Mary Ellen J. Goldhamer

Health professions education is experiencing a paradigm shift, from a focus on the structures and processes of education to a focus on the outcomes health professionals must demonstrate to meet the healthcare needs of the public served. The Competency-based Health Professions Education (CBHPE) movement now has two decades of implementation experience in some contexts. Educators across health professions working on the design, planning, implementation, or maintenance of competency-based systems can benefit from the lessons learned through implementation efforts to date. In this manuscript, the authors capitalize on the experiences of the International Competency-based Health Professions Educators Collaborative (ICBHPE), a multinational and interprofessional group of educators, to summarize some of the common challenges faced and adaptations made after implementation. The lens of post-implementation challenges allows a view of CBHPE programs as they have matured. The challenges are organized by the five core components of CBHPE: outcome competencies, sequenced progression, tailored learning experiences, competency-focused instruction, and programmatic assessment. For each component, the authors review those challenges that are most common and provide examples of adaptations that have been successful. The challenges and their adaptations are synthesized through “lessons learned” to provide practical insights for designing, planning, implementing, and maintaining CBHPE programs to continue driving the evolution of CBHPE globally.

Competency-based health professions education (CBHPE) has transformed learner education through explicit competencies, sequenced progression, direct observation, coaching, and programmatic assessment. However, faculty development—the mechanism that should prepare educators to enact CBHPE—has not undergone a parallel evolution. This misalignment limits the effectiveness and sustainability of CBHPE. In this paper, the authors propose a model of Competency-Based Faculty Development (CBFD) that applies CBHPE design principles to the growth of educators and introduces the Master Adaptive Teacher (MAT) as a developmental outcome for faculty. Using Van Melle’s five core components of CBHPE as an organizing framework, the authors synthesized existing educator competency frameworks, literature on adaptive expertise, faculty development theory, and implementation science and mapped these components to faculty development structures, strategies, and assessment processes. The core components can be directly translated to faculty development. Implementing CBFD requires (1) defining educator competencies aligned with institutional roles, (2) building developmental pathways linked to outcomes, (3) integrating flexible, workplace-based learning and coaching, (4) designing instruction that models CBHPE principles, and (5) adopting a longitudinal assessment program using multiple data sources. The MAT framework further operationalizes adaptive expertise as a core capability developed through reflection, coaching, community, and system-level support. In summary, CBFD represents a structural redesign that positions faculty as learners within a developmental ecosystem. When aligned with culture and institutional infrastructure, CBFD strengthens educator identity, enhances teaching quality, and enables CBHPE to achieve its full potential.

Competency-based health professions education (CBHPE) is in various stages of implementation around the globe. While program evaluation is essential to drive improvement, adaptation, and the evolution of CBHPE, it may be intimidating for educators given the breadth of program evaluation methods and wide variation globally in local resources and expertise. In this manuscript, the authors summarize key examples of program evaluations highlighting an array of CBHPE implementations, evaluation methods, and settings. The examples are organized by five evaluation focus areas: readiness to implement, fidelity of implementation, assessment program validity, educational outcomes, and clinical outcomes. Illustrative examples from around the globe provide a roadmap featuring program evaluation methods that may be adapted to the setting, goals, size, and resources of individual programs. Capturing the evaluation of CBHPE implementation is essential for informing ongoing implementation efforts and iterative improvements to CBHPE.

The educational alliance describes a framework for the trusting relationship between trainee and supervisor as they engage in meaningful, effective feedback. This framework emphasizes interpersonal relationships, shared goals, and agreement on actionable steps to achieve these goals. In this theory-informed conceptual analysis, the authors propose that the educational alliance logically extends to support and enhance competency-based medical education and health professions education, collectively known as competency-based health professions education (CBHPE). Authors describe how key features of the educational alliance align with the five core components of CBHPE: outcome-based competencies, sequenced progression, tailored learning experiences, competency-focused instruction, and programmatic assessment – by facilitating individualized learning that is centered on the trainee-supervisor relationship. Relevant theories that support the effective implementation of the educational alliance in CBHPE to advance learning include growth mindset and self-regulated learning theories. Authors present specific actionable recommendations regarding trainee and supervisor roles and responsibilities within an educational alliance for creating shared mental models, building relationships, engaging in team training, and attending to ethical considerations, including conflicts of interest and using data for the determination of trainee competency and advancement. Additionally, the authors introduce an Educational Agreement applicable to all training levels, designed to foster, guide, and strengthen the educational alliance. The Agreement is intended to be voluntary, co-constructed, and may be adapted to local contexts. Finally, the authors identify areas for future empirical examination through research on the educational alliance in CBHPE programs.

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: Graduate medical education (GME) selection processes may pose significant barriers to implementing competency-based health professions education (CBHPE). Current selection metrics are largely nonpredictive of future success, and the removal of clerkship grades has given rise to a shadow economy of effort focused on publications, research hours, and other activities that detract from clinical training. This misalignment between selection practices and CBHPE principles constitutes a wicked problem that requires innovative approaches to develop new solutions. Methods: We conducted a TRIZ (Theory of Inventive Problem Solving) exercise, a Liberating Structure that challenges assumptions by asking what would make a process fail spectacularly. Eight participants representing three countries, two continents, and four medical specialties convened via video conference in October 2025. Participants served as proxies for key stakeholder groups (students, program directors, medical school leadership, and patients/society), identified elements of the worst-possible selection system, compared them to current practices, and proposed solutions. Results: Participants identified numerous elements characterizing suboptimal selection systems, including inequitable and biased processes, arbitrary decision-making, gaming of metrics, resource-intensive processes that fail to differentiate candidates, misinformation from training sites, and prioritization of self-interest over patient needs. Many of these elements were recognized as present in current GME selection systems worldwide. Discussion: Recommendations to align selection with CBHPE included embedding social accountability throughout selection, leveraging coproduced competency frameworks, prioritizing workforce diversity, ensuring equity in assessment and selection, incentivizing a growth mindset through a transparent learner handover, and implementing structural innovations, including preference signaling or potentially lottery systems, to better align CBHPE and selection.

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.

Background Promotion in Place (PIP) is a competency-based time-variable graduate medical education innovation model developed at Mass General Brigham and not previously tested for feasibility, acceptability, or outcomes. Objective To assess early PIP outcomes in the Massachusetts General Hospital (MGH) pathology residency program. Methods Approved by the American Board of Pathology, PIP was launched in 2021. The Clinical Competency Committee developed and implemented explicit graduation criteria. Trainees meeting criteria who chose early graduation became credentialed, board-eligible junior attendings at MGH in a period of “sheltered independence” and were assessed using the Focused Professional Practice Evaluation. PIP sheltered independence (PIP-SI) participation rates, time, and activities were followed. We also assessed board pass rates, Milestones, and patient safety reports for all residents. We measured additional participant time and resources. Results Over 4 years, 24 of 30 (80%) residents qualified for PIP-SI, 17 of 24 (71%) accepted, and 7 of 24 (29%) declined. Eleven of 17 (65%) had a period of sheltered independence as junior attendings (median 9 weeks [range 5-24 weeks]) in various anatomic and clinical pathology roles. Of 6 eligible residents not participating, 4 took a leave of absence, and 2 experienced licensing or visa delays. All residents passed their board examinations on the initial attempt and none had concerns identified through patient safety reports. Time and resource requirements were acceptable to stakeholders. Conclusions Most residents met criteria for PIP-SI and accepted, demonstrating high acceptability. PIP-SI was feasible with implementation into standard workflows over 4 years. PIP-SI attendings had no adverse outcomes identified.