Competency-Based Education: Milestones or Millstones1?

In the past decade, there has been increasing interest in competency-based education (CBE), the notion that an expert physician is defined by a broad set of identified competencies. The idea has been advanced, nearly simultaneously, in several countries—Canada (CanMEDS roles),1 the United States (Accreditation Council for Graduate Medical Education [ACGME] competencies),2 the United Kingdom (Tomorrow's Doctor),3 and Scotland (the Scottish Doctor)4—and adopted by others. CanMEDS competencies have been adopted and adapted by 16 countries, including the Netherlands, Denmark, and Mexico.5 Moreover, the Carnegie Foundation's influential Flexner centenary strongly recommended adopting CBE and made the claim that “Adoption of OBE [outcome-based or competency-based education] would better equip medical graduates to respond effectively in complex situations and efficiently continue to expand the depth and breadth of the requisite competencies.”,6,7 Similar promises emerge from many of these foundational documents. Harden8(p666) ascribes a number of advantages to OBE/CBE: OBE is a sophisticated strategy for curriculum planning that offers a number of advantages. It is an intuitive approach that engages the range of stakeholders . . . it encourages a student-centred approach and at the same time supports the trend for greater accountability and quality assurance . . . [it] highlights areas in the curriculum which may be neglected . . . such as ethics and attitudes . . .. Regrettably, these declarations appear to be more a matter of faith than of evidence. The primary intent of CBE is, we believe, transparency, so that the profession and the public can be confident that a training program is producing competent physicians who are equipped with the knowledge and skills for practice. It is hard to challenge that premise; the issue is whether the proposed mechanisms can deliver on the promise. A corollary common to both CBE and its predecessor—behavioral objectives—is the notion that different learners will achieve different competencies at different rates, so that residents may be certified competent in starting an intravenous line early in their career but may take longer to achieve competency in intubation. The individual need not take additional time practicing skills for which he or she is competent and can, therefore, learn more efficiently by focusing on those skills for which competence has not yet been achieved. An extrapolation of that notion is that some residents may well achieve all the competencies available on a particular rotation earlier or later than others, and so, can progress through graduate medical education (GME) at a different pace. Whether the approach can be operationalized satisfactorily at the level of precision required to implement CBE, the fact remains that it may have positive side benefits, such as increased observations of residents, greater attention to the GME curriculum, and so forth. To ensure that those goals are met and the implementation of CBE is not sidelined by a ponderous administrative superstructure, this editorial is intended to elaborate potential problems at 3 levels: conceptual, psychometric, and logistic.

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