APM perspective
Competency-based Advancement: Risky Business

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Residency as a Delicate Learning Community

We are concerned that the “one-resident-at-a-time” focus of competency-based training ignores the reality that a residency program is a delicate ecosystem where residents depend heavily on their peers for growth and learning. This supportive social learning community struggles, advances, and grows together, and mutually fosters the individual transition from student to physician for each member of the group. The high standards of the residency program, and of the profession, are embodied by the

Honest Accountability for That Which is Measurable, and That Which is Not

Many of the beliefs that underpin competency-based advancement assume that we are able to accurately measure the acquisition of all important competencies. Yet the development of adequate and reliable assessment tools for even the most basic competencies is in the earliest of stages. We believe the central educational experience of residency is a dedicated learner and a dedicated teacher at a patient's bedside. Direct observation by the master teacher is the cornerstone of evaluation in this

Integrity of Teaching Services

Although we seek to strike a balance between service and learning, Osler's educational environment is made possible only by providing service in the care of patients. Residency programs have been entrusted with establishing teaching services to meet this end, and this commitment to staffing a residency service is fixed: Because patient needs are constant, the service cannot be sometimes staffed and sometimes not. The current model of training enables a program director to assess resources to

The Pitfalls of Early Transition to Fellowship: Accountability to All Subspecialties and to Fairness in Career Decision-Making

Competency-based advancement will allow some residents to begin fellowship after only 2 years of core internal medicine training. We acknowledge that well-established milestones and assessment tools may allow identification of a small number of residents who achieve competency after only 2 years. Practically, however, this determination could not be made until well into the second postgraduate year, certainly no more than 6 months before the proposed advancement to fellowship would occur. The

Conclusions

We applaud and support the movement to competency-based education based on developmental milestones and reliable methods of assessment. We believe that graduate medical education programs should be judged on the quality of their educational outcomes, and that individual practitioners should be certified on the basis of achievement of broad-based competency in their discipline.

At the same time we urge caution regarding implementation of a system of advancement that encourages residents to leave

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There are more references available in the full text version of this article.

Funding: None.

Conflict of Interest: None of the authors have any conflicts of interest associated with the work presented in this manuscript.

Authorship: All authors had access to the data and played a role in writing this manuscript.

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