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Practical Considerations

Enhanced Requirements for Assessment in a Competency-Based, Time-Variable Medical Education System

Gruppen, Larry D. PhD; ten Cate, Olle PhD; Lingard, Lorelei A. PhD; Teunissen, Pim W. MD, PhD; Kogan, Jennifer R. MD

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doi: 10.1097/ACM.0000000000002066
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Competency-based medical education (CBME) has captured considerable attention from teachers, learners, and regulatory bodies. It has changed the perceptions and practices of curriculum designers, faculty developers, clinician educators, and program administrators. CBME has particularly significant implications for assessment.

In 2010, Frank et al1,2 defined CBME as “an outcomes-based approach to the design, implementation, assessment, and evaluation of medical education programs, using an organizing framework of competencies” that “de-emphasizes time.” This definition highlights the contrast between traditional educational models, which can be characterized as “fixed time, variable outcomes,” and CBME, which can be described as “fixed outcomes, variable time.” Because fixed outcomes are necessary to ensure standards of quality care and patient safety, time variability is a logical implication of CBME when one recognizes that individual learners come to medical education with variable preparation and skills, pursue and attain competencies at different rates, and demonstrate their competence while possibly needing remediation or acceleration.3–5 Fundamentally, CBME can be seen as an approach to honor the commitment to meet public expectations of the profession.

In this article, we will explore the implications of time variability for assessment. Assessment is even more important in CBME programs than in most traditional programs, particularly postgraduate ones. Traditional programs assume that a specified period in training will lead to competence; thus, assessment is largely a “safety check.” However, this assumption is crumbling under the weight of individual learner cases in which competence was not acquired in the set period of time and not established from the assessment data itself, which identify specific areas of deficiency and needed remediation. In CBME programs, which do not make this assumption, the learners’ progression trajectories are more individualized, and assessment must bear the significant burden of justifying consequential differences in length of training.

Principles of Assessment in CBME

Because CBME treats time as a variable rather than a constant, it requires an alternative method for deciding when a learner is prepared to move on to the next phase of education. This method is predicated on assessing and judging competence. Competence is defined as:

the array of abilities across multiple domains or aspects of physician performance in a certain context. Statements about competence require descriptive qualifiers to define the relevant abilities, context, and stage of training. Competence is multi-dimensional and dynamic. It changes with time, experience, and setting.1

Time variability places considerable demands on the assessment process, demands that are both larger and more varied than is typical for most traditional programs. We will use a modern assessment validity framework5–7 to guide our examination of these demands.

A key principle is that assessment always has a target, a construct about which we are trying to make a judgment. Constructs are intangible and based on our theories of education, performance, judgment, etc.8 Common constructs for assessment in medicine are knowledge, professionalism, communication, teamwork, and numerous others. CBME posits that competencies are the key constructs about which we need to make judgments and for which we need to gather data.

A second key principle is the distinction between assessment data and the assessment judgments that are made from those data. In a multiple-choice test of knowledge, assessment data (the scores) are often distinct from the assessment judgments and decisions (pass/fail, remediation, commendation). In contrast, assessment judgments based on assessment data in the clinical arena can become less obvious. The faculty observer is often the source of the assessment data when evaluating performance; the coach or advocate of the learner and the judge making use of those data decide whether the learner is competent—that is, has achieved a milestone, can progress, etc.9 The measurement tool (form, checklist) merely provides data for these judgments and is only a means to this greater end, not the end itself.

A third key principle regards the decision that is the consequence of the judgment. In usual educational testing settings, this decision pertains to student progress or to receiving a diploma. In clinical education, the decision resulting from an assessment may also result in feedback or the permission to act with less supervision in patient care (i.e., to a decision that a learner can be entrusted to act at a specified level of supervision).10 Assessment decisions may be summative or high-stakes decisions (e.g., graduation) or formative, low-stakes decisions (e.g., performance feedback that a learner may use to guide her or his own learning).

Implications for Gathering Assessment Data

Assessment tasks

Because we cannot assess competencies directly, we must define construct-relevant tasks or activities that produce behaviors that we can observe and measure in some way. These tasks can be as simple as answering a question (in a survey of knowledge test) or as complex as discussing palliative care with a patient and her family. The selection of these tasks has profound consequences for the validity of our assessment judgments. Good assessment judgments require multiple sources of data from a range of relevant tasks that use a variety of assessment methods.9 Thoughtful blueprinting of assessment procedures will improve the quality of assessment judgments.

Despite the fact that expert opinions do not always agree, they are increasingly considered valuable and even necessary to arrive at valid assessment decisions regarding clinical trainees.11,12 Such opinions require the alignment of assessment data gathering with how individual clinicians (as assessors) interact with and gain trust in trainees in the authentic work environment.13,14 This is a new domain of investigation15 related in part to entrustment decision making.16–18

Innovation in assessment

CBME programs will need assessment expertise to guide innovation and experimentation in assessment methods and procedures for integrating and using the data. It will become necessary to develop or recruit expertise in assessment, data analytics, information management, and decision support if the full promise of CBME is to be realized. CBME will not be viable if we continue to depend on occasional, prescheduled written or performance examinations and fragmentary faculty evaluations of clinical performance. This will, in turn, require resource reallocation, often in the face of overall budgetary constraints.

If we commit to developing and using a variety of established and innovative assessment methods, CBME can take advantage of naturally occurring assessment data that are presently neglected. These include learner products (e.g., entries in an electronic health record), team-based performance (e.g., based on multisource feedback), administrative data (e.g., prior qualifications and tests, activities performed), faculty judgments (e.g., mini-CEX, other observations, case-based discussions), and other assessment opportunities that may not be presently thought of as “good enough” for high-stakes, summative assessment decisions.9 While single observation events require high psychometric standards, multiple measures in combination, each of which may not be standardized or reliably reproducible, may yield generalizable results.19 In principle, the notion of the entrustable professional activity (EPA)20 illustrates this point. As a naturally occurring task (e.g., conducting a risk factor assessment for a health maintenance examination), an EPA can be both a unit or focus of instruction and an assessment task.

Patient outcomes offer other, critically important sources of assessment data that can be incorporated into competency decisions21 and enhance the validity of assessments that seek to address the triple aim of enhancing the patient experience, improving population health, and reducing costs.22 However, linking patient outcomes to educational activities is extremely complex.23–26 Gathering such data, understanding trainees’ contributions to the outcomes, and establishing how these data should inform competency decisions about individuals remain part of the research agenda for CBME.27

Time flexibility in assessment

If time is not a fixed quantity in the CBME learning process, it also cannot be fixed in assessment. Because competency judgments can be made at any time, assessment data need to be available for those judgments and thus gathered (more or less) continuously. In particular, the formative uses of assessment data in providing feedback to learners need to be linked closely to the setting and time of the performance. Formative feedback requires a dialogue between teacher and learner28 and, thus, assessments that are tied to those dialogues. Such assessments are time consuming for faculty and constitute a significant potential cost for implementing CBME.

Time-flexible assessment also imposes considerable demands on administrative and logistical resources, particularly in trying to schedule formal assessments (e.g., objective structured clinical examinations required for graduation) for large numbers of learners who are pursuing individual learning sequences or plans. Flexible and continuous assessment is particularly difficult to accommodate with the rigid scheduling of high-stakes assessment. The increased assessment flexibility required by CBME will necessitate significant organizational changes in the relevant examination bodies. However, time variability may also be beneficial in that respect. With the fixed length of training modules, there is significant pressure to evaluate multiple learners in a short period of time, whereas variable length could spread assessment effort more evenly over time.29

Managing assessment data

Because CBME assessment requires data from multiple sources that are gathered more frequently and on variable schedules, it requires a greater level of data sharing, management, and communication than is typical of more traditional assessment systems.30 The logistics and the ethics of communicating a trainee’s assessment data within and across programs is a necessary challenge that has not yet received a great deal of attention.31–33 Electronic portfolios of performance and assessment data may be part of the solution, but they lack standardization, being quite variable from one institution to the next. Learning analytics may serve to support such data management and analysis,34 and mobile technology may be used for the collection of data in the natural course of clinical activities. Warm et al35 demonstrated the feasibility of tracking almost 200 internal medicine residents over three years with 360,000 data points. CBME will need to address systems for interpreting and sharing competency assessment information across programs and stakeholders (including learners) that may span more than 30 years of professional practice and learning.

Context specificity

Context specificity is a problem for all assessments of complex performance that take place during real-world practice. A pervasive finding is that an assessment of performance in one setting, situation, or case does not perfectly predict performance in even a similar case. Context specificity requires that multiple assessments be done by multiple observers over multiple cases in a variety of contexts to obtain a meaningful and trustworthy estimate of performance. E-portfolios and mobile technology could help capture natural encounters in the workplace to provide feedback, formative assessment, and summative decisions regarding progress in various contexts.36

Along with context specificity, assessment data may be limited by the existence of “implicit” components of competence that may not be easily definable, such as professional identity formation. The inherent uncertainty and imprecision of assessment in aiding these decisions must not be forgotten.

Implications for Making Assessment Judgments

Formative and summative judgments

Assessment judgments range in the impact they have on the learner and the educational systems. High-stakes (summative) judgments include decisions about passing or failing a course, graduating or retaining a learner, investment in curricular changes, and decisions about competence. Low-stakes (formative) judgments include feedback to guide student self-regulated learning, self-testing such as is included in many e-learning modules, and progress testing.37

In CBME, formative and summative decisions can be viewed as different ends of the same spectrum. A learner early in her training may be assessed for the purpose of providing formative guidance on how to address gaps and accentuate strengths. A more advanced learner may be assessed with the same method for a summative decision related to his progression or remediation. Importantly, the same assessment data can be used for either formative or summative judgments—an assessment activity, per se, is neither formative nor summative. However, summative judgments and decisions generally require greater amounts of higher-quality assessment data than do formative judgments.

In the programmatic assessment literature, a series of formative assessments, each of which separately serves to stimulate learning (an approach labeled assessment for learning), together may serve to make summative decisions (or what is called assessment of learning).38 Similarly, entrustment decisions have been identified as part of ad hoc assessments about learners for training purposes in health care tasks and as part of summative decisions about certification for health care tasks.10,20

Assessment standards and criteria

Summative judgments require not only solid assessment data but also a standard or criterion for performance that defines the decision (competent vs. not competent). These standards may be quantitative and derived by formal group judgment procedures, such as Angoff or Hofstee methods,39 or they may be qualitative and describe a given performance level based on needed supervision or milestone achievement.40 The complex competencies identified by CBME do not readily lend themselves to traditional standardized psychometrics, so considerable effort has been devoted to systematizing more “subjective” judgments (whether qualitative or quantitative) on the part of faculty. These efforts include behavioral anchors for ratings scales, detailed descriptions of what “competent” performance looks like, and faculty development to calibrate faculty to a common set of criteria, such as milestones.41 Schuwirth et al12,30,42 also have emphasized that multiple “subjective” assessments from individual faculty raters may contribute multiple, meaningful perspectives on a learner, in spite of appearing unreliable according to psychometric theory.

EPAs and entrustment decisions

Although not a logical necessity for implementing CBME, EPAs have emerged as a key aspect of many CBME systems. EPAs have been defined as units of professional practice to be entrusted to learners for unsupervised execution once they have demonstrated adequate performance.43 One of the key features of EPAs is the link between authentic, often-everyday tasks of a profession and the opportunities to observe and assess learners’ performance completing those tasks.

A key component of the EPA concept is entrustment. Entrustment requires that faculty and assessors make a judgment that integrates learner performance with assessor expectations and the nature of the task/EPA. It has enormous practical value because it captures the assessor’s overall judgment in the context of an important professional criterion—Is the learner “trustworthy” to do this task independently?—and the judgment is based on an estimation of the amount of supervision the learner requires.

Entrustment of a learner to perform a task independently may or may not be the goal for each EPA identified for an educational program. Depending on expectations, some EPAs may not be fully mastered by the end of the program. However, under a CBME framework, individual learners may exceed program expectations and attain sufficient mastery for full entrustment of “unsupervised practice” long before the end of the program because of particular skills, motivation, or learning opportunities.

EPAs provide a framework for granting responsibility as soon as learners are ready for it. Not all learners will attain the targeted competencies at the same rate because of prior learning and differences in sequencing of learning experiences. Therefore, variation in the time required to master EPAs may require individualized training pathways.44 Time variability in mastering individual EPAs is not necessarily the only contribution to variability in total program time; the variable number of EPAs that need to be mastered by an individual learner also may affect the total program time.

Entrustment decisions, as an assessment outcome, can be dichotomous (entrusted vs. not entrusted) or incremental to accommodate a development framework for assessment. Different levels of entrustment may reflect different levels of independence or supervision, such as the learner observing only, participating in the EPA with direct supervision (in the room), participating with indirect supervision (not in the room but quickly available), and with distant supervision not quickly available.45

If the purpose of assessment is defined as making entrustment decisions for EPAs in clinical practice and the scale of this assessment is framed as the amount of supervision the learner requires, assessment instruments can be created. Early studies have found that these construct-aligned approaches13 show favorable validity evidence.14,46,47 However, it is important to acknowledge individual differences in faculty observers’ criteria for less intensive supervision. Variability among faculty judges is a threat to the validity of these entrustment judgments.

Transitions and individual plans

It is common for faculty and researchers to identify inadequate preparation in learners who are transitioning from one phase to another in medical education: from undergraduate to graduate education,48,49 from graduate to fellowship programs,50 or into unsupervised practice.51 These gaps in preparation have led to a variety of responses, including boot camps to help prepare medical students for the transition to internship.52 Similarly, many residency programs have immersion experiences at their beginning. CBME assessments could aid these efforts by providing clearer expectations of performance and better data on learners’ strengths and weaknesses so that remediation and early learning plans could be adapted to individual needs, rather than to the perceived needs of the group as a whole.

Systems for making assessment judgments

Clinical competency committees (CCCs or entrustment committees) provide an example of innovation in how faculty collaborate around making assessment decisions.53,54 These committees collect, review, and synthesize assessment data from various sources and times, organized around defined competencies. The CCC takes these assessment data and uses them to make assessment judgments about the competence of each student, balancing the risks and benefits of the decisions about trust and progression through the program.18 Although many CCCs tend to focus on identifying at-risk trainees,53 this decision-making structure and process holds promise for making decisions regarding accelerated learning and early graduation as well.55 Of particular importance to CBME, the CCC structure would and should support the implementation of a truly time-variable education process.


The assessment of learning outcomes has always been essential to all levels of medical education, but competency-based, time-variable education places particular demands on assessment quality, frequency, purpose, and management that exceed the traditional requirements. As CBME programs multiply and mature, the investment of time, money, and talent into assessment methods and systems will also grow. We envision that the field of assessment will be a dynamic area of innovation over the next several decades as medical education commits to meeting the obligations of being able to document its educational promises to learners, to patients, and to society.


The authors wish to thank the guest editorial team and reviewers of this supplement.


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