What is Competence by Design?

Competence by Design (CBD) is the Royal College of Physicians and Surgeons of Canada’s major change initiative to reform the training of medical specialists in Canada. It is based on a global movement known as Competency-based medical education (CBME), and is led by the medical education community. The objective of CBD is to ensure physicians graduate with the competencies required to meet local health needs. It aims to enhance patient care by improving learning and assessment in residency.

CBD can be explained as:


Stages of Training

The Royal College Specialty Committees organize each specialty program into four distinct stages of training.


Clear learning objectives

Within each stage of training, residents are provided with a list of learning objectives called Entrustable Professional Activities (EPAs) and milestones, based on the CanMEDS 2015 framework.


Residents observed

The resident must be observed completing each EPA. This allows for coaching and feedback opportunities to guide learning.


Observations documented

Observers record EPA observations and feedback on resident performance in an electronic portfolio. The resident can review the information to drive performance improvements.


Committee Review

At regular intervals during each stage of training, a competence committee reviews the documented observations along with other assessment data in the electronic portfolio and provides the recommendation to the Residency Training Committee on the resident’s progression to the next stage of training. Any gaps in learning are identified and addressed prior to progressing to the next stage.


Progress to next stage

The residence will progress to the next stage to tackle a new set of competencies or EPAs. Resident progress is assessed at all four stages of training, before being permitted to progress to the next stage. The Royal College exam becomes only one of many assessment points. Under CBD, specialty committees have the flexibility to move the Royal College exam to the end of stage three, to allow residents to focus on the transition to practice stage.

Benefits of Competence by Design


Clear learning expectations for trainees


Opportunities for feedback and coaching


Residents have more control of learning


Helps prevent gaps in knowledge = increased confidence and care


Promotes use of feedback in lifelong learning

CBD is a hybrid CBME model designed to work within the Canadian context, and combines a time-based and an outcomes-based approach to learning. It reviews the design, implementation, assessment and evaluation of each specialty program across Canada’s 17 medical universities, using CanMEDS 2015 as an organizing framework of competencies.

In CBD, progression of competence occurs within a structured but flexible curriculum consisting of five core components. More specifically, in a competency-based approach, competencies required for practice form a framework and are accordingly organized into a progressive sequence. Promoting resident progression forms the basis for the design of all curricular elements: learning experiences that are tailored to the acquisition of competencies, instruction that is competency-focussed and assessment that is programmatic in approach.