No Environment, No Education: Honoring the Clinical Learning Environment as the Engine of Competency-Based Education – A Call to Action

Eusang Ahn; Kelly J. Caverzagie; Arvin Damodaran; Soeren Huwendiek; Kimberly Lomis; Adrian P. Marty; David A. Turner; Teri Turner; Adelle Atkinson; As members of the International Competency-Based Health Professions Educators Collaborative

doi:10.5334/pme.2548

No Environment, No Education: Honoring the Clinical Learning Environment as the Engine of Competency-Based Education – A Call to Action

Volume 15 (2026): Issue 1

By: Eusang Ahn , Kelly J. Caverzagie , Arvin Damodaran , Soeren Huwendiek , Kimberly Lomis , Adrian P. Marty , David A. Turner , Teri Turner , Adelle Atkinson and As members of the International Competency-Based Health Professions Educators Collaborative

Open Access

|Sep 2026

Abstract

Competency-Based Health Professions Education (CBHPE) has transformed health professions training by emphasizing demonstrated competence over time-based progression. Yet the clinical learning environment (CLE), the social, cultural, and organizational ecosystem in which learning occurs, has not evolved in parallel. Persistent hierarchies, workload pressures, and inadequate faculty development limit CBHPE’s full potential. Thus, the authors sought to identify priorities for CLE reform. A structured consensus process was conducted at the International Competency-Based Education Collaborators Summit in February 2025, where interdisciplinary health professions educators identified CLE reform priorities. Findings were refined through virtual meetings over three months. Five interdependent priorities were identified as essential for transforming the CLE:

Psychological safety: enabling vulnerability, feedback, coaching, and growth through faculty and learner development
Teaching environment: prioritizing faculty well-being, recognition, and sustainable teaching capacity
Desirable difficulty and productive struggle: balancing challenge and safety to promote adaptive expertise and resilience
Interdependence and collectivism: reframing education from individual performance to team-based competence and shared accountability
Partner alignment: integrating educational and healthcare system goals to advance patient care and workforce well-being

Together, these domains outline the CLE as both a developmental and operational engine for CBHPE. Realizing the promise of CBHPE depends on transforming the CLE into a psychologically safe, appropriately challenging, interdependent, and system-aligned ecosystem. Reform demands cultural change that values coaching, feedback, vulnerability, and collective responsibility as professional imperatives. By aligning structures and empowering adaptive educators, the CLE can evolve from a passive setting to an active driver of successful competency-based transformation.

References

Torre D, Rice NE, Ryan A, et al. Ottawa 2020 consensus statements for programmatic assessment-2. Implementation and practice. Med Teach. 2021;43(10):1149–1160. DOI: 10.1080/0142159X.2021.1956681
Open DOI Search in Google Scholar Back to article
Boursicot K, Kemp S, Wilkinson T, et al. Performance assessment: Consensus statement and recommendations from the 2020 Ottawa Conference. Med Teach. 2021;43(1):58–67. DOI: 10.1080/0142159X.2020.1830052
Open DOI Search in Google Scholar Back to article
Van Melle E, Frank JR, Holmboe ES, et al. A core components framework for evaluating implementation of competency-based medical education programs. Acad Med. 2019;94(7):1002–1009. DOI: 10.1097/ACM.0000000000002743
Open DOI Search in Google Scholar Back to article
Ryan MS, Lomis KD, Deiorio NM, et al. Competency-based medical education in a norm-referenced world: A root cause analysis of challenges to the competency-based paradigm in medical school. Acad Med. 2023;98(11):1251–1260. DOI: 10.1097/ACM.0000000000005220
Open DOI Search in Google Scholar Back to article
Hall J, Atkinson A, Chan MK, et al. The clinical learning environment in CanMEDS 2025. Can Med Educ J. 2023;14(1). DOI: 10.36834/cmej.75537
Open DOI Search in Google Scholar Back to article
Sawatsky AP, Huffman BM, Hafferty FW. Coaching versus competency to facilitate professional identity formation. Acad Med. 2020;95(10):1511–1514. DOI: 10.1097/ACM.0000000000003144
Open DOI Search in Google Scholar Back to article
Ahn E, LaDonna KA, Landreville JM, et al. Only as strong as the weakest link: Resident perspectives on entrustable professional activities and their impact on learning. J Grad Med Educ. 2023;15(6):676–684. DOI: 10.4300/JGME-D-23-00204.1
Open DOI Search in Google Scholar Back to article
Asch DA, Nicholson S, Srinivas SK, et al. How do you deliver a good obstetrician? Outcome-based evaluation of medical education. Acad Med. 2014;89(1):24–26. DOI: 10.1097/ACM.0000000000000067
Open DOI Search in Google Scholar Back to article
Koh NJ, Wagner R, Newton RC, et al. CLER National Report of Findings 2025. Chicago: Accreditation Council for Graduate Medical Education; 2025.
Search in Google Scholar Back to article
Thoma B, Caretta-Weyer H, Schumacher DJ, et al. Becoming a deliberately developmental organization: Using competency-based assessment data for organizational development. Med Teach. 2021;43(7):801–809. DOI: 10.1080/0142159X.2021.1925100
Open DOI Search in Google Scholar Back to article
Nordquist J, Silva S, Caverzagie K, et al. Clinical learning environments: Updates. Med Teach. 2025. DOI: 10.1080/0142159X.2025.2459361
Open DOI Search in Google Scholar Back to article
Miller KA, Nagler J, Wolff M, et al. It takes a village: Optimal graduate medical education requires a deliberately developmental organization. Perspect Med Educ. 2023;12(1):282–293. DOI: 10.5334/pme.936
Open DOI Search in Google Scholar Back to article
Do V, Lewis M, Goldstein C, et al. Fostering a health-promoting learning environment in medical education: Adapting the Okanagan Charter for administrators and medical educators. Acad Med. 2023;98(6):672–679. DOI: 10.1097/ACM.0000000000005159
Open DOI Search in Google Scholar Back to article
Rosenthal GE, McClain DA, High KP, et al. The academic learning health system: A framework for integrating the multiple missions of academic medical centers. Acad Med. 2023;98(9):1002–1007. DOI: 10.1097/ACM.0000000000005259
Open DOI Search in Google Scholar Back to article
Woodruff JN, Vela MB, Lee WW, et al. Enhancing the graduate medical education clinical learning environment through community of practice forums. Acad Med. 2024. DOI: 10.1097/ACM.0000000000005862
Open DOI Search in Google Scholar Back to article
Soemantri D, Herrera C, Riquelme A. Measuring the educational environment in health professions studies: A systematic review. Med Teach. 2010;32(12):947–952. DOI: 10.3109/01421591003686229
Open DOI Search in Google Scholar Back to article
Ferguson PC, Caverzagie KJ, Nousiainen MT, et al. Changing the culture of medical training: An important step toward the implementation of competency-based medical education. Med Teach. 2017;39(6):599–602. DOI: 10.1080/0142159X.2017.1315079
Open DOI Search in Google Scholar Back to article
Cartwright-Stroupe LM, Cosme S. Creating an optimal IP learning environment: NCICLE Pathways to Excellence. J Contin Educ Nurs. 2022;53(4):150–152. DOI: 10.3928/00220124-20220311-02
Open DOI Search in Google Scholar Back to article
National Collaborative for Improving the Clinical Learning Environment. NCICLE Pathways to Excellence 2021. Chicago: NCICLE; 2021. DOI: 10.33385/NCICLE.0003
Open DOI Search in Google Scholar Back to article
Hallen S, Zelaya MI, White P, et al. Creating optimal clinical learning environments through interprofessional bedside rounding models: Lessons from the iPACE story. Acad Med. 2024. DOI: 10.1097/ACM.0000000000005863
Open DOI Search in Google Scholar Back to article
Edmondson A. Psychological safety and learning behavior in work teams. Adm Sci Q. 1999;44(2):350–383. DOI: 10.2307/2666999
Open DOI Search in Google Scholar Back to article
Cruess SR, Cruess RL, Steinert Y. Role modelling: Making the most of a powerful teaching strategy. BMJ. 2008;336(7646):718–721. DOI: 10.1136/bmj.39503.757847.BE
Open DOI Search in Google Scholar Back to article
Ulmer F, Krings R, Haberli C, et al. Patient safety 4.0: “Failure of the Week”: It’s all about role modelling. Dtsch Med Wochenschr. 2023;148(15):E87–E97. DOI: 10.1055/a-2061-1554
Open DOI Search in Google Scholar Back to article
Richardson D, Kinnear B, Hauer KE, et al. Growth mindset in competency-based medical education. Med Teach. 2021;43(7):751–757. DOI: 10.1080/0142159X.2021.1928036
Open DOI Search in Google Scholar Back to article
Pot M. Epistemic solidarity in medicine and healthcare. Med Health Care Philos. 2022;25(4):681–692. DOI: 10.1007/s11019-022-10112-0
Open DOI Search in Google Scholar Back to article
LaDonna KA, Hatala R, Lingard L, et al. Staging a performance: Learners’ perceptions about direct observation during residency. Med Educ. 2017;51(5):498–510. DOI: 10.1111/medu.13232
Open DOI Search in Google Scholar Back to article
Sivananthajothy P, Adel A, Afhami S, et al. Equity, diversity, and… exclusion? A national mixed methods study of “belonging” in Canadian undergraduate medical education. Adv Health Sci Educ Theory Pract; 2023. DOI: 10.1007/s10459-023-10265-4
Open DOI Search in Google Scholar Back to article
Dweck CS. Mindset: The New Psychology of Success. Updated ed. New York: Random House; 2016.
Search in Google Scholar Back to article
Hopkins SR, Rae VI, Smith SE, et al. From safety net to trampoline: Elevating learning with growth mindset in healthcare simulation. Adv Simul (Lond). 2023;8(1):1–6. DOI: 10.1186/s41077-023-00264-1
Open DOI Search in Google Scholar Back to article
Xiao F, Zhang Z, Zhou J, et al. The relationship between a growth mindset and the learning engagement of nursing students: A structural equation modeling approach. Nurse Educ Pract. 2023;73:103796. DOI: 10.1016/j.nepr.2023.103796
Open DOI Search in Google Scholar Back to article
Shida Q. Mediating effects of achievement goal orientation on the relationship between growth mindset and learning engagement in medical students: A cross-sectional descriptive study. Medicine (Baltimore). 2024;103(21):e38158. DOI: 10.1097/MD.0000000000038158
Open DOI Search in Google Scholar Back to article
Field L. Guglielmino’s Self-Directed Learning Readiness Scale: Should it continue to be used? Adult Educ Q. 1991;41(2):100–103. DOI: 10.1177/0001848191041002004
Open DOI Search in Google Scholar Back to article
Wolcott MD, McLaughlin JE, Hann A, et al. A review to characterise and map the growth mindset theory in health professions education. Med Educ. 2021;55(4):430–440. DOI: 10.1111/medu.14381
Open DOI Search in Google Scholar Back to article
Hopkins SR, Rae VI, Smith SE, et al. Trainee growth vs. fixed mindset in clinical learning environments: Enhancing, hindering and goldilocks factors. BMC Med Educ. 2024;24(1):1199. DOI: 10.1186/s12909-024-06211-6
Open DOI Search in Google Scholar Back to article
Bell ST, Brown SG, Colaneri A, et al. Team composition and the ABCs of teamwork. Am Psychol. 2018;73(4):349–362. DOI: 10.1037/amp0000305
Open DOI Search in Google Scholar Back to article
Szulewski A, Braund H, Dagnone DJ, et al. The assessment burden in competency-based medical education: How programs are adapting. Acad Med. 2023;98(11):1261–1267. DOI: 10.1097/ACM.0000000000005305
Open DOI Search in Google Scholar Back to article
Ginsburg S, Stroud L. Necessary but insufficient and possibly counterproductive: The complex problem of teaching evaluations. Acad Med. 2023;98(3):300–303. DOI: 10.1097/ACM.0000000000005006
Open DOI Search in Google Scholar Back to article
Wisener K, Driessen E, Tan A, et al. From constructive to critical and everywhere in between: Education leaders’ decision-making related to harsh feedback from learners about their teachers. Adv Health Sci Educ Theory Pract. 2025;30(2):497–513. DOI: 10.1007/s10459-024-10367-7
Open DOI Search in Google Scholar Back to article
Seabrook MA. Medical teachers’ concerns about the clinical teaching context. Med Educ. 2003;37(3):213–222. DOI: 10.1046/j.1365-2923.2003.01437.x
Open DOI Search in Google Scholar Back to article
Damodaran AK, Jones P, Shulruf B. Trust and risk pitfalls in medical education: A qualitative study of clinical teachers. Med Teach. 2021;43(11):1309–1316. DOI: 10.1080/0142159X.2021.1944613
Open DOI Search in Google Scholar Back to article
Terrett AM, Damodaran A, Burnet S, et al. The rheumatology workforce in Australia: Current and projected shortfalls. Intern Med J. 2025;55(9):1500–1507. DOI: 10.1111/imj.70123
Open DOI Search in Google Scholar Back to article
Vygotsky L, Kozulin A. Thought and Language. 2nd ed. Cambridge: MIT Press; 1986.
Search in Google Scholar Back to article
Bjork EL, Bjork RA. Making things hard on yourself, but in a good way: Creating desirable difficulties to enhance learning. In: Psychology and the Real World: Essays Illustrating Fundamental Contributions to Society. New York: Worth Publishers; 2011. pp. 56–64.
Search in Google Scholar Back to article
Guadagnoli M, Morin MP, Dubrowski A. The application of the challenge point framework in medical education. Med Educ. 2012;46(5):447–453. DOI: 10.1111/j.1365-2923.2011.04210.x
Open DOI Search in Google Scholar Back to article
Guadagnoli MA, Lee TD. Challenge point: A framework for conceptualizing the effects of various practice conditions in motor learning. J Mot Behav. 2004;36(2):212–224. DOI: 10.3200/JMBR.36.2.212-224
Open DOI Search in Google Scholar Back to article
Branfield Day L, Miles A, Ginsburg S, et al. Resident perceptions of assessment and feedback in competency-based medical education: A focus group study of one internal medicine residency program. Acad Med. 2020;95(11):1712–1717. DOI: 10.1097/ACM.0000000000003315
Open DOI Search in Google Scholar Back to article
Frank JR, Snell LS, Cate OT, et al. Competency-based medical education: Theory to practice. Med Teach. 2010;32(8):638–645. DOI: 10.3109/0142159X.2010.501190
Open DOI Search in Google Scholar Back to article
Auerbach L, Santen SA, Cutrer WB, et al. The educators’ experience: Learning environments that support the master adaptive learner. Med Teach. 2020;42(11):1270–1274. DOI: 10.1080/0142159X.2020.1801998
Open DOI Search in Google Scholar Back to article
Snydman LK, Memari M, Puri A, et al. The master adaptive clinician educator: A framework for future educational leaders in academic medicine. J Gen Intern Med. 2025;40(4):927–932. DOI: 10.1007/s11606-024-09199-3
Open DOI Search in Google Scholar Back to article
Daloz LA. Effective Teaching and Mentoring: Realizing the Transformational Power of Adult Learning Experiences. San Francisco: Jossey-Bass; 1986.
Search in Google Scholar Back to article
Lingard L. Paradoxical truths and persistent myths: Reframing the team competence conversation. J Contin Educ Health Prof. 2016;36(Suppl 1):S19–S21. DOI: 10.1097/CEH.0000000000000078
Open DOI Search in Google Scholar Back to article
Langlois S. Collective competence: Moving from individual to collaborative expertise. Perspect Med Educ. 2020;9(2):71–73. DOI: 10.1007/S40037-020-00575-3
Open DOI Search in Google Scholar Back to article
Bleakley A. Embracing the collective through medical education. Adv Health Sci Educ Theory Pract. 2020;25(5):1177–1189. DOI: 10.1007/s10459-020-10005-y
Open DOI Search in Google Scholar Back to article
Sebok-Syer SS, Chahine S, Watling CJ, et al. Considering the interdependence of clinical performance: Implications for assessment and entrustment. Med Educ. 2018;52(9):970–980. DOI: 10.1111/medu.13588
Open DOI Search in Google Scholar Back to article
Ginsburg S, McIlroy J, Oulanova O, et al. Toward authentic clinical evaluation: Pitfalls in the pursuit of competency. Acad Med. 2010;85(5):780–786. DOI: 10.1097/ACM.0b013e3181d73fb6
Open DOI Search in Google Scholar Back to article
Hofstede G. Dimensionalizing cultures: The Hofstede model in context. Online Readings Psychol Cult. 2011;2(1). DOI: 10.9707/2307-0919.1014
Open DOI Search in Google Scholar Back to article
Morera I, Galván C. Hofstede’s cultural dimensions in the educational context. In: Proceedings. 2019. DOI: 10.15405/epsbs.2019.04.02.38
Open DOI Search in Google Scholar Back to article
Ahn E, Sebok-Syer SS, Maniate JM, et al. Beyond individualism and independence: Exploring collectivism and interdependence as paradigms of healthcare and health professions education. Perspect Med Educ. 2025;14(1):939–955. DOI: 10.5334/pme.2000
Open DOI Search in Google Scholar Back to article
Crossley N. A dependent structure of interdependence: Structure and agency in relational perspective. Sociology. 2022;56(1):166–182. DOI: 10.1177/00380385211020231
Open DOI Search in Google Scholar Back to article
Van Lange PAM, Balliet D. Interdependence theory. In: APA Handbook of Personality and Social Psychology, Volume 3: Interpersonal Relations. Washington: American Psychological Association; 2015. pp. 65–92. DOI: 10.1037/14344-003
Open DOI Search in Google Scholar Back to article
O’Brien BC, Battista A. Situated learning theory in health professions education research: A scoping review. Adv Health Sci Educ Theory Pract. 2020;25(2):483–509. DOI: 10.1007/s10459-019-09900-w
Open DOI Search in Google Scholar Back to article
Barry ES, Teunissen P, Varpio L, et al. Leadership and followership dynamics in interprofessional health care teams: Attending physician perspectives. Acad Med. 2024. DOI: 10.1097/ACM.0000000000005819
Open DOI Search in Google Scholar Back to article
Katzenbach JR, Smith DK. The Wisdom of Teams: Creating the High-Performance Organization. New York: HarperBusiness Essentials; 2006.
Search in Google Scholar Back to article
Molloy E, Bearman M. Embracing the tension between vulnerability and credibility: “Intellectual candour” in health professions education. Med Educ. 2019;53(1):32–41. DOI: 10.1111/medu.13649
Open DOI Search in Google Scholar Back to article
Sebok-Syer SS, Lingard L, Panza M, et al. Supportive and collaborative interdependence: Distinguishing residents’ contributions within health care teams. Med Educ. 2023;57(10):921–931. DOI: 10.1111/medu.15064
Open DOI Search in Google Scholar Back to article
Schrage M. Shared Minds: The New Technologies of Collaboration. New York: Random House; 1990.
Search in Google Scholar Back to article
Sebok-Syer SS, Shaw JM, Asghar F, et al. A scoping review of approaches for measuring “interdependent” collaborative performances. Med Educ. 2021;55(10):1123–1130. DOI: 10.1111/medu.14531
Open DOI Search in Google Scholar Back to article
Uhl-Bien M, Riggio RE, Lowe KB, Carsten MK. Followership theory: A review and research agenda. Leadersh Q. 2014;25(1):83–104. DOI: 10.1016/j.leaqua.2013.11.007
Open DOI Search in Google Scholar Back to article
Baldwin J. Extreme ownership: How U.S. Navy SEALs lead and win. Engineer. 2017;47(2):55.
Search in Google Scholar Back to article
Skochelak SE, Hammoud MM, Lomis KD. Health Systems Science. Philadelphia: Elsevier; 2021.
Search in Google Scholar Back to article
Miles S, Swift L, Leinster SJ. The Dundee Ready Education Environment Measure (DREEM): A review of its adoption and use. Med Teach. 2012;34(9):e620–e634. DOI: 10.3109/0142159X.2012.668625
Open DOI Search in Google Scholar Back to article
Chan CYW, Sum MY, Lim WS, et al. Adoption and correlates of Postgraduate Hospital Educational Environment Measure (PHEEM) in the evaluation of learning environments: A systematic review. Med Teach. 2016;38(12):1248–1255. DOI: 10.1080/0142159X.2016.1210108
Open DOI Search in Google Scholar Back to article
Bradham TS, Sponsler KC, Watkins SC, Ehrenfeld JM. Creating a quality improvement course for undergraduate medical education: Practice what you teach. Acad Med. 2018;93(10):1527–1530. DOI: 10.1097/ACM.0000000000002253
Open DOI Search in Google Scholar Back to article
Shaheen AW, Fedoriw KB, Khachaturyan S, et al. Aligning medical student curriculum with practice quality goals: Impacts on quality metrics and practice capacity for students. Am J Med. 2019;132(12):1478–1483. DOI: 10.1016/j.amjmed.2019.08.011
Open DOI Search in Google Scholar Back to article
Gonzalo JD. Value-Added Roles for Medical Students. Philadelphia: Elsevier; 2021.
Search in Google Scholar Back to article
National Academy of Medicine. Learning Health System Shared Commitments Initiative. https://nam.edu/publications-of-the-leadership-consortium (accessed 6 June 2026).
Search in Google Scholar Back to article
Kegan R, Lahey L, Fleming A, et al. The deliberately developmental organization. https://orghacking.wordpress.com/wp-content/uploads/2016/06/thedeliberatelydevelopmentalorganization.pdf (accessed 6 June 2026).
Search in Google Scholar Back to article