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Competence by Design:

Fundamental elements of a new residency education system

Responding to the global movement to competency based medical education (CBME), the Royal College of Physicians and Surgeons of Canada, in collaboration with the seventeen Canadian Faculties of Medicine, has launched their own adaptation of CBME, implementing a particular, hybrid model of CBME that is built for the Canadian context of specialist medical education.

The Royal College’s particular brand of CBME is called Competence by Design (CBD). The Royal College has embarked upon the CBD Initiative because the enterprise of medical education is at a crossroads. CBD is prompted by powerful technological and societal changes including, not least of which, an increased focus on accountability. CBD aims to ensure accountability for the training of physicians who are optimally prepared to meet the health needs of Canadians in both their current and future practice.

Doctors in training

This section outlines the key features of the CBD model, as it is being implemented in the Canadian context of specialist medical education. The CBD Model incorporates different elements of other CBME models, as well as enabling operational changes to ensure alignment with the principles of outcomes-focused education that are inherent to CBME. CBD is focused on the continuum of medical education, incorporating residency education, as well as continuing professional development. Ultimately, a move to CBD is about a better way to train health professionals.

Key Features of the Royal College CBD Residency Model

The key features of the CBD Initiative for residency education were constructed in order to align with the core components of CBME outlined by Van Melle (2016). The key features of the CBD Residency Model as they align with these core components are summarized below. Additional information about the CBD model can be found in more detail in the Royal College’s document: The Application of the Core Components of CBME in Competence by Design

Key Features of the Royal College CBD Residency Model
Core component of CBME Features of the CBD Initiative
FRAMEWORK: Competencies are clearly articulated
  • Social accountability: Competencies and outcomes are aligned with societal needs
  • Every discipline will have Royal College Entrustable Professional Activities (EPAs) and associated milestones that will provide discrete markers of competence.
  • CanMEDS 2015 and discipline-specific competencies
PROGRESSION: Competencies are sequenced progressively
  • CBD Competence Continuum: Specific, distinct, integrated stages of training are employed to mark increasing progression on a continuum of competence (stages of increasing competence and independence in practice)
  • Achievement of competencies are sequenced progressively: Categorization of milestones and EPAs within each stage of progression
TAILORED EXPERIENCES:>Learning experiences facilitate progression
  • Authentic, work-based environments for learning that match the settings of future practice.
  • Learning experiences are organized to acquire competencies and demonstrate EPAs
  • A hybrid model of competency-based, timed rotations between time-free and a time-dependent approaches.
  • A de-emphasis on time to ensure that learning experiences are organized to immerse the learner in authentic practice conditions.
COMPETENCY-FOCUSED INSTRUCTION: Teaching practices promote progression
  • Learning guided by real-time, high quality feedback from multiple observations
  • EPAs to structure learning and focus instruction (in contrast to extemporaneous approaches)
  • EPAs to structure learning and focus instruction (in contrast to extemporaneous approaches)
PROGRAMMATIC ASSESSMENT: Assessment practices support & document progression
  • Assessment for Learning: Competency-based assessment focused on EPA observations in the workplace
  • Assessment for Progression: Promotion decisions and certification is accomplished upon successful completion of EPAs and progression through stages of training, and is to be determined by a Competence Committee responsible for regular review of learner progress using highly integrative data from multiple EPA and milestone observations and feedback in clinical practice.
  • Changes to the certification examination: Entry to the Royal College examinations will be aligned with promotion decisions entrusted to the Competence Committees. Examinations will be maintained, but the timing and emphasis of such examinations will shift to occur earlier in training to promote a smoother transition to practice.
  • An electronic portfolio to demonstrate and record developments in competence and independence.

For more information about the CBD model, the application of the core components of CBME and its implementation across Canada, you may explore the following links: