From Competence by Time to Competence by Design: Lessons From A National Transformation Initiative

Competency based medical education (CBME) is a global movement to reform health professions education (HPE).In contrast to the traditional time-based training, it is an educational design approach that emphasizes necessary learner abilities, greater learner-centeredness, and better alignment with public's needs for healthcare providers.Unlike numerous previous HPE innovations, CBME is framed as a complex transformational change with multiple proposed elements [1].Training programs employing a competency-based approach can have five core components to operationalize their implementation with fidelity: outcome competencies, progressive sequencing, tailored learning experiences, competency-focused instruction, and programmatic assessment [2].Health professions education institutions, disciplines, and programs across the globe have been implementing CBME at an ever-increasing rate.The CBME movement began with early innovations such as the CanMEDS framework [3-7], the ACGME Outcomes Project [8-10], entrustable professional activities [11,12], the Dutch CBME curriculum [13,14], the Cincinnati observable practice activities [15], the College of Family Physicians of Canada Triple C Curriculum [15-17], and the University of Toronto Orthopedic program [18].CBME has now spread worldwide with implementations in, for example, Switzerland, Taiwan, Australian Orthopedic training [19], Finland, South Africa, Brazil, and many more countries.Competency based education is now a part of many health professions beyond medicine, including nursing [20] and veterinary medicine [21].Despite the global implementation effort, the current discourse around CBME is still largely focused on theoretical underpinnings and potential [22,23] and countered with skeptical criticisms [24,25].There are early efforts to evaluate and clarify the outcomes of these CBME curricula [26,27].However, what is needed at this stage of the diffusion of these innovations is sharing CBME praxis: examples of the application of the CBME approach to real-life HPE systems and the lessons learned for others who follow.In this special issue of Perspectives on Medical Education, a team of educators has come together to describe a unique Canadian configuration of CBME implementation called Competence by Design (CBD).Worldwide, the majority of CBME innovations have focused on implementing

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