Implementing CBME: Reflections of a Former Program Director, over coffee.

By: Adelle Atkinson (@AtkinsonAdelle)

For 15 years, it has been the privilege of my career to have had the opportunity to be the Program Director for a large Paediatric Training Program.  When I recently stepped away, I was asked what I loved about the role, and I found it hard to put into words.  There is so much.  But what really stands out for me, upon reflection, are the relationships, especially with learners, as they embark upon their journey, whatever that might look like.  The opportunity to mentor, guide, support and celebrate their ultimate successes.

Program Directors, by necessity, need to be great problem solvers (often in real time!) and change implementers, and implementing CBME into our program, was for me, the biggest change management initiative I had ever faced.  And……..I learned a lot.  Being “in the weeds” with CBME implementation locally and nationally, has helped me to think differently about what supporting our learners in their journey looks like.

Let me start by saying, that I believe in CBME and the benefits for patients and our learners.  The opportunity to think about what competence looks like in one’s discipline and design a developmental program of learning around those competencies (that can be individualized), using Entrustable Professional Activities and Milestones as a framework, mapped to Training Experiences, with a comprehensive program of assessment that is intentional, robust and includes Work-Placed Based Assessment is the kind of design that every medical educator dreams of.  As is producing competent specialists, who can provide comprehensive care to our diverse patient population.  But…….now we have to implement the design into our programs.

A chat over coffee (or tea)

There are so many moving parts to CBME and approaches we know are important to successful implementation.  Here are a few things (3 in fact), about which I found I needed to start thinking differently, that I would both highlight and share/discuss with someone embarking on this journey, over coffee (coffee on me), that may ultimately be helpful in designing their implementation strategy.  Lessons learned if you will.

Faculty Development

Faculty Development has always been an integral part of any implementation strategy for CBME, and I would argue that it may in fact be the key to success of CBME implementation.  There are different levels and types of Faculty Development; for hospital/departmental leadership, educators and frontline faculty, as examples.  We need to ensure that everyone understands the goals of CBME, what it will look like, how it is different from what we have been doing and we need to introduce new concepts and vocabulary.  But here is what I have learned: We need to work really hard to engage our faculty in this journey.  It is not enough to just attend a session and understand what we are trying to do, we need them to buy in and partner with us.  We need them to embrace the concepts and be active participants in the process, especially in the context of Workplace-Based Assessment where they will provide invaluable feedback and coaching to help our learners develop and ultimately achieve competence.  We need our faculty to partner with the residents in creating opportunities for feedback and coaching, it needs to come from both sides.  This will take time to cultivate, but is important, as when it is largely coming from the learners alone, there are some unintended consequences such as assessment fatigue, being selective about assessors and anxiety.  We need to mitigate these issues through intentional and ongoing Faculty Development strategies, such as:

  • Telling stories – real examples of where CBME worked in the program, make it relevant for them
  • Friendly competition – letting them know how they are doing with respect to CBME expectations, as compared to a larger group of faculty
  • Encouraging them to stimulate the coaching/feedback conversation through discussing why it should not always be initiated by the resident – they are the content experts
  • Frequent check-ins to hear about and act on their feedback about the process
  • Make the process simple for them – eg. A QR code they can scan to get right to the information they need such as EPAs or the assessment platform
  • Nurturing a growth mindset

Resident Development

Like Faculty, preparing residents through an intentional Resident Development program, is paramount to successful implementation. A logical place to start, is when residents start the program, to have a devoted session for them, centred around what CBME is, what are the advantages for our patients and for their learning, what the program looks like for them, and what their responsibilities are, in detail, with respect to actively engaging in the process.  But here is what I have learned, this isn’t nearly enough.  Sure, it all makes sense to them in theory in that moment, but they don’t have any practical experiences in which to anchor the information.  And of course, orientation is a busy time with information overload, while they are trying to figure out where to get their ID badges and where the call rooms are!

So, while they do need this initial orientation session, they then need intentional ongoing Resident Development, which may include:

  • nurturing a growth mindset
  • regular, frequent check-ins to see how things are progressing and a chance to identify issues/questions that can be answered in real time – especially early on
  • frequent reminders as to how they are doing with respect to expectations, while there is still time to “catch up” if they are behind
  • tips and tricks as to where they might find high yield experiences relevant to the competencies
  • tips and tricks around partnering with faculty, and highlighting to the faculty what they need
  • ensuring transparency in the process – “not about them, without them”.  They need to be fully aware of the processes that surround them to support their progression

Fostering a Growth Mindset

Fostering a Growth Mindset in our learners is currently a frequent topic of conversation in medical education.  It is certainly integral to the success of CBME as it pertains to the learner embracing the feedback and coaching process, and being intentional, with mentorship, about their learning trajectory and growth.  But it isn’t enough to nurture this only in our learners, we as leaders must role model a Growth Mindset, as must our competence committees, as must our hospital/departmental leadership and our systems.  Only then, will the benefits of a growth mindset, and allowing oneself to be vulnerable, be successful in our context. (Sawatsky et. al)

So, now coffee time is over – at least for now – but the journey of learning how to successfully implement CBME will continue. It is paramount that we execute CBME with fidelity while ensuring that it adds value to our medical education systems, most importantly for our learners and our patients.

About the author: Adelle R. Atkinson, MD, FRCPC, is a Professor of Paedaitrics at the University of Toronto, and Associate Chair – Education in the Department of Paediatrics.  She is a Clinician Educator at the Royal College of Physicians and Surgeons of Canada.


Sawatsky AP, Huffman BM, Hafferty FW (2020) Coaching versus competency to facilitate professional identity formation. Acad Med. 95:1511–1514.

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