Understanding Competency-Based Medical Education

Editor’s Note: This post is the first of two on the topic of competency-based medical education. Check back next week to read more on this topic.

By: Robert Englander, MD, MPH, Terri Cameron, MA, Amy Addams, Jan Bull, MP, and Joshua Jacobs, MD

Dr. Englander is the former senior director of competency-based learning and assessment at the Association of American Medical Colleges (AAMC). Ms. Cameron is director of curriculum programs at the AAMC. Ms. Addams is director of competency-based admissions at the AAMC. Ms. Bull is lead specialist in competency-based learning and assessment at the AAMC. Dr. Jacobs is senior director of electronic portfolios at the AAMC.

Medical education is in the middle of a paradigm shift across the continuum from premedical studies through practice to competency-based medical education (CBME). [1] The shift from the old style of medical education, referred to as “Structure/Process” education, originally outlined by Abraham Flexner in 1910, [2] to a competency-based system of education requires four components: (1) identifying the outcomes; (2) defining performance levels for each competency; (3) developing a framework for assessing competencies; and (4) continuous evaluation of the CBME program to see if it is indeed producing the desired outcomes—in this case, competent physicians. [1] In this blog post, we will describe the current state of the first two steps—identifying the outcomes and defining performance levels. In a follow-up blog post, we will elucidate one potential framework for assessment—entrustable professional activities.

Step 1 to Shifting the Paradigm: Identifying the Outcomes

The implementation of CBME requires an organized and structured set of interrelated competencies known as a competency framework. Examples of common frameworks are the Accreditation Council for Graduate Medical Education (ACGME)/American Board of Medical Specialties (ABMS) Outcomes Project [3] and the CanMEDs roles. [4] Each competency framework starts with broad distinguishable areas of competence that, in the aggregate, define the desired outcomes for a physician. These broad areas are called domains of competence within the ACGME/ABMS framework and roles within the CanMEDS framework.

Using the ACGME/ABMS framework as a reference, the AAMC synthesized more than 150 competency lists for health professionals and developed a defining list of competencies for physicians. This resulted in 58 competencies in 8 domains called “The Physician Competency Reference Set”(PCRS). [5] These competencies define the desired outcomes across the continuum of education, training, and practice. See below for the Domains of Competence in the PCRS and for an example of the competencies within the domain of systems-based practice.

Domains of Competence (DoC) in the Physician Competency Reference Set (PCRS)

  1. Patient Care (PC)
  2. Knowledge for Practice (KP)
  3. Practice-based Learning and Improvement (PBLI)
  4. Interpersonal and Communication Skills (ICS)
  5. Professionalism (Prof)
  6. Systems-based Practice (SBP)
  7. Interprofessional Collaboration (IPC)
  8. Personal and Professional Development (PPD)

Example of the Competencies in the Domain of Systems-Based Practice

  • Work effectively in various health care delivery settings and systems relevant to one’s clinical specialty
  • Coordinate patient care within the health care system relevant to one’s clinical specialty
  • Incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care
  • Advocate for quality patient care and optimal patient care systems
  • Participate in identifying system errors and implementing potential systems solutions
  • Perform administrative and practice management responsibilities commensurate with one’s role, abilities, and qualifications

Step 2 to Shifting the Paradigm: Defining Performance Levels for the Competencies (Milestones)

In the United States, reporting progress towards achieving desired competencies uses the language of milestones. Milestones are markers of achievement of levels of performance in a developmental continuum. These markers have been defined for performance in graduate medical education (GME) by each specialty. [6] For the purposes of developing undergraduate medical education (UME) milestones, the AAMC defined two performance levels, corresponding to novice performance and the performance expected of a graduating MD. In GME, as a result of the ACGME Milestones Project, each of the specialties generally defined five milestones for each competency, with the first designed to describe the entering resident and the last to define either the resident graduate or a practicing physician (called an “aspirational milestone”). Milestones in GME are thus behavioral descriptions of performance roughly corresponding to a novice, advanced beginner, competent individual, proficient individual, and expert physician. The performance levels for practicing physicians have not been defined for most specialties.

The relationship between domains of competence (DoC), competencies (C), and milestones (M) are depicted in the figure below.



Competency framework: An organized and structured representation of a set of interrelated and purposeful competency objects.

Competency-based medical education: An outcomes-based approach to the design, implementation, assessment of learners, and the evaluation of medical education programs, using an organizing framework of competencies. [2]

Domains of competence: Broad distinguishable areas of competence that, in the aggregate, constitute a general descriptive framework for a profession. [5]

Competency: An observable ability of a health professional, integrating multiple components such as knowledge, skills, values, and attitudes. Since competencies are observable, they can be measured and assessed to ensure their acquisition.[2]

Milestone: A defined, observable marker of an individual’s ability along a developmental continuum. [7]


  1. Carraccio C, Wolfsthal SD, Englander R, Ferentz K, Martin C. Shifting paradigms: From Flexner to competencies. Acad Med. 2002;77:361-367.
  2. Frank JR, Snell LS, Ten Cate O, et al. Competency-based medical education: Theory to practice. Med Teach. 2010;32:638-645.
  3. Swing SR. The ACGME outcome project: Retrospective and prospective. Med Teach. 2007;29:648-654.
  4. Frank JR, Danoff D. The CanMEDS initiative: Implementing an outcomes-based framework of physician competencies. Med Teach. 2007;29:642-647.
  5. Englander R, Cameron T, Ballard AJ, Dodge J, Bull J, Aschenbrener CA. Toward a common taxonomy of competency domains for the health professions and competencies for physicians. Acad Med. 2013;88:1088-1094.
  6. Accreditation Council for Graduate Medical Education (ACGME). (2013). Milestones Accessed April 16, 2015 from http://www.acgme.org/acgmeweb/tabid/430/ProgramandInstitutionalAccreditation/NextAccreditationSystem/Milestones.aspx
  7. Englander  R, Frank J, Carraccio C, Sherbino J, Ross S. Continuing to pursue a shared language for competency-based medical education. Unpublished manuscript. 2015.

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  1. Christine Savi
    May 19, 2015 at 8:07 PM

    Above, it states

    “For the purposes of developing undergraduate medical education (UME) milestones, the AAMC defined two performance levels, corresponding to novice performance and the performance expected of a graduating MD.”

    Are these performance levels understood to be the entrustment levels of pre and full entrustment, or is it referring to something else?
    Many thanks,

  2. Robert Englander
    May 20, 2015 at 12:31 AM

    Yes that is correct Christine. If you look at the Curriculum Developer’s Guide for the Core EPAs for Entering Residency you will see that for each of the competencies critical to the EPAs we defined two milestones. One which would represent the novice level ( “pre-entrustable” milestone), and one that represented the level at which the undergraduate medical student would be entrusted (“entrustable” milestone) which was defined as able to perform the activity without direct supervision.

  3. Christine Savi
    May 20, 2015 at 1:57 PM

    Thanks so much, Bob, for the clarification. Although pre-entrustable and entrustable are anchored as novice and perhaps ‘upon graduation’, there may very well be other levels that exist between these on a developmental scale. Defining what students are to accomplish along curriculum continuum, we’ve experienced a sort of semi-entrustable stage at where students are perhaps applying what they know with and without direct faculty supervision, which would support a developmental framework rather than two levels. As long as pre-entrustment evolves into entrustment, there may be mid-milestones of developmental behavior along the way, yes?

  4. Terri Cameron
    May 20, 2015 at 2:35 PM

    Hi, Christine. You make a very good point, and one which the pilot schools are currently discussing — the concept of entrustment for performance with supervision from a distance being the appropriate level for UME. In GME, entrustment is related to ability to perform without supervision.

    You can read more about it in the following article and on the Core EPA listserv (subscribe at subscribe-coreepas@lists.aamc.org).

    The Case for Use of Entrustable Professional Activities in Undergraduate Medical Education Chen, H. Carrie; van den Broek, W.E. Sjoukje; Cate, Olle ten Academic Medicine., Post Author Corrections: December 2, 2014 (PAP)


  5. Robert Englander
    May 20, 2015 at 11:31 AM

    Another great comment Christine. If you use the Dreyfus and Dreyfus model, there is probably at least one level between novice and competent (to perform without direct supervision), which would correspond to an “advanced beginner”. Interestingly, the drafting panel for the Core EPAs for Entering Residency discussed adding this level of milestone, but in the end decided to stick with two levels balancing issues of complexity of the document with a full delineation of the developmental progression. One would also expect developmental milestones beyond “entrustable” as one goes on to “master” these EPAs and to work on those EPAs designed for specialties and the transition from GME to practice.

  6. Rahul Patwari
    May 21, 2015 at 8:22 PM

    I have a practical question about the CEPAER’s and the PCRS. I tried to map the PCRS to the CEPAER’s (as in the diagram) and had a lot left over (health prevention, research, communicating with patients/families, etc). Additionally, there were several EPA’s that had no corresponding competencies (obtaining consent, entering orders, etc).

    I get that neither list is meant to be comprehensive. Should we teach/measure both (resource intensive)? Create new EPA’s for skills we think are important?

    Thanks. This is a great discussion.

    • Robert Englander
      May 22, 2015 at 12:51 PM

      Thanks for your question Rahul. Almost all of the competencies from the PCRS (45 of the 58) mapped to at least one of the Core EPAs for Entering Residency. The grid that shows the mapping of each of the 13 EPAs to their critical competencies is in Appendix D of the Core Entrustable Professional Activities for Entering Residency Curriculum Developers’ Guide (available through the AAMC website).

      All of the EPAs were mapped to their critical competencies, including obtaining informed consent and entering orders. You can find the specific competencies mapped to each EPA in the initial table for each EPA under the row entitled “Competencies within each domain critical to entrustment decisions.”

      Finally, the Core Competencies were not designed to be the sum total of requirements for graduation (rather they provide the “Core” of the MD degree). I would expect that medical schools will have mission driven graduation requirements as well as advanced specialty-specific graduation requirements (for the transitioning fourth year medical student) that would augment the Core EPAs and may thus touch upon the few competencies from the PCRS that were not addressed by the Core EPAs. Finally, the PCRS was designed to be a comprehensive list of competencies (a real reference set) that reflected/integrated the more than 150 lists that we looked at across the profession, across the continuum, across countries and across other health professions. I suspect that if we do a great job at teaching and assessing the 45 associated with the Core EPAs we will be far advanced in ensuring the competence of our graduates!

      • Rahul Patwari
        May 22, 2015 at 1:59 PM

        Thanks! I’ll check out Appendix D (I missed that).

  7. Developing a Framework for Competency Assessment: Entrustable Professional Activities (EPAs) | AM Rounds
    May 27, 2015 at 6:01 PM

    […] first blog post focused on outlining the three steps to developing a competency-based medical education (CBME) […]

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