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References

  1. Carraccio C, Wolfsthal SD, Englander R, Ferentz K, Martin C. Shifting paradigms: From Flexner to competencies. Acad Med. 2002;77(5):361–367. DOI: 10.1097/00001888-200205000-00003
  2. McGaghie WC. Competency-based curriculum development in medical education. An introduction. Public health papers no. 68. 1978. DOI: 10.3109/0142159X.2010.501190
  3. 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
  4. Karpinski J, Stewart J, Oswald A, et al. Competency-based medical education at scale: A road map for transforming national systems of postgraduate medical education. Perspect Med Educ. 2024;13(1):24–32. DOI: 10.5334/pme.957
  5. Nousiainen MT, Caverzagie KJ, Ferguson PC, Frank JR, Collaborators I. Implementing competency-based medical education: What changes in curricular structure and processes are needed? Med Teach. 2017;39(6):594–598. DOI: 10.1080/0142159X.2017.1315077
  6. Chou FC, Hsiao CT, Yang CW, Frank JR. “Glocalization” in medical education: A framework underlying implementing cbme in a local context. J Formos Med Assoc. 2022;121(8):1523–1531. DOI: 10.1016/j.jfma.2021.10.024
  7. Aschbrenner KA, Rabin BA, Bartels SJ, Glasgow RE. Methodological recommendations for assessing the impact of adaptations on outcomes in implementation research. Implement Sci. 2025;20(1):30. DOI: 10.1186/s13012-025-01441-8
  8. Hall AK, Andriole D, Chen AMH, Englander R, Rojas D, Ryan MS, Boscardin CK, Caretta-Weyer H, Dalseg TR, Incoll IW, Ladenheim RI, Niemi-Murola L, Oswald A, Pinilla S, Turner DA, Goldhamer MEJ, As members of the International Competency-Based Health Professions Educators Collaborative. Approaches to the Evaluation of Competency-Based Health Professions Education Implementation from Around the Globe. Perspectives on Medical Education. 2026;15(1):1001–1016. DOI: 10.5334/pme.2628
  9. 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
  10. Frank JR, Snell LS, Sherbino J. Canmeds 2015 physician competency framework. Ottawa: Royal College of Physicians and Surgeons of Canada; 2015.
  11. Swing SR. The ACGME outcome project: Retrospective and prospective. Med Teach. 2007;29(7):648–654. DOI: 10.1080/01421590701392903
  12. ten Cate O. Entrustability of professional activities and competency-based training. Med Educ. 2005;39(12):1176–1177. DOI: 10.1111/j.1365-2929.2005.02341.x
  13. Sherbino J, Bandiera G, Doyle K, et al. The competency-based medical education evolution of canadian emergency medicine specialist training. CJEM. 2020;22(1):95–102. DOI: 10.1017/cem.2019.417
  14. Fitzpatrick JA, Chesbro SB, Jensen GM, et al. Describing the process to develop core entrustable professional activities for entrance into physical therapist practice: Applying a national consensus approach. J Phys Ther Educ. 2026. DOI: 10.1097/JTE.0000000000000465
  15. Banse HE, Kedrowicz A, Michel KE, et al. Implementing competency-based veterinary education: A survey of AAVMC member institutions on opportunities, challenges, and strategies for success. J Vet Med Educ. 2024;51(2):155–163. DOI: 10.3138/jvme-2023-0012
  16. Humphrey-Murto S, Varpio L, Gonsalves C, Wood TJ. Using consensus group methods such as delphi and nominal group in medical education research(). Med Teach. 2017;39(1):14–19. DOI: 10.1080/0142159X.2017.1245856
  17. Englander R, Flynn T, Call S, et al. Toward defining the foundation of the md degree: Core entrustable professional activities for entering residency. Acad Med. 2016;91(10):1352–1358. DOI: 10.1097/ACM.0000000000001204
  18. Health Professions Council of South Africa. Core competencies for undergraduate students in clinical associate, dentistry and medical teaching and learning programmes in south africa. Pretoria. 2014.
  19. Busari JO, Chan M-K, Damodaran A, Schwartz A, Ladenheim R, Jones B, et al. CBE and the Missing ‘E’: Making Competency-Based Education an Equitable Framework for Global Health Professions Education. Perspectives on Medical Education. 2026;15(1):880–893. DOI: 10.5334/pme.2551
  20. Kalafatis N, Sommerville T, Gopalan P. Defining fitness for purpose in south african anaesthesiologists using a delphi technique to assess the canmeds framework. Southern African Journal of Anaesthesia and Analgesia. 2019;25(2):7–16. DOI: 10.36303/SAJAA.2019.25.2.2193
  21. Mnguni L. The curriculum ideologies underlying the afrimeds curriculum framework for undergraduate medical and dental education in south africa. International Medical Education [Internet]. 2024;3(1):44–61. DOI: 10.3390/ime3010005
  22. Maart R, Adam R, Frantz J. Development of a framework for a dental curriculum to align to afrimeds competency framework through document analysis. South African Dental Journal. 2024;79(7):375–380. DOI: 10.17159/sadj.v79i07.18335
  23. Li SM, Chang YW, Lin MN, et al. Importance and fitness of family medicine milestone project from america to taiwan. BMC Med Educ. 2025;25(1):120. DOI: 10.1186/s12909-025-06699-6
  24. Post-graduate medical education regulations (pgmer) 2023. Available from: https://www.nmc.org.in/MCIRest/open/getDocument?path=/Documents/Public/Portal/LatestNews/PGMER%202023.pdf.
  25. Kini R. Faculty development e-course on entrustable professional activities in postgraduate pathology; 2025. Available from: https://schoolofpathology.kciapm.org/courses/EPA-Pathology-672a2056c5920908be915895.
  26. Edgar L, Hatlak K, HI L, et al. The milestones guidebook for residents and fellows; 2025.
  27. Swing S. ACGME launches outcomes assessment project. Jama. 1998;279(18):1492. DOI: 10.1001/jama.279.18.1492
  28. Nasca TJ, Philibert I, Brigham T, Flynn TC. The next gme accreditation system–rationale and benefits. N Engl J Med. 2012;366(11):1051–1056. DOI: 10.1056/NEJMsr1200117
  29. Edgar L, Roberts S, Holmboe E. Milestones 2.0: A step forward. J Grad Med Educ. 2018;10(3):367–369. DOI: 10.4300/JGME-D-18-00372.1
  30. Englander R, Hicks P, Benson B, Pediatric Milestone Project Working G. Pediatrics milestones: A developmental approach to the competencies. J Pediatr. 2010;157(4):521–522, 2 e1. DOI: 10.1016/j.jpeds.2010.07.001
  31. Andrews JS, Bale JF, Jr., Soep JB, et al. Education in pediatrics across the continuum (epac): First steps toward realizing the dream of competency-based education. Acad Med. 2018;93(3):414–420. DOI: 10.1097/ACM.0000000000002020
  32. O’Connor MM, Hobday PM, Long M, et al. Competency-based advancement in medical education: Outcomes of the education in pediatrics across the continuum (EPAC) project. Academic Medicine. 2025. DOI: 10.1093/acamed/wvaf066
  33. Yamazaki K, Shammet R, Lekdee A, et al. Ppv report 2024. Accreditation Council for Graduate Medical Education (ACGME): Chicago, IL, USA; 2024.
  34. Schumacher DJ, Michelson C, Poynter S, et al. Thresholds and interpretations: How clinical competency committees identify pediatric residents with performance concerns. Medical teacher. 2018;40(1):70–79. DOI: 10.1080/0142159X.2017.1394576
  35. Schumacher DJ, Michelson C, Winn A, et al. Graduating residents’ readiness for unsupervised practice. Pediatrics. 2025;155(5). DOI: 10.1542/peds.2024-070307
  36. Engelhardt KE, Bilimoria KY, Johnson JK, et al. A national mixed-methods evaluation of preparedness for general surgery residency and the association with resident burnout. JAMA Surg. 2020;155(9):851–859. DOI: 10.1001/jamasurg.2020.2420
  37. Duchscher JE. Transition shock: The initial stage of role adaptation for newly graduated registered nurses. J Adv Nurs. 2009;65(5):1103–1113. DOI: 10.1111/j.1365-2648.2008.04898.x
  38. Casey K, Fink R, Krugman M, Propst J. The graduate nurse experience. J Nurs Adm. 2004;34(6):303–311. DOI: 10.1097/00005110-200406000-00010
  39. Martinez-Lage M, Goldhamer MEJ, Pusic MV, et al. Implementing the promotion in place model of competency-based time-variable graduate medical education in pathology. J Grad Med Educ. 2025;17(2 Suppl):64–71. DOI: 10.4300/JGME-D-24-00664.1
  40. Goldhamer MEJ, Pusic MV, Nadel ES, Co JPT, Weinstein DF. Promotion in place: A model for competency-based, time-variable graduate medical education. Acad Med. 2024;99(5):518–523. DOI: 10.1097/ACM.0000000000005652
  41. Balmer DF, Pusic MV, Weinstein DF, Co JPT, Goldhamer MEJ. In the eye of the beholder: A stakeholder analysis of the value of the “promotion in place” competency-based time-variable graduate medical education pilot. Acad Med. 2025;100(3):331–339. DOI: 10.1097/ACM.0000000000005928
  42. Kinnear B, Santen SA, Kelleher M, et al. How does timeless training impact resident motivation for learning, assessment, and feedback? Evaluating a competency-based time-variable training pilot. Acad Med. 2023;98(7):828–835. DOI: 10.1097/ACM.0000000000005147
  43. Cooper D, Holmboe ES. Competency-based medical education at the front lines of patient care. N Engl J Med. 2025;393(4):376–388. DOI: 10.1056/NEJMra2411880
  44. Spector N, Blegen MA, Silvestre J, et al. Transition to practice study in hospital settings. Journal of Nursing Regulation. 2015;5(4):24–38. DOI: 10.1016/s2155-8256(15)30031-4
  45. Goode CJ, Lynn MR, McElroy D, Bednash GD, Murray B. Lessons learned from 10 years of research on a post-baccalaureate nurse residency program. J Nurs Adm. 2013;43(2):73–79. DOI: 10.1097/NNA.0b013e31827f205c
  46. Li SA, Sherbino J, Chan TM. Mcmaster modular assessment program (mcmap) through the years: Residents’ experience with an evolving feedback culture over a 3-year period. AEM Educ Train. 2017;1(1):5–14. DOI: 10.1002/aet2.10009
  47. Acai A, Li SA, Sherbino J, Chan TM. Attending emergency physicians’ perceptions of a programmatic workplace-based assessment system: The McMaster modular assessment program (mcmap). Teach Learn Med. 2019;31(4):434–444. DOI: 10.1080/10401334.2019.1574581
  48. Sebok-Syer SS, Klinger DA, Sherbino J, Chan TM. “It’s complicated”: Understanding the relationships between checklists, rating scales, and written comments in workplace-based assessments. Academic Medicine. 2016;91(11):S10–S. DOI: 10.1097/acm.0000000000001373
  49. Chan TM, Sebok-Syer SS, Yilmaz Y, Monteiro S. The impact of electronic data to capture qualitative comments in a competency-based assessment system. Cureus. 2022;14(3):e23480. DOI: 10.7759/cureus.23480
  50. Stoneham EJ, Witt L, Paterson QS, Martin LJ, Thoma B. The development of entrustable professional activities reference cards to support the implementation of competence by design in emergency medicine. CJEM. 2019;21(6):803–806. DOI: 10.1017/cem.2019.395
  51. Orr CJ, Sonnadara RR. Coaching by design: Exploring a new approach to faculty development in a competency-based medical education curriculum. Adv Med Educ Pract. 2019;10(null):229–244. DOI: 10.2147/AMEP.S191470
  52. Richardson D, Landreville JM, Trier J, et al. Coaching in competence by design: A new model of coaching in the moment and coaching over time to support large scale implementation. Perspect Med Educ. 2024;13(1):33–43. DOI: 10.5334/pme.959
  53. Baenziger K, Chan M, Colman S. Coaching in postgraduate competency-based medical education: A qualitative exploration of three models. Acad Psychiatry. 2023;47(1):10–17. DOI: 10.1007/s40596-022-01628-x
  54. Mand SK, Caretta-Weyer H, Jewell C, et al. The coaching approach in graduate medical education: Practical considerations for program creation and implementation. AEM Educ Train. 2025;9(Suppl 1):S12–S23. DOI: 10.1002/aet2.70019
  55. Yilmaz Y, Carey R, Chan TM, et al. Developing a dashboard for faculty development in competency-based training programs: A design-based research project. Can Med Educ J. 2021;12(4):48–64. DOI: 10.36834/cmej.72067
  56. Chan TM, Sebok-Syer SS, Sampson C, Monteiro S. The quality of assessment of learning (qual) score: Validity evidence for a scoring system aimed at rating short, workplace-based comments on trainee performance. Teach Learn Med. 2020;32(3):319–329. DOI: 10.1080/10401334.2019.1708365
  57. Spadafore M, Yilmaz Y, Rally V, et al. Using natural language processing to evaluate the quality of supervisor narrative comments in competency-based medical education. Acad Med. 2024;99(5):534–540. DOI: 10.1097/ACM.0000000000005634
  58. Society for improving medical professional learning Available from: https://simpl.org/.
  59. Zwischenberger JB, Hatchett SP, Rahman NA, et al. Implementing workplace-based assessments at scale: The SIMPL approach. Ann Surg Open. 2023;4(4):e353. DOI: 10.1097/AS9.0000000000000353
  60. Bohnen JD, George BC, Williams RG, et al. The feasibility of real-time intraoperative performance assessment with SIMPL (system for improving and measuring procedural learning): Early experience from a multi-institutional trial. J Surg Educ. 2016;73(6):e118–e130. DOI: 10.1016/j.jsurg.2016.08.010
  61. Warm EJ, Held JD, Hellmann M, et al. Entrusting observable practice activities and milestones over the 36 months of an internal medicine residency. Acad Med. 2016;91(10):1398–1405. DOI: 10.1097/ACM.0000000000001292
  62. Violato C, Cullen MJ, Englander R, et al. Validity evidence for assessing entrustable professional activities during undergraduate medical education. Acad Med. 2021;96(7S):S70–S75. DOI: 10.1097/ACM.0000000000004090
  63. Violato C, Englander R, Dale E, Gauer JL. Implementing core entrustable professional activities in undergraduate medical education: A psychometric study. Acad Med. 2025;100(5):585–591. DOI: 10.1097/ACM.0000000000005907
  64. Cheung WJ, Bhanji F, Gofton W, et al. Design and implementation of a national program of assessment model – integrating entrustable professional activity assessments in canadian specialist postgraduate medical education. Perspect Med Educ. 2024;13(1):44–55. DOI: 10.5334/pme.956
  65. Ross S, Hauer KE, Wycliffe-Jones K, et al. Key considerations in planning and designing programmatic assessment in competency-based medical education. Med Teach. 2021;43(7):758–764. DOI: 10.1080/0142159X.2021.1925099
  66. Dalseg TR, Hall AK, Williams K, et al. Resident physician pulse check; report from the 2021 collaborative study. Ottawa, ON: Royal College of Physicians and Surgeons of Canada & Resident Doctors of Canada; 2022.
  67. Hall AK, Oswald A, Frank JR, et al. Evaluating competence by design as a large system change initiative: Readiness, fidelity, and outcomes. Perspect Med Educ. 2024;13(1):95–107. DOI: 10.5334/pme.962
  68. Ott MC, Pack R, Cristancho S, et al. “The most crushing thing”: Understanding resident assessment burden in a competency-based curriculum. J Grad Med Educ. 2022;14(5):583–592. DOI: 10.4300/JGME-D-22-00050.1
  69. Fédération des médicins résidents du Québec. Year 3 of implementation of competence by design: Negative impact still outweighs theoretical benefits. Fédération des médicins résidents du Québec; 2020 July.
  70. 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
  71. Competence by design adaptations plan2025. Available from: https://news.royalcollege.ca/content/dam/document/newsroom/CBD%20Adaptations%20Plan.pdf.
  72. Hsiao CT, Chou FC, Hsieh CC, Chang LC, Hsu CM. Developing a competency-based learning and assessment system for residency training: Analysis study of user requirements and acceptance. J Med Internet Res. 2020;22(4):e15655. DOI: 10.2196/15655
  73. Niemi-Murola L, Antila A, Ryytty M, Helin-Salvmivaara A. Electronic assessment system implements epas in practice. Erikoislääkäri. 2022;32:91–93.
  74. Lee CW, Chen GL, Lee YK. User experience evaluation of the epas-based e-portfolio system and an analysis of its impact. J Acute Med. 2020;10(3):115–125. DOI: 10.3390/app10062055
  75. Guo FC, Chen YT, Hsu WC, et al. Emyway workplace-based entrustable professional activities assessments in otolaryngology residency training: A nationwide experience. Otolaryngol Head Neck Surg. 2025;172(4):1242–1253. DOI: 10.1002/ohn.1104
  76. Van Der Vleuten CPM, Schuwirth LWT, Driessen EW, Govaerts MJB, Heeneman S. Twelve tips for programmatic assessment. Med Teach. 2015;37(7):641–646. DOI: 10.3109/0142159X.2014.973388
  77. Pack R, Lingard L, Watling CJ, Chahine S, Cristancho SM. Some assembly required: Tracing the interpretative work of clinical competency committees. Med Educ. 2019;53(7):723–734. DOI: 10.1111/medu.13884
  78. Ekpenyong A, Baker E, Harris I, et al. How do clinical competency committees use different sources of data to assess residents’ performance on the internal medicine milestones?A mixed methods pilot study. Med Teach. 2017;39(10):1074–1083. DOI: 10.1080/0142159X.2017.1353070
  79. Oswald A, Dubois D, Snell L, et al. Implementing competence committees on a national scale: Design and lessons learned. Perspect Med Educ. 2024;13(1):56–67. DOI: 10.5334/pme.961
  80. Lomis K, Amiel JM, Ryan MS, et al. Implementing an entrustable professional activities framework in undergraduate medical education: Early lessons from the aamc core entrustable professional activities for entering residency pilot. Acad Med. 2017;92(6):765–770. DOI: 10.1097/ACM.0000000000001543
  81. Brown DR, Moeller JJ, Grbic D, et al. Entrustment decision making in the core entrustable professional activities: Results of a multi-institutional study. Acad Med. 2022;97(4):536–543. DOI: 10.1097/ACM.0000000000004242
  82. Moeller JJ, Warren JB, Crowe RM, et al. Developing an entrustment process: Insights from the AAMC CoreEPA pilot. Med Sci Educ. 2020;30(1):395–401. DOI: 10.1007/s40670-020-00918-z
  83. Ginsburg S, Stroud L, Brydges R, Melvin L, Hatala R. Dual purposes by design: Exploring alignment between residents’ and academic advisors’ documents in a longitudinal program. Adv Health Sci Educ Theory Pract. 2024;29(5):1631–1647. DOI: 10.1007/s10459-024-10318-2
  84. Fédération des médicins résidents du Québec. Profile of competence by design – year 4. Fédération des médicins résidents du Québec; 2022.
  85. Gauthier S, Braund H, Dalgarno N, Taylor D. Assessment-seeking strategies: Navigating the decision to initiate workplace-based assessment. Teach Learn Med. 2024;36(4):478–487. DOI: 10.1080/10401334.2023.2229803
  86. Ahn E, LaDonna KA, Landreville JM, McHeimech R, Cheung WJ. 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
  87. Ryan MS. (placeholder – icbhpe paper) Assessment fit for (more than one) purpose? Reconciling dual purposing in competency-based health professions education. PME. 2026;15(1):946–958. DOI: 10.5334/pme.2592
  88. van der Vleuten CP, Schuwirth LW, Driessen EW, et al. A model for programmatic assessment fit for purpose. Med Teach. 2012;34(3):205–214. DOI: 10.3109/0142159X.2012.652239
  89. Schumacher DJ, West DC, Schwartz A, et al. Longitudinal assessment of resident performance using entrustable professional activities. JAMA Netw Open. 2020;3(1):e1919316. DOI: 10.1001/jamanetworkopen.2019.19316
  90. Weiss PG, Schwartz A, Boyer DL, et al. Pediatric fellows and their ability to meet minimum supervision levels at graduation. Pediatrics. 2025;156(1). DOI: 10.1542/peds.2025-070682
  91. Surgery ABo. Entrustable professional activities (epas 2025 [Available from: https://www.absurgery.org/get-certified/epas/.
  92. Pediatrics ABo. SIMPL approach to implementing epas in pediatrics pilot project: American Board of Pediatrics; 2025 Available from: https://www.abp.org/cbme-simpl.
  93. Van Heest AE, Armstrong AD, Bednar MS, et al. American board of orthopaedic surgery’s initiatives toward competency-based education. JB JS Open Access. 2022;7(2):e21.00150. DOI: 10.2106/JBJS.OA.21.00150
  94. Tulshian P, Montgomery L, McCrory K, et al. National recommendations for implementation of competency-based medical education in family medicine. Fam Med. 2025;57(4):253–260. DOI: 10.22454/FamMed.2025.866091
  95. Haas MRC, Davis MG, Harvey CE, et al. Implementation of the SIMPL (society for improving medical professional learning) performance assessment tool in the emergency department: A pilot study. AEM Educ Train. 2023;7(1):e10842. DOI: 10.1002/aet2.10842
  96. Brasel KJ, Lindeman B, Jones A, et al. Implementation of entrustable professional activities in general surgery: Results of a national pilot study. Ann Surg. 2023;278(4):578–586. DOI: 10.1097/SLA.0000000000005991
  97. Chou FC, Fitzpatrick S, Taylor DR, et al. Managing curriculum reform in the transition to competency-based education using entrustable professional activities. Entrustable Professional Activities and Entrustment Decision-Making in Health Professions Education; 2024. DOI: 10.5334/bdc.v
  98. Kotter JP. Leading change Harvard Business Review Press. 2012. DOI: 10.15358/9783800646159
  99. Damschroder LJ, Aron DC, Keith RE, et al. Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implement Sci. 2009;4:50. DOI: 10.1186/1748-5908-4-50
  100. Biggs J. Constructive alignment in university teaching. Herdsa review of higher education. 2014;1:5–22.
  101. Lucey CR, Thibault GE, Ten Cate O. Competency-based, time-variable education in the health professions: Crossroads. Acad Med. 2018;93(3S Competency-Based, Time-Variable Education in the Health Professions):S1–S5. DOI: 10.1097/ACM.0000000000002080
  102. Nousiainen MT, Mironova P, Hynes M, et al. Eight-year outcomes of a competency-based residency training program in orthopedic surgery. Med Teach. 2018:1–13. DOI: 10.1080/0142159X.2017.1421751
DOI: https://doi.org/10.5334/pme.2580 | Journal eISSN: 2212-277X
Language: English
Page range: 930 - 945
Submitted on: Mar 25, 2026
Accepted on: Jun 15, 2026
Published on: Sep 29, 2026
Published by: Ubiquity Press
In partnership with: Paradigm Publishing Services

© 2026 Robert Englander, Mary Ellen Goldhamer, Aleda M. H. Chen, Anna Oswald, Adelle Atkinson, Holly Caretta-Weyer, Teresa M. Chan, Fremen Chihchen Chou, Timothy R. Dalseg, Reshma G. Kini, Roberta I. Ladenheim, Leila Niemi-Murola, David A. Turner, Linda Snell, Andrew K. Hall, As members of the International Competency-Based Health Professions Educators Collaborative, published by Ubiquity Press
This work is licensed under the Creative Commons Attribution 4.0 License.