Editor’s Note: This post is the first of two on the topic of competency-based medical education. Read the second post here.
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).  The shift from the old style of medical education, referred to as “Structure/Process” education, originally outlined by Abraham Flexner in 1910,  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.  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  and the CanMEDs roles.  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).  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)
- Patient Care (PC)
- Knowledge for Practice (KP)
- Practice-based Learning and Improvement (PBLI)
- Interpersonal and Communication Skills (ICS)
- Professionalism (Prof)
- Systems-based Practice (SBP)
- Interprofessional Collaboration (IPC)
- 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.  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. 
Domains of competence: Broad distinguishable areas of competence that, in the aggregate, constitute a general descriptive framework for a profession. 
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.
Milestone: A defined, observable marker of an individual’s ability along a developmental continuum. 
- Carraccio C, Wolfsthal SD, Englander R, Ferentz K, Martin C. Shifting paradigms: From Flexner to competencies. Acad Med. 2002;77:361-367.
- Frank JR, Snell LS, Ten Cate O, et al. Competency-based medical education: Theory to practice. Med Teach. 2010;32:638-645.
- Swing SR. The ACGME outcome project: Retrospective and prospective. Med Teach. 2007;29:648-654.
- Frank JR, Danoff D. The CanMEDS initiative: Implementing an outcomes-based framework of physician competencies. Med Teach. 2007;29:642-647.
- 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.
- 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
- Englander R, Frank J, Carraccio C, Sherbino J, Ross S. Continuing to pursue a shared language for competency-based medical education. Unpublished manuscript. 2015.