Understanding Competency Based Education
Lessons from an unlikely source

I was recently asked to speak at a conference on the topic of Competency Based Education.  My assignment was to provide definitions of that topic and to discuss the advantages and challenges associated with developing such an approach in an undergraduate medical program.

graph-nov12My search for a universally accepted definition of CBE began with a call to Theresa Suart, Educational Developer, who promptly alerted me to the reality that no such thing exists and, in fact, I had stumbled into an area of considerable controversy.  She directed me to helpful references, including a 2010 paper by Jason Frank and colleagues (Medical Teacher 32; 631-637) that is actually a systematic review of published definitions!  They reviewed a total of no fewer than 173 published definitions and, as illustrated in this table from their paper, the topic has been attracting increasing interest in recent years.  All this leads me to doubt the practical utility or relevance of a topic that so many bright people have difficulty even defining.  However, one becomes accustomed to such dilemmas when venturing into the world of medical education, and begins to view such uncertainties as opportunities to re-examine basic principles and search for patterns or examples of prior success that may be applicable.

Screen Shot 2013-11-11 at 2.36.58 PMThe principle I always find useful in assessing educational change is the fundamental triad of associations between Objectives, Learning and Assessment.  One of my first practical lessons in curricular design (and accreditation standards) is that these three components must be closely linked if any medical curriculum is to be effective.  Objectives must drive instruction and learning, and assessment must be linked to the teaching provided and the stated objectives.


With this in mind, I searched for a simple example that might help advance our understanding of Competency Based Education.  A conversation with one of my nieces who’d recently completed her Driver’s Education course provided that example.  The granting of a Driver’s License is, in fact, recognition of a competence for which there exists an easily understood and widely accepted global objective, specifically the ability to safely operate an automobile.  That global objective requires a body of knowledge, skills and personal CanDriveattributes which, with apologies to the Royal College and with tongue firmly in cheek, could be expressed as the CanDRIVE competency domains, which centre around a body of knowledge and understanding (the Driving Expert) but require additional attributes, such as (we might conjecture) Judgement, fundamental Literacy, physical Coordination, Social Accountability, Alertness (no cell phones) and Sobriety.  The knowledge component is completely and clearly articulated by the Ministry of Transportation in the Driver’s Manual, and the assessment of competencies is demonstrated in three parts, a written examination with questions taken directly from the manual, a cursory visual assessment involving recognition of traffic signs, and a performance based driving test during which the candidate must demonstrate the global objective (drive the car) while exhibiting the component competency domains (show up sober, pay attention, etc…).

And so, two parts of the educational triad are provided.  The true brilliance of the Ministry of Transportation however, is in how they handle the teaching/learning component.  Fundamentally, they don’t.  Learning is the responsibility of the applicant.  That learning is guided, to be sure, by both implied and explicit expectations, but the candidate is expected to seek out their own education, at their own expense, carried out at their own schedule.  There is absolute clarity, however, of the ultimate goals and no mystery about the eventual summative evaluation (answer the questions, read the eye chart, drive the car).

Screen Shot 2013-11-11 at 9.39.27 AMThus, the Ministry of Transportation has (whether intentionally or not) developed a masterful model of Competency Based Education that:

  • Is based on objectives that are clearly understood by learners and assessors alike.
  • Built on a knowledge base that is discrete, well-described and accessible by all.
  • Requires a set of personal attributes that are understood by all and accepted as relevant to mastery of the competency
  • Does not attempt to assess those attributes individually, but rather evaluates the overall competency in a blended, performance based method, the format (and content) of which is completely understood and open to everyone involved.
  • is truly Learner centred

But, you’ll note, there’s obviously a world of difference between driving a car and practicing Medicine.  Indeed there is.  However, the ability to assess and manage a patient presenting with a particular clinical presentation is, like driving a car, a competency set that requires a combination of knowledge, skills, personal attributes (a set of objectives), that must be learned and must be reliably evaluated.  What can we learn from our simple example that’s relevant to any attempt to develop a Competency Based Medical Education program?

  1. The learning objectives must be developed and expressed in meaningful, pragmatic terms.  Competency to do what?  What specific things should the “competent” learner be able to do?  In this regard, the emerging development of Entrustable Professional Activities will no doubt play a major role.
  2. The assessment should be performance-based and relate clearly and directly to those objectives.  There should be no mystery as to what will be expected, and the method of evaluation must be pre-defined and understood by all.
  3. Learning is primarily driven by the learner, not an inflexible curriculum, nor should it be based on any particular schedule.
  4. The responsibility of the program (or institution) should be to provide clarity regarding learning goals, an environment in which learning can occur, and support for the learning process.

Finally, I provide the reader with the best definition of CBE that I’ve encountered to date, which emerged from the previously mentioned article by Frank and colleagues.  It not only expresses these principles succinctly, but does so in a manner applicable to either driving a car or caring for a trauma patient, perhaps the best test of any definition attempting to capture such a complex combination of knowledge, skills and personal attributes.

 Screen Shot 2013-11-11 at 2.40.05 PM

Thanks to Theresa Suart (Educational Developer) and Lynel Jackson (master graphic designer) for their assistance in the development of this article. 

3 Responses to Understanding Competency Based Education
Lessons from an unlikely source

  1. David Walker says:

    Brilliant Tony!

  2. Richard van Wylick says:

    Tony, excellent blog as usual. As food for thought, one might say that medical education has become more like learning to pilot WWII bombers rather than drive cars. The typical Lancaster had a crew (a team in our world) of 7: pilot, flight engineer, navigator, bomb aimer/nose gunner, wireless operator, mid-upper and rear gunners. It was recognized, of course, that the pilot should stay focussed on flying the aircraft and ensuring its well-being and that tasks needed to be shared. I am certain there was some “cross-training” but each person had a well-defined role in the team and relied on each other. Perhaps we should take lessons from that: focus on teaching core medical knowledge in medical school and specialize the roles and functions (including, dare I say, many of the CanMeds roles) thereafter into some (and I don’t just mean doctors) specifically trained in the area.

    • Thanks Richard. An apt extension of the analogy. It also highlights the need for a pilot who, although not as expert in all components of the operation, has to keep their focus on the ultimate destination, be on the look-out for obstacles along the way and ensure safe arrival of all crew members.

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