Competency-based medical education: Its time has arrived

In 2015, the Royal College of Physicians and Surgeons of Canada launched ‘‘Competence By Design’’ (CBD), a multi-year initiative designed to transform residency training in Canada using the principles of competencybased medical education (CBME). Departments of anesthesia in Canadian universities will be implementing a CBD curriculum with the cohort of new residents starting in July 2017. As described in this issue of the Journal, the Department of Anesthesiology at the University of Ottawa enrolled its first cohort of residents into an innovative competency-based program in July 2015. Many department chairs, clinicians, funding agencies, and other stakeholders may ask why we should change the way we’ve been training physicians for the past 100 years. They well recognize that we already turn out the most highly educated physicians in history and would be hard pressed to show that most are not competent. Are we currently educating residents in the most effective and efficient way possible to ensure they are prepared for certification, transition to practice, ongoing maintenance of certification, and development of advanced expertise? All stakeholders, including patients, hospital administrators, and governments, are increasingly demanding greater accountability and assurance that residents are trained in the most cost-effective manner, that specialists graduate with all the abilities required for independent practice, and that they continuously and transparently maintain and improve their performance. In our existing system, many trainees feel inadequately prepared for independent practice on graduation from residency. This is despite the fact that our training programs are perceived as very high standard and there is a high overall pass rate at the Royal College certification examinations. One of the guiding principles of CBME is to develop a program designed for graduates to achieve certain predefined outcomes —i.e., the competencies to practice safely and independently. The CBME methods and assessment tools are selected or developed to achieve these outcomes. Most jurisdictions have introduced some form of restricted duty hours, resulting in a significant reduction in time available for residency training, particularly for acquisition of clinical experience. It is therefore imperative that we rethink the way we currently train residents to ensure the training is more focused, effective, efficient, and cost-effective. Despite the reduction in total training time, the majority of residents still successfully complete residency and achieve specialty certification within the prescribed period. Does this signify that each graduate is ready for safe independent practice or that there are current limitations in measuring performance in a valid and reliable way? The inability of programs to identify underperforming residents, particularly early in training, may be compounded by the well-recognized concept of the ‘‘failure to fail’’. Dudeck et al. identified lack of documentation and ‘‘a lack of knowledge of what to specifically document’’ as two significant barriers to reporting a failing undergraduate student. Currently, residents are most commonly evaluated using poorly defined non-standardized metrics. In a CBME system, evaluators will need to use formative assessments based on M. F. Levine, MBBCh (&) Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, The University of Toronto, Toronto, ON, Canada e-mail: mark.levine@utoronto.ca