Defining Competence and Entrustment in CBE

Judging competence and delegating tasks

Competency-based education starts with what a person can do after completing training and at what level. In medical education, this means incorporating the health needs of patients and communities into learning objectives. Assessment examines whether learners demonstrate knowledge, skills, communication, and judgment together in clinical practice. An EPA is a unit of professional practice that can be entrusted to a learner who possesses these competencies. An entrustment decision determines the level of supervision and scope of responsibility appropriate for that task.

Curriculum design starting from local health needs

A literature review and conceptual discussion linking health workforce training to improvements in global health identified the health needs of local populations as the starting point for CBE (Gruppen et al., 2012). The review presented five characteristics of competence: specifying performance at the end of training, reflecting external stakeholders’ expectations, describing measurable behaviors, setting achievement standards based on professional judgment, and sharing expectations and professional values. The CBE curriculum comprises three stages: deriving competencies from health needs, designing learning experiences to develop those competencies, and developing assessments alongside them. Needs analysis can draw on health data and community input, key informant analysis, field observations and practitioner surveys, expert panels, and national consensus building.

Communication skills appeared in all 5 competency frameworks reviewed, but only 2 included competencies related to information management or lifelong learning. The University of New South Wales divided effective communication, one of 8 competencies, into 3 sub-competencies—communication with patients and families, with peers and tutors, and with the community. It specified activities such as health risk counseling and connecting patients with community services. In a case of obstructed labor based on the 10 competency domains of Indiana University School of Medicine, performance in 6 domains was linked to learning and assessment methods. Explaining treatment options to the mother was paired with simulated patient practice and standardized patient exercises. Confirming the cause through physical examination was paired with simulation and direct observation. Identifying community resources was paired with self-directed exploration and written examinations. Ethical judgment was linked to case discussions and oral exams, identifying and referring high-risk cases to problem-solving and medical record audits, and confidentiality to policy review and supervisor assessment. This structure illustrates the assessment principle that evidence of actual performance carries increasing weight as assessment moves from ‘knows’ and ‘knows how’ to ‘shows’ and ‘does’ on Miller’s pyramid.

The EPA concept was introduced as a way to supplement ‘checkbox education’ focused on completing individual items. The example assessed patient care, medical knowledge, and communication together during a normal delivery. Learners reach a common achievement standard, but the time and methods they use can vary. They can be exempted from some educational experiences if they have already demonstrated the required performance. Implementing this approach requires an information system to track individual progress, faculty to determine when learners advance to the next stage, and minimum performance standards for each competency. In resource-constrained regions, competencies and the professions responsible for them are determined in light of health priorities, teaching staff, and available resources. Task shifting—transferring tasks to professions that have demonstrated the same level of performance—can also be considered.

Achievement standards and time flexibility in postgraduate training

A conceptual paper outlining the history and terminology of graduate medical education situates CBME within the trend toward organizing education around predefined performance outcomes (ten Cate, 2017). The paper connects the four questions of the 1949 Tyler rationale—educational purposes, learning experiences, organization of experiences, and evaluation—with Bloom’s taxonomy of educational objectives and Carroll’s 1963 discussion of learning time. The observation that achievement can vary even when learners are given the same amount of time provides the educational basis for mastery learning and adjustments to individual learning time. In medical education, the outcome-based approach spread through the integration of basic science and clinical objectives at Case Western Reserve University in the 1950s. Further developments included the form of CBME focused on local clinical functions proposed in 1978, CanMEDS in the 1990s, and the subsequent ACGME Outcome Project. The two core characteristics of CBME are expressing outcomes as specific competencies and flexibly adjusting the duration of training according to defined achievement levels.

The paper describes competence as a comprehensive ability to use communication, knowledge, skills, clinical reasoning, emotions, values, and reflection judiciously in daily practice. Its components are identified as competencies. A medical competency is the ability to perform specific, integrated tasks in professional work. It is learnable, durable, and measurable. Broad categories such as the 7 roles of CanMEDS and the 6 core competencies of ACGME are domains of competence. Patient care encompasses gathering patient information, performing physical examinations, and developing and implementing treatment plans. These abilities can be demonstrated differently depending on available resources and support. ‘Competent’ refers to both the ability to perform and the authority to act. Demonstrated competence is linked to decisions that confer the rights and obligations of independent practice.

Introduced in 2005, the EPA concept brings together multiple competencies within actual work. Entrustability scales express the level of supervision required for that work. The Dreyfus model comprises five stages: Novice, Advanced Beginner, Competent, Proficient, and Expert. Competent is the threshold at which unsupervised performance is socially accepted and entrustment can be justified. Professional development continues beyond this point. Milestones describe the successive performance levels expected along the path to that threshold. Differences in learners’ starting points and workplace experiences can lead to differences in educational pathways and the time required. The paper extends the principle of time flexibility to clinical researchers’ education and family planning, as well as continuity between undergraduate medical education and graduate medical education. Implementing individualized training requires adjustments to clinical staffing and regulations.

Distinguishing individual ability and entrustable tasks

A conceptual paper examining the conflation of EPA and competence distinguished the roles of the two concepts through a review of definitions, prior literature, and educational and clinical cases (ten Cate & Schumacher, 2022). Competencies and skills are inferred from observations of task performance or responses to examinations. Competence is a person’s ability to perform, and an EPA is a unit of professional work that can be entrusted to someone who has demonstrated that ability. An EPA is a specific, observable activity with a beginning and an end that yields a recognizable work product. A party with legitimate authority can decide whether to entrust it. A single EPA requires multiple competencies, and a single competency contributes to multiple EPAs, so their relationship can be expressed as a matrix. EPAs for medical students, residents, and fellows differ in the scope of work and extent of responsibility they entail. Entrustment decisions can draw on the professional judgment of teams or committees as well as department heads or supervisors.

The paper identified two sources of confusion: the tendency to express all learning objectives as EPAs and the use of entrustment decisions solely for promotion without corresponding changes in clinical responsibility. It proposed three responses to the first issue. Defining interprofessional collaboration as ‘chairing an interprofessional meeting’ and contributions to safety culture as ‘investigating a patient safety event’, including report writing, allows these objectives to be structured as entrustable tasks. Confidentiality, truthfulness, reliability, or collaboration with operating room staff can be included as conditions for entrusting the corresponding EPA. The ability to reflect on politics, ethics, economics, history, climate change, racism, and the humanities can remain a general requirement for education and graduation.

The second issue concerns how a trainee’s autonomy and responsibility change after assessment. In Canada’s Competence-By-Design at the time, summative entrustment decisions were used for promotion to the next training stage. The paper noted limited connections to reduced supervision and expanded responsibility for each EPA. It also discussed arrangements in which responsibility increased after a specified period regardless of evidence of performance. Entrustment acquires educational meaning when evaluations of past performance are connected to future responsibilities. The autonomy available to unlicensed students is governed by institutional supervision requirements. Short clerkships also limit the time supervisors have to get to know trainees. The paper described a surgical resident who felt trusted when preoperative plans were no longer corrected.

Competency-based curriculum implemented through integrated and longitudinal education

A project report from Charité university medicine described the reorganization of the curriculum around competencies and outcomes during 2010–2016 and the subsequent student evaluation (Hitzblech et al., 2019). The reform curriculum introduced in 1999 enrolled 63 students per year, about 10% of the total student body, and incorporated PBL, integrated thematic blocks, and early patient contact. Building on this experience, the Modular Curriculum of Medicine (MCM), approved for introduction in 2010, is a 6-year program that includes a final-year clinical clerkship. Participants in its development included a planning committee led by the dean, experts in curriculum development and change management, institutes and clinical departments, and student representatives. Module planning groups developed the content through an 8-step procedure. Objectives for each class were aligned with teaching, learning, and assessment. Basic science was integrated with clinical education through the 10th semester. Longitudinal education comprised 118 units for patient examination courses, 358 units for bedside teaching, and 240 units for PBL. It also comprised 102 units for communication and teamwork training, 154 units for scientific competency training, and 30 units for principles of medical theory and practice. Elective modules comprised 60 units in the 6th semester and 50 units each in the 7th and 8th semesters. Based on the EPA concept, the proposed structure would engage students in professional activities from the outset. Task complexity would increase and supervision decrease as they progressed through the semesters.

A student evaluation using a 5-point Likert scale was conducted in the 2017/2018 winter semester. It assessed satisfaction with integrated and longitudinal education, the extent to which learning outcomes were reflected in the curriculum, and readiness for exams and clerkships. Of 2,974 students, 1,047 responded, yielding a 35% response rate. Of respondents, 64% were female, and the mean age was 24.5 years (SD 4.2 years). There were 795 respondents in semesters 1–6 and 252 in semesters 7–10, with respective response rates of 41% and 25%. Data from semesters 7–10 were used to analyze learning outcomes and readiness. Final-year clerkship students were excluded because of a low response rate. Comparison data came from a 2016 final-year survey using the same items. Responses came from 120 regular curriculum students and 64 MCM students, yielding response rates of 20% and 29%, respectively. Satisfaction was reported by 76% for patient examination courses, 68% for bedside teaching, and 71% for elective modules. It was reported by 58% for principles of medical theory and practice, 50% for communication and teamwork training, 38% for PBL, and 41% for scientific competency training. 64% of MCM students reported feeling well prepared for their final-year clinical clerkship, and 89% reported being satisfied with their decision to choose the MCM. In the 2016 regular curriculum survey, 19% reported feeling well prepared for the final-year clerkship.

Students rated all competency and content domains as important for a physician’s duties. The extent to which these were reflected in the curriculum varied by domain. Sufficient coverage was reported by 83% for diagnostics, therapy, and care and 81% for communication and teamwork. It was reported by 26% for teaching others, 23% for self-assessment, professional development, and self-care, and 29% for interprofessional collaboration. Coverage was rated higher in the MCM than in the regular curriculum, with the largest differences in communication and teamwork and in practical skills. These results are based on voluntary self-reports at a single institution. They describe students’ curricular experiences and perceived readiness, taking into account survey timing, the distribution of respondents across semesters, and response rates. To supplement education in medical decision-making, an interdisciplinary working group developed and implemented bedside teaching plans. It mapped key symptoms to graduation outcomes and NKLM Chapter 20 ‘Reasons for Consultation’. Classes with students from other health professions and an intra-campus network were introduced for interprofessional education.

The relationship connecting assessment experience and professional identity formation

A qualitative study of cardiology trainees’ professional growth investigated how assessment, feedback, and mentoring in CBME relate to transformational learning (TL) and professional identity formation (PIF) (Chow et al., 2025). The analysis drew on Mezirow’s transformational learning, examining connections among disorienting dilemmas that unsettle existing perspectives, critical reflection, discourse, and action. Participants were Canadian cardiology PGY4–PGY6s and graduates who had completed training within the past 3 years. Online semi-structured interviews were conducted from November 2021 to January 2023. The 22 participants comprised 8 recent graduates, 4 PGY6s, 4 PGY5s, and 6 PGY4s. Of these, 17 were male, 20 had McMaster training experience, and 11 had received their undergraduate medical education outside North America. The research team conducted interviews and analysis concurrently, discussing the material every 2 weeks. Theme development progressed from reflexive thematic analysis to directed content analysis, in which data and theory were considered together. Dedoose 9.0.90 was used to organize the data. Interpretations were checked using audit trails, interview memos, and a review of competing hypotheses.

The analysis did not identify a distinct relationship between the introduction of CBME and TL experiences or PIF. Participants described individual patient care experiences and relationships with peers and mentors as major catalysts for transformation. Participants reported assessment fatigue and documentation burdens while completing numerous EPAs and workplace-based assessments (WBAs). Some described formal assessment requests as reducing opportunities for spontaneous coaching conversations. Accounts of shifts in perspective included reconsidering the meaning of treatment after witnessing an elderly cardiac arrest patient’s recovery. Another account described changing practice to establish patient preferences first after hearing a heart failure patient’s wish for a peaceful death. Mentors’ support and sponsorship for fellowship, employment, and academic opportunities helped participants develop a sense of responsibility and professional identity. Self-doubt associated with the impostor phenomenon, which appeared in nearly all interviews, was interpreted as both a driver of learning and a factor constraining transformation. Participants also described feedback they found difficult to trust or accept as a threat to their identity.

A participant who attributed a patient’s death entirely to their own actions revised that judgment through repeated conversations with peers and supervisors. Another reflected by recording emotions and plans for improvement. Because the interview questions were expanded after interviews with 7 graduates from before CBME was introduced, and 20 of the 22 participants trained at McMaster, experiences before and after its introduction are best interpreted in light of changes to the questions and the institution’s training context. The study suggested that major transformational events may be less prominent when perspectives are continually adjusted through a growth-oriented attitude. Readiness for the next stage was described as encompassing both EPA completion and access to relationships and support that help trainees manage self-doubt and difficult clinical experiences.

Reading notes

Even when curriculum objectives and assessments are aligned, changes in supervision levels and clinical participation following entrustment require separate examination. From an HRD perspective on workplace learning, examining assigned tasks, autonomy in exercising judgment, and relationships with peers and mentors through which trainees review experiences offers a concrete approach to researching competency development. In the MCM, translating assessment results into revisions to bedside teaching plans illustrates how competency-based education is implemented.

References

• Gruppen, L. D., Mangrulkar, R. S., & Kolars, J. C. (2012). The promise of competency-based education in the health professions for improving global health. Human Resources for Health, 10(1), Article 43. https://doi.org/10.1186/1478-4491-10-43
• ten Cate, O. (2017). Competency-based postgraduate medical education: Past, present and future. GMS Journal for Medical Education, 34(5), Doc69. https://doi.org/10.3205/zma001146
• ten Cate, O., & Schumacher, D. J. (2022). Entrustable professional activities versus competencies and skills: Exploring why different concepts are often conflated. Advances in Health Sciences Education, 27(2), 491–499. https://doi.org/10.1007/s10459-022-10098-7
• Hitzblech, T., Maaz, A., Rollinger, T., Ludwig, S., Dettmer, S., Wurl, W., Roa-Romero, Y., Raspe, R., Petzold, M., Breckwoldt, J., & Peters, H. (2019). The modular curriculum of medicine at the Charité Berlin – a project report based on an across-semester student evaluation. GMS Journal for Medical Education, 36(5), Doc54. https://doi.org/10.3205/zma001262
• Chow, J., Al‐Duaij, L., Last, N., Sheth, U., Rehman, M., Azim, A., Khalid, F., Blissett, S., & Sibbald, M. (2025). Transformational learning and professional identity formation in postgraduate competency‐based medical education. Medical Education, 59(4), 409–417. https://doi.org/10.1111/medu.15553