2.
Graduate medical education efforts have provided a framework for the formation of medical professionals in training and CBME has become an international phenomenon with developing frameworks in Australia, Europe, and Scotland. The international competency-based medical education (ICBME) collaborators have been working since 2009 to promote understanding of CBME to accelerate its uptake internationally.
Defining the competencies of a physician in practice was an important first step in assessing clinical skills in our undergraduate medical students and residents, but the devil is in the details. While core competencies can be defined, it is important to develop undergraduate and graduate medical education objectives that are detailed and measurable in order for the learner to understand precisely what they need to do to show competence in those skills. Carraccio and Englander (2016) provided recommendations for developing the learning objectives within the core competencies and called for the following in graduate CBME:
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A standardized language;
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The power of direct observation and assessment;
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The need for developing meaningful measures of performance;
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Desired outcomes as the starting point for curriculum development;
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Dependence on the reflection of expertise;
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Need for exploiting the role of the learner in their learning; and
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Competent clinical systems as the environment to producing competent physicians.
This shift in medical education to CBME is a welcome opportunity for undergraduate medical education to move from assessment of medical knowledge acquisition through standardized testing to assessment of student competence based off skills and attitudes. Adoption of CBME is an opportunity to demonstrate preparation for the independent practice of a physician, especially in the area of clinical skills (Weinberger, Pereira, Lobst, Mechaber & Bronze, 2010).
In undergraduate medical education, the adoption of CBME allows a shift toward defined competencies and expectations for medical students during their professional education. Lessons from graduate medical education have lead educators to define levels of accomplishment for the learner, tailored learning, and programmatic assessment throughout the various stages of medical school. In developing CBME curriculum and assessment, the fundamental question should be “how do we improve medical education to provide better care for patients?” (Carraccio et el., 2017).