Learning Curve Basis of CBME: The Early Phases of Learning

Admin note: This blog is Part 2 in a series! See the first post here and scroll to the end of this post for the upcoming topics.


By: Martin Pusic (@mpusic) and Kathy Boutis (@ImageSim)

The Latent Phase of the Learning Curve

In some learning situations, the learning curve begins in a spectacularly flat fashion. At least in the terms of the y-axis competency metric, no learning appears to be happening. However, invisible to the y-axis metric, a great deal of learning is actually happening. This latent phase is seen when considerable foundational and/or procedural knowledge is required before one can even register on a performance metric.  

Figure 1: Prototypical Learning Curve – Latent Phase

A prototypical learning curve demonstrating how learning effort is related to improved learning outcomes.   The latent phase, where the learner appears to be making no progress, can be an important organizing phase where good structures are repaid downstream with improved outcomes.   

An example would be the anatomy knowledge base required of a beginning radiologist. Or their ability to turn on a radiology workstation, register for a computer password, learn that hospital’s reporting system etc. In some situations, it is best to get through the latent phase as quickly as possible, or at least certain aspects of it. However, in many respects this may be the most important part of the learning curve, the point at which foundational habits are established. The mastery of anatomy will be a life-long pursuit for a radiologist, but an ingrained bias towards deep, mechanistic understanding of anatomy will be repaid in the future many times over through an increase in the adaptability of that person’s expertise (Pusic et al 20191). Slowing down or prolonging (right-sizing) the latent phase in order to inculcate good habits can be thought of like compound interest: slow to start but explosive in the long run.  The “Transition to Discipline” Stage of the Royal College of Physicians and Surgeons of Canada Competency By Design framework is a good example of intentional design to advantage future learning.

Figure 2: Learning Curve Latent Phase

Compound Interest Metaphor for how good early learning begets later accelerated learning.

Of particular relevance to CBME in this early latent phase is learning how to learn. This is the notion of Preparation for Future Learning in which early learning in a domain is partly devoted to learning the subject matter while part is devoted to the mechanics of downstream (later) learning (Mylopoulos et al 20162). For example, the radiology resident described earlier can learn foundational anatomy in the early stages AND they can learn how look up anatomy knowledge in future cases where they have the need. Another good example is learning the skills of Evidence Based Practice and Critical Appraisal of Research Literature. Learning these general skills displaces specific radiology learning (why do I need to know what an Odds Ratio is?) and yet will be repaid many times over when personal development depends on extracting knowledge from the research literature.

Figure 3 – Preparation for Future Learning

In summary, the latent phase of the learning curve is a general phenomenon in the non-linear path to learning.  It can mark a transition to the learning to come, in terms of the desired knowledge, skill or attitude. The opportunity lies in the downstream potential of what is laid down at this early stage. Careful attention to not only the immediate subject matter, but also to how the individual will augment and adapt their knowledge and skill base in the future will be repaid many times over. 

Previous Blog Posts in this Series:
Part 1: OvertureClick here to read

Future Blog Posts in this Series:
Part 3: The nonlinearity of learning Now available Click here to read!
Part 4: Standard setting and the learning curveNow availableClick here to read!
Part 5: Inter-Individual variability of learning curves (coming Dec 15)
Part 6: Summary (coming Dec 22)

About the authors:
Martin Pusic MD PhD is Associate Professor of Pediatrics and Emergency Medicine at Harvard Medical School, Senior Associate Faculty at Boston Children’s Hospital and Scholar-In-Residence at the Brigham Education Institute. 
Kathy Boutis MD FRCPC MSc is Staff Emergency Physician, Senior Associate Scientist, Research Institute at The Hospital for Sick Children and Professor of Pediatrics at the University of Toronto.


1. Pusic M, W Cutrer, SA Santen. How does Master Adaptive Learning advance expertise development? Chapter 2, pp 10-17. In: Cutrer W, Pusic MV, eds. The Master Adaptive Learner, Amsterdam, NL. Elsevier Publishing Group. Nov 2019. Available online at https://bit.ly/3Dugc5k

2. Mylopoulos M, R Brydges, NN Woods, J Manzone & DL Schwartz. Preparation for future learning: a missing competency in health professions education? Medical education. 2016; 50(1): 115-123.

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