Competency-Based Medical Education (CBME) is a model of “fixed standards and flexible paths” that aims to train professionals with acceptable levels of preparedness to meet healthcare needs1. The implementation of the CBME in Brazil can be described according to the five Core Components Framework for Evaluating Implementation of CBME (CCF)2, which includes outcome, sequenced progression, tailored learning experiences, competency-focused instruction, and programmatic assessment.
For the last hundred years, medical training in Brazil was inspired by the Flexnerian model and PG training by Halsted’s model (3). PG training programs are regulated by the National Commission for Medical Residency (NCMR) and subsidized by the Ministry of Education. The average PG training program lasts three to five years, depending on the medical specialty.
In 2014, the first component of CCF started with the National Curriculum Guidelines for Undergraduate Medical Education (NCGUME-2014), which included three significant domains of competence: Health Care, Health Management, and Health Education3. For PG training, between 2019 and 2021, the NCMR approved the Competency Frameworks for 55 medical specialties and 59 subspecialties.
The second component, which corresponds to the progressive sequencing of competencies, has not yet been properly structured. In Brazil, most teachers, students, and stakeholders are not familiar with the concept of EPAs. In the NCGUME-2014, progressive levels of complexity were not established for the acquisition of competencies, and there is no clear description of the activities for which undergraduate medical doctors must be prepared. Recently, the need to review and update the NCGUME-2014 has been discussed. For PG training, most medical specialties have not yet defined the EPAs. Recently, the Brazilian Federation of Gynecology and Obstetrics developed and validated EPAs for PG training in OBGyn, a work involving more than 250 experts representing all Brazilian regions and has served as a model for developing EPAs in other medical specialties4.
Implementing the third component (learning experiences tailored to competencies in CBME) presents the most significant difficulties in Brazil. In undergraduate and PG training, the clinical settings are structured by the care routines of the health system, with little flexibility to meet individual training needs. In addition, in many Brazilian regions, healthcare depends on the PG trainees’ workforce, with an overload of work and little time devoted to supervision and individual feedback. Most medical schools and PG training programs do not have well-structured mentoring programs. Some barriers are being overcome by faculty development programs (FDP), which leads to more involvement of these professionals with the needs of the CBME.
Regarding the fourth component, teaching tailored to competencies, we expect it to develop as EPAs are defined for medical degrees and specialties.
More significant changes will be necessary to implement the fifth component, programmatic assessment. It will include the use of portfolio, formative assessment, and workplace-based assessment in undergraduate medical education and PG training programs. We believe achieving these objectives will require technology, financial resources, and a well-structured FDP focused on the CBME framework.
We have been very encouraged by the reception of schools, faculties, and students, making the foundations for the future implementation of the CBME in Brazil. It is a big challenge, but new doors are opening every day…
About the author: Gustavo Salata Romão is a professor at UNAERP Universidade de Ribeirão Preto in Brazil and PRESIDENT OF FEBRASGO‘S MEDICAL RESIDENCY COMMITTEE.
1. Cooke M, DM Irby and BC O’Brien. Educating physicians: a call for reform of medical school and residency (Vol. 16). 2010. John Wiley & Sons.
2. van Melle E, JR Frank, ES Holmboe et al. A core components framework for evaluating implementation of competency-based medical education programs. Acad Med. 2019;94(7): 1002 – 09.
3. Antunes Dos Santos R., & MDPT Nunes. Medical education in Brazil. Medical Teacher. 2019;41(10): 1106-1111.
4. Romão GS. The Role of Entrustable Professionals Activities in the Training of Specialists in Gynecology and Obstetrics. Revista Brasileira de Ginecologia e Obstetrícia/RBGO Gynecology and Obstetrics. 2022;44(09): 819-820.
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