Frequently Asked Questions
Competency-based medical education (CBME) is an outcomes-based approach to the design, implementation, assessment, and evaluation of a medical education program using an organizing framework of competencies.
To prepare physicians for practice, CBME’s is
- oriented on desired patient outcomes;
- based on patient needs;
- based on the needs of the learner, with more accountability and flexibility; and
- focused on achieving skills, and demonstrating performance, instead of tracking time-spent in training.
Competence by Design (CBD) is the Royal College’s multi-year, medical education, transformational change initiative aimed at implementing a CBME approach to education and assessment to residency training and specialty practice in Canada.
The goal of CBD is to enhance patient care by improving learning and assessment across the continuum (from residency to retirement), ensuring physicians have the skills and behaviours required to continuously meet evolving patient needs.
Our current medical education system assumes that the more time a trainee spends on an activity, the more he/she will progress and hone expertise. While this system has, and continues to produce, excellent physicians, there is growing evidence that the method of training can be improved.
CBD will organize training into stages and clearly lay out markers for teaching and learning at each stage. Each stage of training, and each learning experience, will focus on the identified competencies that must be acquired. Continuous assessments will occur against each competency, and in order for a trainee to progress from one stage to another, he/she must demonstrate that all the competencies (measured by Entrustable Professional Activities (EPAs) / milestones) have been met.
This model will allow physicians to truly focus on the skills and abilities they need to meet evolving patient needs. Additionally, the shift to CBD aligns with the recommendations of the Future of Medical Education in Canada Postgraduate (FMEC-PG) and Future of Medical Education in Canada – Continuing Medical Education (FMEC-CPD projects.
By making the shift, we are signaling to the world that Canadian specialist physicians and residents are committed to continuous learning, improvement, and assessment. Furthermore, we are responding to patient calls for increased transparency and accountability and, finally, we are validating the trust that society has placed in us to self-regulate a physician education system in a manner that promotes best practices and enhances care.
“Pure” CBME is time free; CBD, however, is a hybrid model of CBME. It is not time free. Instead, CBD will re-conceptualize time as a framework.
Within CBD, the number of years needed to complete a residency program is not expected to change for the majority of residents. Residents will have the ability to achieve competencies (measured by Entrustable Professional Activities (EPAs) / milestones) at their own rate within the defined residency program timeframe.
The CBD initiative aims to make it easier for medical educators to:
- identify abilities of individual learners at different stages of training and provide guidance to address identified gaps in learning
- employ better standards for assessment
CBD aims to reduce or eliminate problems arising from:
- completion of FITERs before training is truly complete
- impractical ITERs
- the need for all preceptors to assess everything all the time
- the need for all preceptors to teach everything all the time
- burdensome accreditation processes
- inefficient pre-survey questionnaires (PSQs)
The Royal College understands that CBD represents a significant change within medical education. We are committed to working and learning with our partners to establish the resources and tools to support adoption of a competency-based model.
The CBD initiative aims to provide many benefits for learners, including:
- more frequent assessment and meaningful supervision by expert faculty
- clearly defined targets for acquiring competency and meeting standards throughout training, to guide progression to next stage of training
- a more flexible timeframe, which focuses on personal development
- the ability to continuously strive towards excellence throughout practice.
Right now, the focus is on implementing CBD within residency education. However, CBD is intended to enhance patient care by improving learning and assessment in practice by making it easier for practicing physicians to:
- identify their needs and abilities , and address any gaps through engaging in CPD;
- stay current with constantly evolving medical research, technologies and procedures — and know when to adopt these changes into their practice; and
- plan and track their learning activities to demonstrate competence and performance within their scope of practice throughout multiple career transitions.
We’ve recently begun conversations with Fellows, continuing professional development (CPD) experts and the medical education community to explore the possibility of moving forward with competency-based CPD.
We recognize that the smooth transition to a competency-based CPD model will require careful consideration, coordination and cooperation. All recommendations about moving forward will be shared with stakeholders as a means to seek further guidance and collaboration on a competency-based CPD model that will meet the needs of the public and of the profession.
Will the number of years needed to complete a residency program decrease with the implementation of CBD?
CBD will re-conceptualize time as a resource — not a restriction. The number of years needed to complete a residency program is not expected to change for the majority of residents at this point in time.
CBD will change the framework of residency education. It will create more targeted learning objectives and involve more frequent, formative assessments to ensure residents are learning the skills they need. CBD will also assist residents who are struggling. Residents who achieve competencies early will be able to advance to other competencies and mastery. Early and frequent assessments will help faculty identify struggling residents and take action.
Within the standard timeframe of a residency program, physicians will be able to master competencies at their own rate. Residents who need additional time will be able to focus on their specific learning needs rather than jumping ahead to a new learning objective. Residents who master the needed competencies earlier than their peers can use the remaining time to finesse their skills and abilities and move to a higher level of proficiency. There may be situations where the new model will shorten training time and provide a pathway to earlier graduation; however, timing for the majority of residents will stay the same.
For resident to finish early, he/she must have achieved all mandatory milestones. In this case, the resident can use the additional time to hone skills and further prepare for practice. The resident can be given additional responsibility to finesse transition to practice competencies. Or, the resident can negotiate with the Program Director and start working on additional advanced training.
The Royal College expects that there may be two parallel systems operating at the same time as CBD rolls out across programs.
We do not envision that programs will switch to a competency-based model mid-stream. Residents who begin their training in the current model will finish their training in the current model.
However as part of CBD, we recently updated the CanMEDS Framework to include new content like patient safety, handovers, physician health etc… All programs will be incorporating this new content into their curricula moving forward, so all residents will experience programs which place greater emphasis on these key areas. Also, both residents and faculty in all programs will have the opportunity to benefit from CBD tools, resources, and/or support systems.
The Royal College recognizes that the clinical services provided by residents are integral to both effective medical education and the delivery of timely healthcare. Not only do clinical service rotations allow residents to actively learn at the “bedside”, the service rotations also ensure that teaching hospitals and other sites are appropriately staffed.
Residents learn from clinical experience. CBD will re-emphasize the role of clinical care as a resource for teaching and learning.
The CanMEDS physician competency framework helps physicians deliver quality patient care by setting the highest standards for their training and continuing professional development. Developed by the Royal College in the 1990s, its main purpose is to define the necessary competencies for all areas of medical practice and provide a comprehensive foundation for medical education and practice in Canada.
This educational framework identifies and describes the seven Roles that lead to optimal physician performance, care delivery and health care outcomes. These roles include: Medical Expert (central Role), Communicator, Collaborator, Leader (formerly Manager), Health Advocate, Scholar and Professional.
In Canada, the framework is used by residents in all medical specialties as part of their postgraduate training, and it provides the foundation for the Royal College’s certification and accreditation processes. This competency model has also been adopted by other organizations in Canada and internationally, both in and outside the health professions, making it the most recognized and widely applied health profession competency framework in the world.
CanMEDS 2015 is the foundational project for the Royal College’s Competence by Design (CBD) program. The CanMEDS 2015 Framework includes new competencies relating to patient safety and quality improvement, resource stewardship and handover, for example. It also introduces new competency milestones for each CanMEDS Role.
There are two earlier editions of the CanMEDS Framework, the original edition, which was released in 1996 and a second, which was released a decade later in 2005. This periodic review and revision process is demonstrative of the College’s commitment to continuous quality improvement on behalf of physicians and patients.
- The addition of complementary milestones is arguably the largest change between the 2005 and 2015 versions of the CanMEDS 2015 Framework. The milestones will be available in an online companion document, the CanMEDS Milestones Guide, and unlike the Framework they will undergo continual revision as educators modify the milestones for their specific specialty.
- New themes have been introduced, such as patient safety, quality improvement, handovers, and eHealth.
- A renewed emphasis on the overall coherence of the framework and on its practical application.
- Role descriptions and definitions are expressed in simpler, more direct language.
- Overlapping areas between Roles have been minimized.
- Competencies and milestones describe the abilities to be demonstrated in practice, as distinct from the information or content related to aspects of a Role.
A milestone is an observable marker of an individual's ability along a developmental continuum, which is used for planning and teaching. An Entrustable Professional Activity (EPA) is a task in the clinical setting that may be delegated to a resident by their supervisor once sufficient competence has been demonstrated. Typically, each EPA integrates multiple milestones and it is generally used for overall assessment. The key difference between EPAs and milestones is that EPAs are the tasks or activities that must be accomplished, whereas milestones are the abilities of the individual.
The implementation of the CanMEDS 2015 Physician Competency Framework is occurring as part of the Royal College’s Competence by Design (CBD) initiative. CBD is being implemented through multiple cohorts and over an extended period of time. The final cohort of disciplines converting to CBD is expected to happen no earlier than 2022. One of the main reasons for this extended transition is because CBD involves major systems changes that require careful planning and ongoing consultation.
The changes introduced as part of the CanMEDS 2015 project will lead to better trained physicians and improved patient care. For this reason, Royal College Fellows feel it is important for CanMEDS 2015 to be incorporated into training and practice as rapidly as possible, but in a way that is efficient and mindful of the other systems changes underway. Too long a delay between the development and implementation of CanMEDS will minimize its potential value to the system.
Next steps for implementation
In July 2016, the Royal College will incorporate a CanMEDS 2015 special addendum to the Objectives of Training for all disciplines that transition to CBD in cohorts 3 or later. Its role is to facilitate the timely implementation of CanMEDS 2015 by focusing on key NEW content areas found in the Framework. This approach will ensure the major highlights of CanMEDS 2015 are incorporated into training in a timely way, without over-burdening our stakeholders many of whom are also involved in the broader changes associated with CBD.
Implementing CanMEDS 2015
The Special Addendum focuses on KEY new content areas in the key and enabling competencies of the CanMEDS 2015 Framework and is organized by CanMEDS Role under three main headings: “Patient safety, Quality improvement and Resource management”, “eHealth and Technology” and “Leadership and Physician health”. The content is broadly applicable and it is not expected to require adaptation to the Objectives of Training Requirements of the 58 disciplines that will transition to CBD in cohort 3 or later.
The addendum will apply to those who begin training in the identified disciplines on or after July 1st, 2016. Accountability for ensuring the curriculum is taught in accordance with the Generic OTR addendum and the Discipline-Specific OTR remains with the faculty and program. General accreditation standards will not change as a result of this addendum. Surveyors will, however, seek to determine how the CanMEDS 2015 OTR addendum has been integrated into training. Programs reviewed after July 1, 2017 will be expected to demonstrate that these requirements have been integrated in the program’s curriculum.
Once a discipline has transitioned to CBD and begins to accept trainees into its revised training programs this addendum will no longer apply.
We are committed to providing more support than ever before. Below you will find a detailed list of the tools and resources available to you to help implement CanMEDS 2015.
- CanMEDS Interactive – With this online, interactive platform you can explore and engage with the CanMEDS 2015 Physician Competency Framework, including with the milestones across each stage of the competency continuum. Discover CanMEDS in a way that you haven’t before by using filters to generate the milestones that you choose to use.
- Teaching Quality Improvement in Residency Education – Author Roger Y.M. Wong, MD, FRCPC, has developed an innovative curriculum to teach quality improvement to residents. This electronic publication covers topics such as setting learning objectives, assessing competencies, evaluating curriculum from fundamentals to advanced quality improvement.
- CanMEDS Teaching and Assessment Tools Guide – This is a standalone, practical resource to support program directors as they implement CanMEDS 2015. The guide is designed as a practical teaching and assessment resource for competency-based medical education, and will help clarify important educational concepts.
- CanMEDS Introduction for Clinical Teachers – Video Series – This series features short videos with our Clinician Educators, who explain the changes to each CanMEDS Role, provide information on teaching and assessing each Role, and share how the Roles can be incorporated into practice.
- CBD Community Touchpoint – this new ePublication is released three times a year and is intended to provide you with regular information and progress updates on CBD. Sign up to receive the Touchpoint directly in your inbox, or check out the June 2015 and October 2015 issues.
Additional resources, including slide decks, info sheets and webinars are available in the CBD Resources section of the Royal College website.
CanMEDS is a framework that is already used by various medical education organizations around the world for undergraduate medicine, residency, faculty development and continuing professional development. In Canada, many medical schools use a CanMEDS-like framework for their MD programs. By providing generic milestones for each domain of competence starting at entry to residency, the CanMEDS Milestones will allow educators to adapt CanMEDS to different stages of training – including a practicing physician’s future professional development activities.
As CanMEDS 2015 rolls out over the next few years, the Royal College will work with partners continuing professional development (CPD) leaders, regulatory authority representatives and assessment experts to build recommendations for a CPD model which incorporates CanMEDS content and competency-based practices.
We recognize that the smooth transition to a competency-based CPD model will require careful consideration, coordination and cooperation. All recommendations will be shared with stakeholders as a means to seek further guidance and collaboration on a competency-based CPD model that will meet the needs of the public and of the profession.
Please email email@example.com and we will be happy to discuss this further with you.
Is the Royal College collaborating with other organizations to implement CBD? Yes, the advice, opinions and needs of our stakeholders are integral to CBD. We are committed to working collaboratively throughout the process with postgraduate deans, program directors, specialty committee members, Fellows, government partners, provincial medical regulatory authorities, the College of Family Physicians of Canada, Collège des médecins du Québec, resident associations, and other stakeholders in the medical education community.
Together, we can implement CBD in a manner that addresses current the gaps in the education system while respecting and supporting the needs and resources of faculties across the country.
We are in the process of forming a CBD National Advisory Committee (NAC) with key stakeholders including the PG community. The NAC will provide strategic advice and input for CBD. A series of advisory groups will be formed to advise the Royal College. Membership is being finalized, but the groups will focus on
- Logistics and implementation;
- Policy and guidelines;
- Faculty development;
- Outcomes evaluation; an
- Accreditation (already in place).
As part of the Assessment/ePortfolio working group, and to respond to questions we’ve received, we will be reaching out to the universities to connect with their Information Technology/Information Management staff in an effort to better understand their current data and IT system needs, and logistical and resources challenges with the goal to arrive at a plan for a mutually acceptable solution.
Finally, we are in the process of developing a roadmap for consultation which provides a draft view of CBD in action. This roadmap is intended to help each school see how CBD could work within their specific context and will include information such as CBD purpose/outcomes, CBD core principles, information about our vision for assessment and EPAs etc… This model will be shared with our stakeholders for consultation and field tested with our CBD adopters.
Our intent is not to provide a pathway for implementation which is set in stone. Instead, we aim to create a roadmap which will serve as a fluid guide and can be tailored and adjusted to the needs and context of our partners.
How are the Ministries of Health and the Provincial Medical Regulatory (Licensing) Authorities involved in CBD?
The Ministries of Health and the Regulatory Authorities are aware that we are embarking upon CBD. At this time, the Royal College does not anticipate that CBD will result in extending the length of residency training or increasing the costs of training, and we have shared this information with the Ministries and Regulatory Authorities. However, in 2016 we will be field testing aspects of CBD with Medical Oncology and Otolaryngology – Head and Neck Surgery.
These experiences will allows us to collect real-time data and pinpoint any potential implications to funding and training duration. Using this information, we will work with our stakeholders to develop effective solutions which respect and support the needs and resources of funding partners and faculties across the country.
We are committed to engaging with our partners to create a new era of collaboration and develop a CBD implementation model which is fluid and can be tailored to individual needs. Together, we are working on activities to support competency-based practices which include
- Field test CBD with adopting disciplines
- Develop technology solutions to support competency-based learning and assessment
- Foster adoption of the revitalized CanMEDS content – foundational to CBD
- Improve exams, credentialing and accreditation processes
The Royal College is taking a phased approach to CBD roll-out and implementation. We anticipate that all specialty and subspecialty programs in Canada will adopt CBD in gradual phases – a transition that will occur until 2022.
In 2016, Medical Oncology and Otolaryngology – Head and Neck Surgery (Cohort One) will field test aspects of CBD such as the formation/role of a competence committee, the flow of new assessment processes, and the use of faculty development resources with year one residents. We anticipate that they will integrate CBD into their programs (for year one residents and all residents thereafter) in July 2017.
The remaining disciplines will test, refine and adopt CBD in planned waves (as per the Cohort schedule) over several years. For example, the disciplines scheduled as part of Cohort Two (Anesthesiology, Forensic Pathology, Gastroenterology, Internal Medicine, Surgical Foundations, and Urology) will likely integrate CBD into their teaching and assessment practices for year one residents in 2017 (the same time as Cohort One disciplines adopt CBD).
We know that many disciplines are enthusiastic and want to get started right away. Unfortunately, it just isn’t feasible to transition all specialties and programs to CBD at once. To help those disciplines who may want to start early, we’ve developed a “Meantime Guide”.
This Guide provides tangible tools and steps that disciplines and institutions can take now to prepare for CBD implementation – no matter where they are in the implementation schedule. Steps include things like integrating the improved patient safety aspects of the new CanMEDS framework into program curriculums.
What kind of support will the Royal College offer to help each discipline and institution adopt CBD?
The Royal College is committed to supporting each discipline and institution as they prepare for, and implement CBD. We will work with the specialty committee of each CBD adopter and other volunteers. Together, we have created and will continue to create education and faculty development resources that allow specialties to incorporate competency-based practices into their programs. These include,
- The CBD Meantime Guide
- The CBD Roadmap
- CanMEDS Interactive
- CanMEDS Teaching and Assessment Tools Guide
- CanMEDS Summary Cards
- The CBD Community Touchpoint
- CanMEDS Intro for Clinical Teachers: Video Series
- assessment templates,
- milestone development guides,
- curriculum mapping tools, and
- face-to-face training.
The Royal College’s current ePortfolio is known as MAINPORT. The competency-based version of this system will be a “next generation MAINPORT and is called MAINPORT ePortfolio.
The original vision of CBD assumed that each discipline adopting CBD would use the Royal College’s MAINPORT ePortfolio (an enhanced version of MAINPORT developed for competency-based training) to track and record learning and assessment. However in the past few months, we have learned that many university partners already have systems in place that pose new challenges to how we share, access and integrate data.
We are in the process of finishing a clickable prototype of MAINPORT ePortfolio. This prototype will clarify the data entry processes and assessment workflows which align with the original vision of CBD. The prototype will be shared with our PG Dean partners and other stakeholders so that they can see how the planned assessment and tracking might work within CBD.
The prototype will allow us to have informed conversations with our partners about our next steps. Working together we will examine opportunities to integrate and leverage existing technology and create solutions within and beyond MAINPORT which are usable and practical at the local level.
Within the current system, residents spend the last year of their program preparing for their certification exam. Focusing on the exam often means trainees loose valuable clinical time. Within a CBD model, residency breaks down into four stages:
- Transition to Discipline (orientation and assessment)
- Foundations of Discipline
- Core of Discipline
- Transition to Practice
CBD will examine shifting the exam to the end of the “Core of Discipline” stage, rather than holding it at the end of the “Training to Practice” stage where it currently sits. This will ensure trainees are not lost to textbooks in their final year. Instead, they can take the final year to hone their skills, and emphasis will be placed (as much as possible) on independent work and skills, helping physicians better prepare for independent practice.
No. The examination will become a milestone in the “Transition to Practice” and one of a number of requirements for certification. Passing the exam at the end of the “Core of Discipline” stage will not lead to certification. The Royal College will only grant certification when the resident has successfully completed the “Transition to Practice” stage and has received sign off from the Program Director.
Patients trust us to train competent doctors and maintain those standards throughout physicians’ careers. The quality of our assessment and feedback practices is key to maintaining this trust. We know that our current model of assessment can be improved. CBD aims to create more authentic and usable assessment information by integrating a programmatic model assessment into residency and practice.
To do this, CBD will embed continuous assessment into each program by integrating competency milestones and Entrustable Professional Activities (EPAs) into each stage of training.
- The milestones and EPAs will create a clear learning plan for residents and clear teaching and assessment goals for educators.
This approach will increase the number of assessments needed; however, it will also increase the amount of valuable and practical data we can use to evaluate the competence of our learners. Our aim is to focus assessment on discrete activities. There will be no need to assess (or teach) everything all the time.
As we move forward, our goal is to simplify and reduce burdensome activities. With the new programmatic assessment focus, we anticipate that inefficient activities like ITERS will eventually be removed. We are committed to working with each discipline to make the number of assessments needed manageable, practical and as simple as possible.
In 2013, the Royal College partnered with the College of Family Physicians of Canada (CFPC) and the Collège des médecins du Québec (CMQ) to assess the current system. This collaborative review – the first of its kind in 20 years – highlighted a number of system strengths and challenges.
In fact, we heard numerous comments from the PG community about the “burden” of the existing system and the work load the system places on schools. In response to these challenges and in an effort to meet 21st century needs and support the outcome focus of competency-based medical education, we have collectively developed a proposal to redesign accreditation.
This proposal reflects in-depth stakeholder feedback, and aims to preserve our current systems’ strengths while
- reducing the burden of work on schools,
- promoting continuous evaluation and improvement, and
- eliminating paper-based processes.
Proposed changes include the
- introduction of new general standards (which are currently being developed by several Working Groups),
- creation of streamlined processes, and
- digitization of the accreditation system.
Transitioning to a new accreditation system is complex. The three colleges understand this and commit to providing all schools and programs with time they need to prepare. The proposed changes will NOT affect schools with accreditation visits in 2015 or 2016. The earliest possible testing phases for the proposed changes will be 2017.
All schools will have the time to review, understand, prepare for and integrate the new standards and practices before they are expected to demonstrate compliance. The partners are currently crafting a detailed implementation plan which will examine phasing-in the new standards and processes over a realistic timeframe.
Once a more fulsome plan is developed and discussed with stakeholders, it will be shared more widely and the colleges will begin providing detailed information about the effects of the changes on each university.
Check out our updated CBD Resources page for a variety of informational documents and videos:
- Info Sheets, Reports and Graphics
- Faculty Support
- Articles, eBooks & Newsletter
- Videos and Webinars
- Frequently Asked Questions
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