CBD Community Touchpoint - January 2018


CBD Community Touchpoint

Official CBD newsletter of the Royal College

Created to inform, support and connect. About

Key to 2018:
CBD Leadership & Communication

Royal College CEO Andrew Padmos

Welcome to a new year of CBD implementation!

As we start the new year, let us take stock of our collective achievements and lessons learned in 2017 while we look in anticipation to what lies ahead for CBD implementation across Canada.

We congratulate the two pioneering specialities – Anesthesiology and Otolaryngology – Head and Neck Surgery – and the many colleagues within their school programs who launched CBD mid-year. They have been blazing the trail and collecting advice on best practices along the way to share with the next cohort quickly coming up the path to launch in July 2018: Emergency Medicine, Forensic Pathology, Medical Oncology, Nephrology, Surgical Foundations and Urology.

We welcome many of you who are newly joining the CBD conversation with us as your specialty’s launch date draws nearer. In this issue, we have pulled together the most relevant and practical information for understanding the implications of CBD as you build readiness for the transition within your program.

Whether your specialty is waiting to start CBD implementation or if you are already underway in this ground-breaking collaborative undertaking, we want to ensure you are confidently equipped with the tools and support you need for success. Watch the videos below as a reminder that our combined efforts are preparing a new generation of residents in providing the best specialty medical care to patients in today’s evolving environment.

Best wishes for the exciting year ahead,

Andrew Padmos, BA, MD, FRCPC, FACP
Chief Executive Officer

Why CBD? MedEd Perspective.


Why CBD? Resident Perspective.


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Best CBD Resources of the Year

The best CBD resources of the year to help you understand and implement CBD.

Access these CBD faculty development resources developed by the Royal College, our partners and CBME Leads to support your program during CBD implementation.

Resource Slideshow

Resource Slideshow



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what is CBD

what is CBD pdf
Printable Poster (PDF)

What is CBD?

If you’re a program director or an advocate for Competence by Design (CBD), we hope you’ll take advantage of every opportunity to spread the word about the benefits of CBD. It is important to refine your message – it should be short enough that you could deliver it in an elevator ride.

People will be looking to you for guidance so we’d like to help you answer their questions with these main points:

  • CBD is the Royal College’s version of competency based medical education (CBME).
  • CBME is also being introduced around the world including in the United States, Europe and Australia.
  • CBD is a multi-year, transformational change initiative. It is the biggest change in 100 years of medical education.
  • It is complex and carried out with a variety of partners to support programs throughout the design and implementation process.
  • CBD is an evolution, not a revolution.
  • CBD applies to residency training and specialty practice in Canada but includes broader systems changes like accreditation and CPD.
  • CBD will enhance patient care by improving learning and assessment across the continuum from residency to retirement, provide better support to Fellows in lifelong learning
  • CBD is designed to ensure physicians have the evolving skills needed to meet the constantly evolving needs of patients.
  • CBD organizes training into stages and clearly lays out markers for teaching and learning at each stage.
  • Continuous low-stakes assessments will occur against these competencies.
  • These competencies will be measured by milestones and entrustable professional activities (EPAs).
  • Residents must now demonstrate competence in order to progress through their stages of training.
  • CBD promotes greater accountability, flexibility and learner centeredness – residents will play a greater and active role in their learning.
  • CBD is not likely to change residency timeframes.



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Guidelines to CBD Implementation

Understanding what happens and when as your specialty approaches its CBD launch date.

CBD has been organized so that small groups of specialties can launch CBD in a progression over time between 2017 and 2023. Each July 1st, a new group of specialties move from the traditional teaching method to CBD, according to the CBD Launch Schedule. The process for implementing CBD takes approximately two years to prepare for launch. Although there are many steps to transition a specialty program to CBD, the process is summarized below:


While your speciality is waiting to start the transition process to CBD, behind the scenes the Royal College is talking to your speciality committee and program directors to enlist champions from your school and set dates for your specialty’s CBD workshops, where your program director is guided in how to implement CBD. This is a good time to prepare by becoming familiar with the concepts and key messages of CBD using the following resources:

DESIGN: CBD Workshops 1 & 2

Approximately two years before your specialty is scheduled to launch CBD, program directors from one speciality are invited to attend three CBD workshops together at the Royal College in Ottawa. During Workshop 1 and 2, the program directors are building and testing a CBD program and resources for your specialty under the guidance and coaching of Clinician Educators. The program build includes:

  • Communication and change management process including building readiness for implementation
  • Program policy
  • Competence committees and curriculum maps
  • Specialty-specific EPAs and Milestones
  • Specialty Document Suite (specific to each discipline)
    1. Discipline Competencies
    2. Training Experiences
    3. Standards of Accreditation
  • Exam timing and format implications
  • Resident ePortfolio Review

Critical Success Factor
Program Directors need to communicate the planning information from the Workshops within their programs to test ideas, gather feedback and build readiness.


The last 12 months of the process are spent finalizing and approving all documentation and processes in both official languages. Local implementation becomes the focus with faculty development resources and communications within groups to ensure all stakeholders are aware of roles and requirements. Resident ePortfolio is loaded with your speciality-specific EPAs with early access for your team to operationalize the system. A "Go" meeting is held each spring a year prior to launch with the post-graduate deans from each school who collectively approve the discipline as ready for launch. This forum allows for programs to identify barriers to implementation and work collaboratively in the final year to provide support and offer solutions to ensure all schools within the discipline are prepared and comfortable with the targeted launch date.


As of July 1st, new residents starting training in the year of the CBD launch for their discipline will begin training under CBD. For residents who have started their residency training prior to the CBD launch year, some schools may opt to also train them under CBD, while some schools may opt to continue to train them in the traditional method, where there will be two training methods occurring simultaneously until the traditional system is phased out.

Although much time and care has been invested to ensure a smooth transition for all audiences involved, measures are in place to allow for trial and error, adjustments and revisions. It is important to note that perfection is far from expected at launch. During the transition year, programs will test, learn and adapt the program in a way that best suits their teams. Royal College support and evaluation systems will be in place to work collaboratively over time to ensure a successful adjustment period and implementation.

Workshop Outlines


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Pocket full of Change

Rhonda St. Croix

6 Tips To Leading Complex Change

It’s been 6 months since we celebrated the launch of CBD for our first two “pioneer” disciplines. And likely by now we are all experiencing the good, the bad and the ugly of implementing complex change. I’ve heard from residents some challenges and stresses of getting faculty to fill in feedback forms and the difficulty of receiving feedback that is unexpected. I’ve also heard from Program Directors the challenges being experienced about the number of EPAs, running an effective Competence Committee and the awkward reality of off-service rotations where there is low knowledge of CBD. I’ve also heard great stories of positive impact such as residents acknowledging that they are getting better feedback, they have clearer expectations for their training and that many more robust conversations are happening about learning. Inspiring stories are emerging of masterful change leaders who demonstrate the vision, passion and persistence to affect change in their programs while also building relationships and creating a receptive environment where everyone is contributing to CBD. Indeed we all can learn from these change leaders who are approaching hurdles with curiosity and a growth mindset, succeeding despite the challenges.

Implementing complex change can test our commitment and we can easily forget our common purpose to improve medical education so that it responds to the changing times and the changing needs of learners, patients and other stakeholders This might be the right time to lean into what a good change mindset looks like - we will need it to navigate the choppy waters ahead on our collective change journey.

  1. If we are not uncomfortable, we are probably not changing. The path to a new way of doing things rarely follows a straight line. Those of us who have done change know that it is messy and involves a “dip” that can feel like a threat and includes stress, disruption, fatigue, discomfort and setbacks. The journey to change usually takes longer than we’d like. It’s natural for there to be tension as people adapt to change and make it their own. Resilience is required to help people deal with the pressure, setbacks and the uncertainty. CBD leaders need to build their own resilience and guide others to navigate the changes sustainably with persistence and energy. Often, too much discomfort can indicate a need to focus in on the most important elements that will make the greatest positive difference.
  2. Embrace beginners mind and experimentation. Complex change is an adaptive challenge. This means our first iteration, including EPAs and other elements of our CBD design, is likely not the best. So do not hold onto them too tightly and be willing to quickly let go of what is not working effectively. Be curious and invest time in trying to identify the patterns that make a positive difference. Indeed after multiple iterations our ultimate design may not look at all as we predicted in particular as we adapt it necessarily to match local, unique contexts. The most important thing is that we are taking a step in the right direction.
  3. Be a rebel and not a troublemaker. Helen Bevan, at ICRE 2015, talked about effective change agents who are able “to rock the boat while staying in it”. Drawing on the work of Lois Kelly she distinguished between “rebels” and “troublemakers”. Rebels are adaptive leaders who seek to create innovation and positive change. They are committed to shared purpose and goals. They are driven by their passion, persistence and commitment to make things better. They are optimistic about the future, address challenges productively and see many possibilities for doing things in different ways. They generate energy for change which attracts others to unite with them and take the journey together. Troublemakers also challenge the status quo but not as effectively as rebels. They complain about the situation and tend to focus on their own personal perspective rather than achieving the greater mission. Troublemakers are often reactive and don’t have much confidence that things will get better in the future. They alienate other people and sap energy.
  4. Build relationships and mobilize others. Recent research suggests that the success of complex change requires mobilizing large numbers of people toward the vision of an improved future. Change needs to be led from within by “rebels” who can attract and connect more people to CBD by building relationships and creating an interconnected, distributed social network of change agents. This important relational work facilitates readiness for change while addressing the perspectives, priorities and needs of a large number of individuals and groups who have a stake in the change.
  5. Connect and reconnect with the shared purpose. A vital part of leading change is to frame and re-frame key themes that capture the attention of others – themes that resonate and that people care about will enable shared purpose, drive and passion. Data and intellectual appeals are necessary but not sufficient and we also need to share stories that generate emotional energy, provide important examples of what works and how to overcome challenges, build confidence in our ability to make change happen and mobilize people around what is possible.
  6. Build habits to create culture change. Organizational culture is just a collection of habits. So we don’t do CBD or do culture change. Instead everyone needs to ask “what is my role in changing the culture to align with CBD?” Change leaders need to facilitate everyone involved to identify and practice new behaviours and build new habits. This takes time, feels uncomfortable and we will need to draw on our experimental approach.

Implementing complex change is more art than science. There is no guarantee, certainty or fixed model. The real work is about making sense of a complex situation to identify the patterns that truly make a positive difference to affect change. It’s about leadership, building relationships, framing and reframing key themes, mobilizing others and being willing to start and adapt as we learn all while under pressure and discomfort. Despite the challenges of leading complex change this is a noble cause – there is no other way to improve medical education and to make our cultures and organizations better. It is meaningful and worthwhile work that matters. As change guru Peter Block said “the price of change is measured by our will and courage, our persistence, in the face of difficulty”. I know the medical education community is up for the challenge.


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Dr. Karen Raymer

The faces of CBD

Interview with
Dr. Karen Raymer

Residency Program Director
Department of Anesthesia
McMaster University

"CBD can set the conditions for residents to receive more useful, specific feedback."

"CBD can set the conditions for residents to receive more useful, specific feedback."

With Anesthesiology recently launched as the second discipline to implement CBD, we offer a glimpse into the first few months of the experience. In this edition, we talk to Residency Program Director Dr. Karen Raymer to discuss how implementation is going in the Department of Anesthesia at McMaster University.

Program directors are involved in every step of designing the new CBD program for their discipline, in addition to working with colleagues at their home faculties to prepare for implementation.

After only a few months with CBD in place, we asked Dr. Raymer to reflect on her learnings so far regarding implementation.

What do you see as the real advantage of CBD for the modern physician?

I see two advantages. The first is that we can ensure our residents are being intentionally trained and evaluated in the aspects of our specialty that are important – rather than leaving it to chance. Under the outgoing system we hope that a resident will be exposed to the clinical experience and skills that they need over time. But with CBD, we identify those skills and ensure they’re being both taught and evaluated. The second is that CBD can set the conditions for residents to receive more useful, specific feedback. The “human nature” barriers don’t magically disappear however; it’s important to coach faculty in how to give feedback, and learners in how to receive it.

Describe the role of the Program Director in implementing CBD.

It’s demanding to create and implement a new program while still running an existing one. You need to build a team of good people and you need to delegate. But the bigger thing is ensuring that the curriculum changes improve the educational experience of learners. For example, be cautious about how you use entrustable professional activities (EPAs), especially in the early phases of training. In Anesthesiology, we’ve decided to use the EPAs to complement, rather than replace, our traditional, global evaluation tool. EPAs are, by definition, tasks that can be done independently and therefore the Transition to Discipline EPAs for Anesthesia are quite limited in scope. We’re worried about new residents focusing exclusively on those four EPAs to the detriment of developing a more holistic understanding of the specialty.

What challenges did you encounter?

Managing data. There’s no problem gathering it and entering it into our system, but understanding that data in a meaningful way is challenging. We’re meeting with software developers to find a solution – to turn the trees into a forest. For example, we don’t have an inherent sense of what the benchmarks are for how many attempts a resident will need to achieve a given EPA; we can only compare them to others within their cohort. If a dashboard can present those resident and cohort numbers visually, we hope to build a sense of the expected trajectory.

Another challenge is the inherent labour intensiveness of the CBD curriculum. You need a CBD lead – I have the excellent Dr. Alena Skrinskas – a clinical competence committee, and an academic advisor for every resident. These are all new roles beyond the existing program roles. This challenge will grow each year as a new CBD cohort is added to the program.

Did you encounter any surprises?

The surprising thing to me is how similar the teaching and learning processes are under CBD. It’s easy to get caught up in all these radical changes but, fundamentally, how people teach and learn is no different than before. I’ve also been surprised at how committed and cooperative everyone has been. Faculty is resolved to get this done, which has lent a lot of support to our work. We’ve had good collegiality and camaraderie, and minimal grumbling.

What is important to keep in mind about the CBD implementation process?

Design and implement one phase at a time rather than trying to design the entire program at once. We keep just one phase ahead of the first CBD cohort, which means we have the agility to respond and adjust. For example, when we were mapping EPAs to rotations, we had to decide whether to take a minimalist approach or be more inclusive, allowing for every possible learning opportunity for the residents. With feedback, we got the sense that a long list of EPAs is overwhelming. By working iteratively, we avoid having to re-do work as we learn our lessons.

If you could tell a program director in another medical specialty one thing about preparing to implement CBD, what would that be?

Get good help and remember that you’re an expert team with decades of collective experience in how to teach and evaluate learners. Use that experience to make careful decisions about implementation. Development of your frontline faculty is key, but don’t overwhelm them with complexity; keep it as simple as possible. Also, ask your Chair to remunerate the CBD team well, and recognize their time and energy.


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L’application du portfolio électronique des résidents est maintenant offerte sur iTunes

faces of CBD

Resident ePortfolio App Now Available on iTunes

We are pleased to announce the release of our Resident ePortfolio iOS app.

Download the app or search for “Royal College Res ePortfolio” to find it in the Apple App Store.

Resident ePortfolio enables real-time assessments and collaboration between the Preceptors/Observers and Residents.

Following are some of the features of the app:

  • A Resident can view their Program Learning Plan (PLP).
  • A Resident can request observations from Observers.
  • An Observer can review their pending observation requests and accept or decline them.
  • An Observer can complete and submit observations and also attach evidence to these observations.
  • An Observer can also add narratives.
  • The app also has offline capabilities, so an Observer can record and save an observation while offline that automatically uploads to the system when the device is back online.

The mobile app is an extension of the Resident ePortfolio system and only has a subset of the roles and functions within the app to facilitate Observer and Resident interactions. We would also like to remind our users that the Resident ePortfolio website has a mobile responsive design and you can also access the regular site that can be accessed via your cellphone browser and will automatically align for the smaller screen sizes.


The CBD Community Touchpoint e-newsletter informs the medical community about issues, developments and activities that are related to CBD implementation across Canada.