Daniel J. Schumacher

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.

Purpose: Visual analytics is a nascent and underexplored area in the medical education literature that can assist in synthesizing large volumes of data and information to provide actionable insight. This scoping review aims to identify: 1) the characteristics of the studies that have applied visual analytics in medical education, 2) how visual analytics are being used to support medical education efforts. Method: This study followed the Joanna Briggs Institute (JBI) scoping review guidelines to search four databases in mid-April 2026: PubMed, IEEE Xplore, Scopus, ACM Digital, along with Google Scholar. Key search terms included “medical education” and “visual analytics”; papers that did not implement visual analytics systems in the medical education context were excluded. Variables of the eligible papers were extracted and further analyzed in terms of study characteristics (publication year, study location, primary focus & level of trainees assessed) and application of visual analytics (type of visualization, framework guidance, hardware/software, evaluation technique). Results: Of the 39 eligible papers from 584 screened, 20 (51.3%) were published in the United States. Using visual analytics for learner competency assessment and quality improvement of training programs were the primary focuses. For trainees, nearly all papers focused on assessing residents and medical students. More than 28 (71.8%) studies utilized an interactive tool/dashboard and/or applied an evaluation technique. Only 14 (35.9%) involved a framework-guided design of the visualization. Conclusions: This review highlights that while visual analytics is maturing in medical education, systemic application requires adopting framework-guided visualization design, expertise-matched tools, and goal-oriented evaluation. Future research should prioritize interoperable frameworks for knowledge sharing, controlled field studies assessing impacts on learner competencies, and patient outcomes, and "cross-continuum" dashboards spanning pre-medical through faculty levels. These strategies allow educators and learners to make sense of complex educational data through visual analytics dashboards, ultimately enhancing assessment and patient care quality.

This Foreword introduces the Advancing Competency-Based Health Professions Education (CBHPE) collection of papers. These articles seek to synthesizing practical guidance for CBHPE implementation at a time when CBHPE is rapidly expanding across the globe. Together, the papers in this series highlight that meaningful CBHPE implementation requires attention to adaptive change, fidelity to core components, relational work among learners and supervisors, responsiveness to local context, and systematic study of implementation processes and outcomes.

Background/Problem: Competency-Based Health Professions Education (CBHPE) aims to improve workforce readiness, patient safety, and equity, but achieving these outcomes requires sustained investment. The “No Free Lunch” (NFL) rule underscores that value cannot be realized without visible costs, which can be financial, cultural, temporal, and structural. Although costs are ideally shared across the health professions education and health care ecosystem, interest holders often invest unevenly despite broad benefits. As a result, many programs and institutions struggle to implement and sustain CBHPE, even as adoption grows globally.Purpose/Approach: This paper examines how “value” and return on investment (ROI) in CBHPE are conceptualized across learners, faculty, institutional leaders, governments/funders, clinical systems, accreditors/regulators, professional organizations, and patients/communities. The authors describe tensions regarding who invests and who benefits, identify practical trade-offs, and highlight opportunities for alignment across settings, including low-resource contexts. We propose an interest-holder-informed framework that links typical investments to forms of value/ROI to support explicit, context-sensitive cost-sharing.Key Insight: Value in CBHPE is contextual, shaped by the mission of the interest holder, the time horizon for returns, and available resources. Because benefits are often diffuse or delayed, ROI may be difficult to demonstrate, reinforcing underinvestment. Value must ultimately be judged by benefit to patients and communities.Conclusion: CBHPE cannot rely on the goodwill of those closest to implementation. Sustainability requires clear articulation of value, shared responsibility for costs that are proportional to benefits, and alignment between goals and resources among interest holders. CBHPE should be treated as long-term infrastructure for better care, not a temporary reform.

Purpose: Competency committees use group decision-making procedures to determine when learners may advance in their training. These committees have been well-described in graduate medical education (GME) and efforts have explored transferability of this model to undergraduate medical education (UME). Existing research in UME has focused on committee structure and member perspectives, with little examination of decision-making processes. This study explored how UME competency committees use group decision-making to arrive at competency determinations. Method: This theory-informed, multi-institutional ethnographic study was conducted at 7 medical schools in the United States between 2023 and 2024. Participants were members of each medical school’s competency committee. Data sources included observations of committee deliberations and member interviews. The authors analyzed data using an abductive approach, combining inductive and deductive reasoning with theory to formulate an understanding of group decision-making. Effective group process, a theoretical model for group-decision making in GME, served as the primary lens for analysis. Results: A total of 20 competency committee meetings were observed, during which 242 students were discussed. Committees formulated their decisions in a complex context. Factors contributing to the complexity included the existence multiple groups concerned with student performance (eg, competency committees, advancement committees), other metrics for performance (ie, grades), and academic polices. A similar stepwise process was used to make decisions across sites. However, there was significant inter-institutional variation in procedures and rules related to student presentations and deliberations, voting procedures, and the chair’s role. Outcomes were determined by locally established thresholds and decisions varied; some rendered remediation or entrustment decisions while others provided developmental feedback. Conclusions: Decision-making in the UME setting is complex with features distinct from GME. UME competency committees therefore require unique considerations to support effective group decision-making and mitigate challenges and threats to the process.

Purpose: To develop TRainee Attributable & Automatable Care Evaluations in Real‑time (TRACERs) for inpatient diabetes management, collect validity evidence for their use in formative assessment, and explore performance variation across residents and institutions. Method: In 2023, a multi‑institutional team created 2 TRACERs based on type 2 diabetes guidelines—discourage bolus‑only insulin (TRACER #1) and encourage basal (± bolus) insulin (TRACER #2)—for internal medicine residents at 3 large residency programs. Residents were attributed to inpatient admissions based on placing the most medication orders in the first 12 hours. Structured queries extracted 35 discrete variables from the electronic health record. Two experts per institution reviewed random admissions (July-August 2022) to establish criterion validity. A retrospective cohort (July 2020-June 2023) added validity evidence. Results: Automated extraction achieved ≥96% sensitivity and ≥95% specificity when compared to manual review. Among 615 residents attributed to 6192 admissions of patients with type 2 diabetes at high risk for hyperglycemia, TRACER #1 occurred in 42.6% (1689/3965) of admissions at Program A, 28.9% (408/1410) at Program B, and 26.7% (218/817) at Program C. TRACER #2 occurred in 44.9% (367/817) of Program C admissions versus 24.2% (959/3965) at Program A and 28.2% (397/1410) at Program B (all P < .001). Four resident-level insulin‑ordering profiles were identified—consistent basal-bolus insulin use (most guideline-concordant), basal-predominant, bolus-predominant, and bolus-only (most guideline-discordant)—with between‑resident variation exceeding between‑program differences. Longitudinally, cohort-level trends masked opposing individual trajectories—some residents improved with exposure while others worsened—and performance tertiles were distinguishable early in training. Conclusions: TRACERs revealed substantial resident‑ and institution‑level variation in insulin‑ordering practices, including guideline deviations, demonstrating potential for real‑time formative feedback. Multi‑institutional implementation highlighted scalability barriers, including electronic health record heterogeneity and workflow‑dependent attribution, underscoring the need for continued refinement and broader validation.

Introduction: Inequitable assessments in medical education disproportionately affect historically marginalized trainees and undermine development of a diverse physician workforce. With programs around the world incorporating competency-based medical education (CBME), understanding whether assessment disparities exist in specialty-specific competency frameworks is critical. This study examined disparities in program-reported performance assessments of pediatric residents across demographic groups in two pediatric-specific competency frameworks: the General Pediatrics Entrustable Professional Activities (EPAs) and Accreditation Council for Graduate Medical Education (ACGME) pediatric milestones. Methods: This prospective cohort study was conducted at 15 pediatric residency programs in the U.S. across the 2021–22, 2022–23, and 2023–24 academic years. Clinical Competency Committee-assigned entrustment-supervision levels for 5 EPAs and all milestone levels were collected twice yearly. Residents self-reported ethnoracial group and sex, analyzed as exposure to systems of racism and sexism. Time-to-event analysis and growth curve modeling with intersectional analytic approaches examined disparities across demographic groups. Results: 475 of 803 (59%) residents completed demographic surveys, including 17.3% underrepresented in medicine (URiM), 22.9% Asian, 56.4% white, 70.7% female, and 27.8% male. Time-to-event analyses revealed significant differences for Asian and Asian female residents in reaching the highest EPA supervision level across all EPAs. Growth curve analyses showed Asian males had significantly flatter growth trajectories for EPA 15 (Lead an Interprofessional Team), resulting in lower estimated scores at graduation. URiM female residents had significantly lower scores on EPA 16 (Facilitate Handovers) at graduation. URiM residents showed lower Milestone growth curves for interpersonal communication, and Asian residents for systems-based practice. Discussion: Subtle but meaningful disparities exist in program-reported assessments of pediatric residents, with distinct patterns affecting Asian and URiM residents across both frameworks. These findings highlight the need for proactive attention to equity in competency-based medical education assessment systems.

Introduction: Researchers have emphasized the need to integrate patients into medical education, specifically advocating for patient-based assessments within medical curricula. However, there is a critical gap in understanding how patient involvement is conceptualized and operationalized within assessment practices. Thus, we aimed to gain a deeper understanding of the current discourses surrounding the integration of real patients in the assessment of medical trainees. Methods: We performed a Discourse Analysis using Hodges’ empirical discourse methodology. Coding of the 54 included articles initially focused on “conceptualization,” “ways patients participate,” “opportunities created,” “challenges,” and detailed aspects of “assessment,” including content, development, validation, and format. The team iteratively discussed the codes and themes until they reached a consensus about the data interpretation. Results: We identified three distinct—yet not always mutually exclusive—discourses: (1) patients as survey-fillers, (2) patients as feedback providers, and (3) patients as part of programmatic assessment. Discussion: By illuminating these discourses, this study deepens our understanding of why patient involvement takes the forms it does and suggests that moving toward positioning patients as part of programmatic assessment may offer a more meaningful basis for patient partnership in the assessment of medical trainees.