During the past 15 years, various individuals within the academic medicine community have advocated for the development of a competency-based approach for reforming medical education in the United States, and around the world. The movement had its formal beginning in 1999 when the Accreditation Council for Graduate Medical Education proposed a set of six general competencies that were to be used in establishing a new framework for designing, conducting, and evaluating graduate medical education programs.1 Shortly thereafter, the American Board of Medical Specialties determined that the same set of competencies should also be used by specialty societies and specialty boards in determining the certification status of practicing physicians. Since then, the competency-based medical education (CBME) movement has been dominated by ongoing efforts to determine how best to use assessment approaches for tracking trainees’ progress toward successfully achieving the competencies during their training.
Specialty organizations are now developing milestones that are to be used for the assessment of residents’ progress toward achievement of the competencies throughout the training program. The approach that CBME advocates propose for ensuring that practicing physicians will be clinically competent is based on the assumption that if a resident meets the milestone requirements established for each of the competency domains, he or she will be clinically competent when entering practice on completion of training. At the same time, other members of the medical education community have argued that the CBME movement is ill conceived and actually threatens to undermine the quality of medical education.2 Their concern is that the focus on achieving the milestone requirements for each of the competency domains distracts attention from ensuring that residents are truly clinically competent when they complete their training.
In an article appearing in this month’s issue of the journal, a group of International Competency-Based Medical Education (ICBME) Collaborators have proposed a charter that they hope will help them “forge a path toward the goal of widespread implementation of CBME and to invite the worldwide medical education community to travel with [them] on this journey.”3 The collaborators assert that the transition to a CBME system is necessary based on evidence that the current approaches being used to educate students and residents fall short of producing the best possible doctors. The ICBME Collaborators began their effort to transform medical education by adopting CBME principles in 2009, and they decided to develop the charter to assist in that effort at a summit meeting they held in 2013. The charter reflects discussions held at that summit, as well as additional content contained in scholarly papers presented by various summit participants.
What Does This Mean for Medical Education?
To begin, I agree that there is a compelling need to transform medical education in this country to better prepare new physicians for the practice of medicine. The medical education community must respond to the reality that the amount of foundational knowledge required for providing high-quality medical care is increasing rapidly, that the demographics of the population seeking medical care are undergoing remarkable changes, and that the country’s health care system is changing in ways that are affecting how care is provided. Accordingly, the design and conduct of the educational programs provided by medical schools and graduate medical education programs must change to ensure that new doctors are prepared to respond to the challenges they will encounter on entry into practice. The programs must be redesigned to ensure that they are providing the full scope of relevant content, and that students and residents are being provided opportunities to encounter and care for patients in appropriate clinical care sites. Because the purpose of the educational process is to produce physicians who are capable of providing high-quality care, I believe that medical education programs should be designed and conducted in ways that aim to ensure that new physicians are clinically competent when they enter practice. Thus, the rationale for employing CBME in preparing new doctors for practice makes good sense.
From my perspective, the medical education community must address the position advanced by CBME advocates that the determination of clinical competence may not be based solely on a summative assessment of a trainee’s ability to provide high-quality care at the time the trainee completes his/her training, but that indicators of progress in each of the competency domains—the milestones—must be continuously evaluated as the trainee progresses through each stage of the educational process. The approach recommended is particularly problematic because there is no convincing evidence that it is possible to assess each of the competencies individually.4 If adopted, the CBME approach will require institutions that provide clinical education experiences for residents to commit additional resources to support their educational programs. At the very least, staff physicians will have to commit more time and effort to assess whether residents have met the performance standards required for each of the milestones while rotating through various clinical services. The challenges that institutions will have to address in responding to the implementation of such a CBME framework may be overwhelming for some institutions.
The reality that institutions will face a major challenge if a CBME system is fully adopted is well recognized. In fact, in 2010, the ICBME Collaborators presented a list of seven major “potential perils and challenges of CBME” that would have to be overcome to implement a CBME system, and they called on the medical education community to engage in efforts to determine how best to resolve the issues of concern.5 Now, more than five years later, those issues have not been resolved, and even more important, the Collaborators state clearly in their current article that there is currently no proof that the implementation of CBME would produce better doctors. Nonetheless, they advance the position that the implementation of the CBME model is a necessary endeavor.
Now, I appreciate that my views on the value of using milestones in the various competency domains to ensure that residents are clinically competent when they complete their training may be proven to be wrong at some time in the future. But I believe the claims being made by CBME advocates should be verified before steps are taken by regulatory and professional bodies to mandate the implementation of a CBME system that will require that substantial resources be committed to implement and conduct the system requirements. In reality, the position taken by those advocating for the implementation of a CBME system is so far based solely on a theoretical construct. The fact is that an honest appraisal of the position advocated by the CBME movement is required before more effort is committed to the implementation of the proposed system. A detailed research agenda that will provide a clear understanding of the value of CBME in producing better doctors is clearly needed.6
The Real Challenge
Finally, it is worth noting that the theoretical basis for advocating for a CBME system is that it will produce doctors who are truly capable of providing high-quality medical care in the setting in which they have chosen to practice. I recognize that there are doctors entering practice at the present time who probably would not meet that standard. And just as that is the case with the current approaches in place to ensure that residents and fellows completing training in the graduate medical education system are capable of providing high-quality care, I believe that it will still be the case with a CBME system in place. But even more important in considering how reform of medical education can lead to improvement in the quality of care being provided to patients is the fact that all doctors do not retain their ability to provide high-quality care throughout their careers. I believe that medical care that is of poor quality is more often caused by practicing physicians who have failed to maintain their clinical competence, rather than by physicians who were not clinically competent when they completed their residency training and entered practice.
The fact is that the approaches now in place for monitoring physicians’ practice behaviors are grossly inadequate. The maintenance of certification and relicensure approaches being used by professional organizations and state licensing bodies to assure the public that doctors in practice maintain their clinical competence are not capable of meeting those standards. The fact is that the processes employed to grant maintenance of certification and relicensure do not include any truly meaningful measures of the quality of care being provided by physicians.7 At the same time, the continuing medical education experiences that are supposed to contribute in meaningful ways to doctors’ efforts to maintain their clinical competence are also of little value. There is simply no meaningful way to relate the quality of the care provided by physicians to specific continuing medical education experiences. Thus, if the goal of the CBME advocates is to improve the quality of care, I suggest that as medical educators they should focus their energy and efforts more directly on what might be done to ensure that practicing physicians are maintaining their clinical competence throughout their careers, rather than advocating for the implementation of a CBME system focused largely on graduate medical education.
1. Batalden P, Leach D, Swing S, Dreyfus H, Dreyfus S. General competencies and accreditation in graduate medical education. Health Aff (Millwood). 2002;21:103111.
2. Huddle TS, Heudebert GR. Taking apart the art: The risk of anatomizing clinical competence. Acad Med. 2007;82:536541.
3. Carraccio C, Englander R, Van Melle E, et al. Advancing competency-based medical education: A charter for clinician–educators. Acad Med. 2016;91:645649.
4. Lurie SJ, Mooney CJ, Lyness JM. Commentary: Pitfalls in assessment of competency-based educational objectives. Acad Med. 2011;86:412414.
5. Frank JR, Snell LS, Cate OT, et al. Competency-based medical education: Theory to practice. Med Teach. 2010;32:638645.
6. Holmboe ES, Sherbino J, Long DM, Swing SR, Frank JR. The role of assessment in competency-based medical education. Med Teach. 2010;32:676682.
7. Iglehart JK, Baron RB. Ensuring physicians’ competence—is maintenance of certification the answer? N Engl J Med. 2012;367:25432549.