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Pitfalls in Competency-Based Education

Competencies, milestones, and EPAs: Are those who ignore the past condemned to repeat it?” Kamen DL, Williams RG, Ciancola AT.  Medical Teacher. 2016; 38:9, 904-910.

Reviewed by Michele Haight

Tags: Competencies, EPA’s, Milestones, Teaching, Qualitative

What was the study question?

Based on historical competency-based education models, what are the conceptual concerns for implementing a competency-based framework in medical education?

How was the study done?

Two historical models of competency-based/outcomes-based education (CBE/OBE) in different contexts (K-12 and Department of Defense) were described and analyzed in terms of underlying assumptions about learning and assessment.  These analyses were then compared to the practices in the current competency-based medical education (CBME) framework with a particular focus on observation-based assessment in medical education.


What were the results?

Competency-based /outcomes based education in any context is rooted in multiple assumptions about what learners need to learn and how learners learn. These assumptions are directly translated into the systems created for educating and assessing learners. Some of the more significant challenges for a CBME/OBME framework that were identified in this study include the following: competency-based medical education is inherently “teacher-directed. ” There are limited opportunities and insufficient time for faculty to observe all of the defined behaviors for the competencies, milestones, NAS, COREEPAS, etc.  Assessing pieces of performance does not necessarily equate to overall “competence.” Learning is not linear, progressive and non-recursive.

What are the implications of these findings?

Educational frameworks are rife with assumptions about learning and assessment. Analysis of similar education models is a useful exercise for elucidating these assumptions.  Creating an awareness of underlying educational constructs can assist medical educators in reviewing and refining educational policies and procedures to better align CBME with physician training goals and more effectively engage all teachers and learners in meaningful educational practice.

Editor’s Note: EPA’s are all the rage these days. This study is a useful reminder of the necessity for awareness of the assumptions that underlie competency based education and of the value that can be derived from the study of educational models and practices outside of medicine. (RR)

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