Competencies, the tea bag model, and the end of time

Talk of tea bags and of competencies is much in the air these days, at least among medical educators. If epithets such as the ‘‘tea bag model of medical education’’ reflect dissatisfaction with approaches that emphasize how much time learners spend immersed in a certain context, as opposed to what they actually learn there, they also speak to one of the most pressing issues in medical education today: How do we ensure that all of our graduates are competent? To address this challenge, many jurisdictions around the globe have adopted ‘‘competency frameworks’’ for medical education. The resultant movement from structure- and process-based models to an outcomes-based approach has, in turn, given rise to jargon, controversy, and debate. Some have spoken out against the emerging paradigm of competency-based medical education (CBME), deploring ‘‘the tyranny of competency’’ (Brooks 2009) and emphasizing what they view as the inherent constraints and conflicts of a competency-based approach (Reeves et al. 2009). Medical Teacher has devoted this issue to the discourse around CBME and its implications for all of us who are engaged in educating health professionals. The papers in this theme issue have been authored by the International CBME Collaborators, 1 a unique partnership of interested scholars, practitioners, educators, curriculum planners, and teachers from four continents who came together in mid-2009 to consider the concepts and controversies in this widely debated topic. Although the published discourse on medical education stretches back to the early 20th century, CBME is experiencing a resurgence of sorts. In this issue, a series of papers explores different aspects of CBME from varied perspectives. In a systematic review of the literature Frank and colleagues review published definitions, identify common themes, and propose a definition to stimulate dialogue. The introductory theory-topractice paper (Frank & Snell) describes the results of an international collaboration that identified controversies, proposed consensus definitions of key terms, described the benefits and challenges of competency-based approaches, and explored future directions. These concepts are applied across the continuum of medical education in papers describing implementation, challenges, and approaches at the level of undergraduate education (Harris et al.), postgraduate training (Iobst et al.), and practice, where CBME may foster a progression from competence to excellence (Campbell et al.). Theoretical background from the learning sciences is provided by Swing to form a foundation for further thought, and a paper by ten Cate and colleagues introduces the concept of ‘‘entrustable professional activities’’ and explores the idea of ‘‘competencies in context. ’’ No issue describing a new curricular paradigm would be complete without giving attention to assessment and faculty development. Holmboe and co-authors address issues surrounding assessment, emphasizing the need for robust and multi-faceted assessment systems and evaluation methods. A paper on faculty development by Dath and Iobst describes the challenges of ensuring that faculty understand the concepts of CBME and are comfortable teaching in this context, and suggests solutions at the level of the medical teacher and of the institution. Finally, a paper on policy by Taber and co-authors acknowledges that CBME is not solely a curriculum model that will be used by educators, but will have an impact on and be shaped by the institutions and systems where it is implemented.