Jason R. Frank

Competency-based education is widely endorsed in health professions education (CBHPE) as an outcomes-focused approach to ensuring that all graduates demonstrate the competencies needed to improve patient and population health. Despite adoption of outcomes frameworks, accreditation requirements, and CBHPE tactics, interventions remain siloed within programs and training levels rather than spanning the education to practice continuum. Consequently, learners and teachers experience fragmented educational journeys that can fall short of addressing each learner’s needs for continuous learning and growth. To advance efforts toward a CBHPE continuum, this systems-informed conceptual analysis uses a systems thinking perspective to analyze leverage points, places within complex systems where small, strategic interventions can cause large-scale, lasting changes. Drawing on Meadows’ framework for understanding leverage points in complex systems, we examined barriers and opportunities to achieve a continuum and present five theoretically informed, literature-based, and expert-derived recommendations for transformation. Our analysis revealed that strategic intervention points, including paradigm shifts from ‘time-served’ to ‘competence-demonstrated’ readiness, structural changes through cross-continuum governance alignment, and process modifications via shared competency language and data systems, enable meaningful transformation beyond surface-level adjustments. Key recommendations include: (1) restructuring system architecture to enable seamless learner progression through competency committees and joint governance bodies; (2) shifting mental models to normalize time-variable progression and reconceptualize assessment as growth-supporting; (3) implementing high-impact approaches to assessment with longitudinal learner analytics; (4) changing rules and incentives to reward competency achievement; and (5) establishing continuous data-driven feedback systems. Understanding these leverage points informs targeted approaches, enabling a cohesive, coordinated, learner-centered CBHPE continuum.

Assessment in health professions education has evolved dramatically in the past hundred years. The way in which we conceptualize validity has also required evolution, particularly in the era of competency-based health professions education (CBHPE). The CBHPE approach compels us to reexamine a historical focus on objectivity, individual assessments, and standards of achievement alone. In this manuscript, the authors explore the implications CBHPE places on validity, highlighting three tension points: the paradigm of assessment, levels of validation, and the reference for competence. The authors examine health profession education’s historical orientation toward the post-positivist paradigm including an emphasis on standardization, reliability, and truth-seeking. This is contrasted with two alternative paradigms, constructivism and pragmatism, which prioritize different data sources to build validity arguments. In the section on levels of validation, the authors explore tensions between validity arguments that are holistic (considers the entire picture of performance) and those which use a decomposition approach (distilling competence into individual components). Finally, the authors consider the value in measuring learner competence using norm-referenced standards, criterion-reference approaches, or the measurement of growth throughout (and beyond) their training. Ultimately, the authors propose a balanced approach to address each tension, considering the strengths and weaknesses of traditional methods with the modern needs of CBHPE.

While competency-based programmatic assessment systems have become widespread worldwide, there are few comparisons of competence assessment in orthopaedic surgery between countries. In this paper, we provide a narrative overview of current systems in the United States, Canada, United Kingdom and Ireland, and Australia. We explore what types of workplace-based assessments are used, how many data points are gathered to inform entrustment and progression decisions and whether there is validity evidence using a modified Kane framework. Significant concordance and some variation were found between the programs, and the issues identified are discussed along with the challenges and potential solutions for enhancing competence assessment.

Background: Competency-Based Health Professions Education (CBHPE) is increasingly implemented; however, CBHPE outcomes research remains difficult to interpret and synthesize when studies incompletely report the CBHPE model and other elements. Objective: To develop structured reporting guidelines for CBHPE outcomes studies to improve transparency, interpretability, and transferability across educational contexts and professions. Methods: A multi-phase, iterative consensus-development process was used to create a CBHPE outcomes reporting checklist aligned with a CBHPE Outcomes Theory of Change. Draft reporting elements were generated and refined through structured writing-group deliberations, broad stakeholder feedback gathered through interactive town hall sessions within the ICBHPE Collaborative, and iterative revision cycles. The checklist was then pilot-tested with non-expert users to assess clarity, feasibility, and usability, and revisions were made to reduce redundancy, harmonize terminology, and strengthen guidance for high-impact reporting domains. Results: The final product is a structured reporting checklist, organized by manuscript section, accompanied by brief item descriptions and rationales, and registered with EQUATOR. The guidelines prioritize reporting elements that support causal interpretability in CBHPE outcomes research, including specification of the CBHPE intervention architecture and core components, program theory and intended mechanisms, implementation fidelity and adaptations, assessment system design and governance for progression decisions, multi-level outcomes and indicators across developmental timeframes, contextual enablers and constraints, and equity considerations. Conclusions: These CBHPE outcomes reporting recommendations provide a practical tool and guideline for authors, reviewers, and editors to strengthen the completeness and consistency of CBHPE outcomes reporting and should be considered before beginning a study. Adoption of this checklist may improve interpretability and evidence synthesis across programs and accelerate actionable learning about what works in CBHPE, for whom, in what contexts, and why.

Introduction: Competency-Based Health Professions Education (CBHPE) is an outcomes-based approach to planning and conceptualizing the training of health professionals to serve population needs. Despite its uptake, ongoing debate persists regarding the assumptions underpinning CBHPE, its intended purposes, and how success should be defined and evaluated. This contributes to variable implementation and difficulty aligning core features with meaningful outcomes. To date, no published theory of change has articulated how CBHPE’s core components provide a framework for later evaluation of intended outcomes.Methods: Using Funnell and Rogers’ purposeful program theory, the authors, all members of the International Competency-based Education Health Professions Educators Collaborative (ICBHPE), developed a model theory of change. The authors conducted a broad review of CBHPE literature, supplemented by CBE frameworks from adjacent educational contexts to strengthen underdeveloped constructs in implementation and evaluation. Findings were iteratively synthesized into a program theory and refined through repeated cycles of large-group feedback, consensus building, and member checking within ICBHPE.Results: The authors developed a CBHPE Outcomes Theory of Change that articulates key assumptions, mechanisms of impact, and expected outcomes associated with CBHPE implementation. The framework specifies how van Melle’s CBHPE core components are theorized to function across phases of implementation and identifies proximal and distal outcomes that can reasonably be expected, based on intentional, deliberate program evaluation at each implementation and evaluation stage.Discussion: The CBHPE Outcomes Theory of Change offers scholars and implementers a practical guide to enhance the quality and fidelity of implementation, evaluation, and research efforts related to CBHPE worldwide. Using this guide as a framework, programs can plan, implement, and then examine whether the intended outcomes of CBHPE have been realized.

Introduction: Assessor stringency/leniency (ASL), the tendency for an assessor to consistently provide low or high scores, has been shown to have educationally important effects on learner assessment scores in multiple settings. To date, there is no clear understanding of the underlying drivers of ASL in the context of medical education. Some authors have hypothesized a link between personality traits and ASL, but there is currently insufficient data to reach any conclusions. This study seeks to determine whether there is a significant association between physician assessors' personality traits and ASL.Methods: This prospective cohort study was conducted at an academic emergency department in Ottawa, Canada. Participating assessors volunteered to complete the IPIP‐Neo 120, a personality questionnaire based on the five‐factor model. All end‐of‐shift assessments completed between July 1, 2021, and June 30, 2022, were collected, and ASL was quantified for each assessor using the mean delta method. Linear regression was used to assess the correlation between personality scores and ASL.Results: A total of 2127 assessments, representing 184 learners, were analyzed. Twenty‐five assessors were enrolled, with a wide distribution of assessor personality scores for each trait. While there was a trend toward leniency with increasing assessor extraversion, this did not reach statistical significance (p = 0.07, R² = 0.13). There was no significant link between other personality traits and ASL.Conclusion: Integrating our findings with the existing literature, we conclude that personality traits are likely not educationally important drivers of ASL in medicine. Future research should examine other possible contributors to ASL in medical education.

The peer review process supports authors by providing feedback on manuscripts from external, expert readers. However, not all reviews are supportive. Some reviews are just painful. But just how painful are they? In this study, we set out to validate a matrix describing the levels of pain authors experience in response to the sting of peer reviewer comments. The study was carried out in two phases. In Phase 1, we developed a matrix combining two scales—i.e. the Suffering Scale and the Grind Gauge. The first categorises review‐induced pain across four levels, with Level 1 being the least pain and Level 4 the greatest pain. The second categorises the amount of work required by the author to respond to and address reviewer comments, with Level 1 being the least amount and Level 4 the greatest amount. In Phase 2, we tested the performance of the matrix by recruiting multiple, global study sites to provide performance data. This work resulted in the development and validation of the Reviewer‐Imposed Pain (RIP) matrix. A statistician analysed our data and assures us that the RIP matrix is now a validated tool. Our study shows that the pain associated with academic peer review affects physiologic, affective, and cognitive dimensions. This tongue‐in‐cheek paper pokes fun at the peer review process; however, the response from survey participants suggests that the process is not necessarily funny. Peer review is essential for advancing science; however, for these advancements to occur, peer reviewer comments need to be constructive. The RIP matrix encourages both authors and reviewers to reflect on the impact of reviewer comments. This is essential because, as previous research has illustrated and as Voltaire succinctly stated, pain is real.

Introduction: The field of medical education (ME) has grown substantially over the past decades, yet questions remain about its scope and boundaries. This study examines how research topics and institutional collaborations have evolved in ME from 2000 to 2019. Methods: Adopting a post-positivist stance and using bibliometric network analyses, we examined metadata from 31,338 publications across 22 core ME journals indexed in the Web of Science. We analyzed trends in institutional collaboration and the development of research themes. Extracted metadata included authors’ institutional affiliations and KeyWords Plus (n = 18,218). Bibliometric analyses were conducted using VOSviewer, a widely used tool for network mapping. We generated co-authorship networks to trace institutional collaboration and co-word networks to identify thematic clusters. Results: Co-authorship networks revealed increasing collaboration, with U.S. institutions remaining central and Canadian and Dutch institutions gaining prominence. Co-word analyses identified three stable clusters—teaching and learning, quantitative, and psychosocial—with teaching and learning dominant across all periods and the quantitative cluster expanding in recent years. Discussion: Findings show the consolidation of teaching and learning as the foundation of ME, alongside diversification through quantitative and psychosocial themes. Growing collaborations suggest the field’s maturation, though geographic imbalances persist. Limitations include reliance on a restricted set of Web of Science journals, which overrepresent English-language and highly cited publications, and the use of KeyWords Plus as a proxy for themes. This study offers an evidence-based mapping of ME’s evolution and provides a framework for future research on the interdisciplinary and global dynamics of the field.