What is Competency-Based Medical Education (CBME)? Think flexible, lifelong learning, with knowledge and/or skills assessed throughout a continuum of learning. In a competency-based educational program, you don’t just acquire knowledge and then spit it back at the time of a final exam. Instead, the method of assessment is formative rather than summative, and you are evaluated on how you apply your knowledge to clinical situations that physicians often face. While summative exams, such as certification exams, play an important role in gauging levels of acquired knowledge, formative assessments are equally important.

Competency-based assessments are used to distinguish between the skills and knowledge that you already have and those for which you need more education and training. In contrast to time-based educational methods, CBME is a learner-centered, active, and lifelong experience that incorporates feedback between the teacher and the learner to fulfill the desired competency outcomes.

Adoption of the Competency-Based Medical Education Construct

The concept of competency-based training began in the 1920s, when U.S. industry and businesses started researching ways of teaching their employees the specific knowledge and skills needed to create a specific product in a standardized manner. However, in the 1960s, a movement to de-emphasize basic skills in education arose. The resulting decline in traditional scores of achievement eventually sparked a demand for the renewal of minimum standards and performance competencies.

The design of a competency-based system of education can be approached using the following steps:

  • Identify the desired outcomes
  • Define the level of performance for each competency
  • Develop a framework for assessing competencies
  • Evaluate the program on a continuous basis to be sure that the desired outcomes are being achieved

In 1999, the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) endorsed six domains of core competencies, and the outcome initiative (the Outcome Project) was soon launched.

The six ACGME Core Competencies are:

  1. Patient Care
  2. Medical Knowledge
  3. Professionalism
  4. Interpersonal and Communication Skills
  5. Practice-Based Learning and Improvement
  6. Systems-Based Practice

Even though there was standardized language around the core competencies of medical education, there were still no standardized assessment methods to determine whether or not a learner had achieved all of the core competencies prior to completion of residency training. This deficiency ultimately led to the creation of milestones to operationalize and implement the competencies. These milestones described the performance levels residents and fellows are expected to demonstrate for skills, knowledge, and behaviors in the six clinical competency domains and are significant points in development that are unique to each specialty.

In 2014, the ACGME required the reporting of milestones as part of the Next Accreditation System (NAS) for all ACGME-accredited residency and fellowship programs. In undergraduate medical education, there are two AAMC-defined performance levels: novice performance and performance expected of a graduating MD. In graduate medical education, there are five performance levels for each competency: novice, advanced beginner, competent individual, proficient individual, and expert physician.

The Next Goal

The Core Competencies are now the basic language for defining physician competence and are also the principles used in the training of physicians. The next goal of CBME is to link education in the competencies to improved quality of patient care. This ambitious step will require standardized methods to securely collect patient data and stratify for various clinical variables including disease specificity, overall patient health, and the multitude of health care professionals who care for each patient.


The shift to CBME was an important transition that allowed residents and fellows to be active agents in their own learning by comparing their milestone assessment and feedback data to their personal learning plans. However, the future of CBME is just being realized and offers many exciting opportunities moving forward.

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