By: Shelley Ross (@S_RossUofA)
Over the past decade, competency-based medical education (CBME) has become the prevalent approach to medical education on a global basis. CBME is perhaps the most prominent keyword for articles in health professions education journals over the last few years (I say “perhaps” because I have not actually done that study), with new publications appearing every week. Navigating the CBME literature can be enhanced by having an understanding of the history of CBME – when making sense of such a prolific and diverse literature, it helps to know what came before.
A recently published BEME Guide by Hamza and colleagues1 can be a great resource for both those who are new to CBME and those who are already well-versed in multiple aspects. Based on the analysis of 387 articles identified through a scoping review, the Guide offers a historic overview, by decade, of literary conversations about CBME. This comprehensive summary of the shifting perceptions of CBME over time gives context and insight into the advantages, disadvantages, and challenges of CBME that scholars have been publishing (and talking) about since McGaghie and colleagues initially proposed adopting a competency-based approach to medical education in 19782.
While it seems that new findings, new perspectives, and new considerations of CBME appear in the literature regularly, it could be argued that much of what is being published mirrors decades-old discussions and research about CBME. Since 1978, certain themes have appeared regularly in the CBME literature. Some of those themes, such as assessment, educational developments (e.g., curriculum and/or adaptation), and the credibility of the evidence base for CBME, have been prevalent topics of literary discussion since the 1970s and continue to be dominant today. Other themes, such as the impacts of CBME on learners, institutions, and society, did not become prominent until the last decade.
Where knowledge of the historic conversations in the CBME literature becomes most valuable, however, is in interpreting the growing critiques of CBME. From 1978 to 2000, discussions of the perceived advantages of CBME were more than double the number of discussions of perceived disadvantages. The discussions of perceived disadvantages of CBME tended to be concentrated under a few themes (credibility and educational developments). By 2010, that trend had reversed, with discussions of the perceived disadvantages of CBME not only noticeably outnumbering discussions of perceived advantages, but also appearing across all themes.
The criticisms and concerns about CBME have been surprisingly consistent over the decades. Very similar challenges to assumptions about, and definitions of, both competence and competencies were expressed by Pollock in 19813, Norman and colleagues in 20144, and by Brydges and colleagues in 20215. Similarly, literary discussions about the potentially negative impact of CBME on teachers and organizations, particularly the challenges associated with aspects of change management, covered similar ground in the 1970s and 1980s as can be seen in articles from the last five years. This consistency over the decades in criticisms of CBME highlights an important point: there is still work to do. This is particularly important given the growing backlash against CBME seen in institutions and in the literature: CBME was abandoned in health professions education in the 1980s for the same problematic aspects that are currently being discussed. As CBME researchers and teachers, we need to engage with the literary conversations about the concerns and critiques of CBME and seek to find workable solutions.
In highlighting the similarities and recurrent themes in the CBME literature over the decades, my intention is not to imply or suggest that there is needless repetition, or that the impressive array of new research about CBME around historically consistent themes lacks value – quite the opposite. The proliferation of CBME research findings, commentaries, and perspectives published in the last decade have expanded our knowledge of what CBME can (and cannot) contribute to best practices in training health professionals across multiple disciples and fields. There is enormous value in the application of established theories of learning and assessment to understanding and furthering innovations and ideas for and about CBME.
In approaching current literary conversations armed with the knowledge of historical shifts in perceptions of the value of CBME, we can identify where there is still work to do. It cannot be denied that there are also emergent literary conversations that are worth pursuing – McGaghie could never have imagined the stunning possibilities (and dangers?) that are now being explored due to advances in technology, computing, and machine learning. However, there are also questions that remain unanswered or that have been underexamined over the decades. We need to pay attention to those conversations, especially the ones that pose legitimate critiques of CBME. Otherwise, the current reign of CBME as the dominant approach to health professions education is in danger of suffering the same fate as the CBME movement of the early 1980s.
In other words, to quote George Santayana, “Those who cannot remember the past are condemned to repeat it”6.
About the author: Shelley Ross, PhD, is President of the Canadian Association for Medical EducatioN, as well as Academic Director, Teaching and Learning Strategic Planning Initiatives, at the University of Alberta’s Faculty of Medicine and Dentistry.
References:
1.Hamza DM, KE Hauer, A Oswald, E van Melle, Z Ladake, I Zuna, MK Assefa, GN Pelletier, M Sebastianski, D Keto-Lambert, S Ross. Making sense of competency-based medical education (CBME) literary conversations: A BEME scoping review: BEME Guide No. 78. Medical Teacher 2023. Online ahead of print January
2. McGaghie WC, GE Miller, AW Sajid, TV Telder. Competency-based curriculum development on medical education: an introduction. Public Health Pap. 1978;(68):11-91.
3. Pollock MB. Speaking of competencies. Health Education. 1981;12(1):9-13.
4. Norman G, J Norcini, G Bordage. Competency-based education: milestones or millstones? Journal of graduate medical education. 2014 Mar;6(1):1-6.
5. Brydges R, Boyd VA, Tavares W, Ginsburg S, Kuper A, Anderson M, Stroud L. Assumptions about competency-based medical education and the state of the underlying evidence: a critical narrative review. Academic Medicine. 2021;96(2):296-306.
6. Santayana G. The Life of Reason, Or, The Phases of Human Progress: Reason in art. C. Scribner’s sons; 1905.
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