Competency-Based Medical Education in a Norm-Referenced World: A Root Cause Analysis of Challenges to the Competency-Based Paradigm in Medical School

Public Board Score Reporting Undermines Holistic Review for Residency Selection

Holistic review has become the gold standard for residency selection. As a result, many programs are de-emphasizing standardized exam scores and other normative metrics. However, if standardized exam scores predict passing of an initial certifying exam, this may lead to an increase in board failure rates within specific residency training programs who do not emphasize test scores on entry. Currently, the board pass rates of residency programs from many of the American Board of Medical Subspecialities (ABMS) are publicly reported as a rolling average. In theory, this should create accountability but may also create pressure and distort the way residency program selects applicants. The risk to programs of having a lower board pass rate publicly reported incentivizes programs to focus increasingly on standardized test scores, threatening holistic review. All programs do not recruit students entering residency with an identical chance of passing boards. Therefore, we believe the ABMS member boards should stop publicly reporting raw certifying exam rates above a certain threshold for normative comparison. We strongly encourage the use of learning analytics to create a residency "expected board pass rate" that would be a better metric for program evaluation and accreditation.

Post competency training in standardized training of resident physicians and integrated postgraduates

We focus on the importance and necessity of post-competency-based training in medical education alongside its current challenges and opportunities. Integrating post competency training into standardized educational frameworks is increasingly recognized as a critical component of preparing residents and postgraduates for real-world clinical practice. Post competency training represents a commitment to excellence in medical education, striving to produce competent, skilled practitioners to meet the challenges of modern healthcare.

Advancing anti-oppression and social justice in healthcare through competency-based medical education (CBME)

Competency-based medical education (CBME) focuses on preparing physicians to improve the health of patients and populations. In the context of ongoing health disparities worldwide, medical educators must implement CBME in ways that advance social justice and anti-oppression. In this article, authors describe how CBME can be implemented to promote equity pedagogy, an approach to education in which curricular design, teaching, assessment strategies, and learning environments support learners from diverse groups to be successful. The five core components of CBME programs - outcomes competency framework, progressive sequencing of competencies, learning experiences tailored to learners' needs, teaching focused on competencies, and programmatic assessment - enable individualization of learning experiences and teaching and encourage learners to partner with their teachers in driving their learning. These educational approaches appreciate each learner's background, experiences, and strengths. Using an exemplar case study, the authors illustrate how CBME can afford opportunities to enhance anti-oppression and social justice in medical education and promote each learner's success in meeting the expected outcomes of training. The authors provide recommendations for individuals and institutions implementing CBME to enact equity pedagogy.

On Purpose: The Case for Alignment in Assessment

In this issue, Ryan and colleagues underscore the need for criterion-based assessments in the context of competency-based curricula in undergraduate medical education (UME). They also point out that the same scores are often interpreted from a norm-referenced perspective to support the admissions process for residency training. This problem is not unique to UME because in graduate medical education (GME), the same assessments are often used for both decision making and providing feedback. Unfortunately, an assessment with 2 purposes is neither optimal nor efficient for either purpose and may be accompanied by significant side effects. One approach to addressing these challenges is to develop a system of assessment that addresses both purposes but where each component is focused on a single purpose. This leads to alignment and transparency from purpose to test content and from test content to score interpretation and/or feedback. It ensures that the test material is optimized for the task, that individual assessments are constructed to enhance the validity of their scores, and that undesirable side effects are limited.