Holly Caretta-Weyer

It is generally assumed that competency-based health professions education (CBHPE) is a positive and ongoing educational reform. However, the assumption that CBHPE naturally leads to more equitable outcomes has not been thoroughly examined. This ‘Eye Opener’ identifies global challenges in implementing equitable CBHPE, with particular attention to majority-world (low- and middle-income) contexts. These tensions include: 1) variable approaches to adoption that limit transferability, 2) uneven infrastructure for implementation and innovation, 3) export of predeveloped conceptual frameworks that may not be locally fit for purpose or implemented alongside collaborative knowledge exchange, and 4) pressures for fidelity in implementation that impede flexibility and compromise effectiveness in local contexts. In each area of tension, the authors outline challenges to equity and suggest potential ways forward. From their analysis, the authors propose that equity must be deliberately embedded in CBHPE at multiple levels, and the proposed solutions include addressing equity on three levels – the micro level of individual learner access and assessment; the meso level of curricula, faculty development, and program learning culture; and the macro level of national accreditation standards and education policies. Examples of opportunities at each level and for each of the five core components of CBHPE are also provided. The authors argue for a shift in perspective—from “outside-in,” in which Western nations export CBHPE to the majority world, to “outside-in, inside-out and all around,” in which CBHPE frameworks are co-created to leverage contributions from both Western and majority-world education systems. They believe that more thoughtful adaptation and embracing Global South ways of knowing, doing, and being, rather than simple replication, alongside the continuous application of a social justice lens, are needed to ensure that CBHPE serves all communities and contributes to equitable, high-quality learning and healthcare without discrimination.

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) 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.

Background: Advanced Emergency Medicine Ultrasonography (AEMUS) has become a recognized subspecialty within Emergency Medicine, yet no unified national curriculum or assessment framework exists for fellowship training. As competency‐based medical education develops, entrustable professional activities (EPAs) offer a structured approach to defining essential tasks, guiding curriculum design, and standardizing assessment. To support high‐quality, equitable AEMUS fellowship training, the Education Committee of the Society of Clinical Ultrasound Fellowships (SCUF) convened a diverse expert panel to develop core EPAs for AEMUS fellows. Methods: We employed a modified virtual nominal group technique (vNGT) to achieve expert consensus. Eleven AEMUS education leaders participated between July 2024 and June 2025. Prior to the initial session, panelists reviewed curated literature and independently generated EPA ideas. During structured virtual meetings, participants engaged in round‐robin idea sharing, clarification, and discussion, guided by existing national AEMUS standards of certification and program accreditation. Ideas were subsequently subjected to iterative voting, with ≥ 80% agreement required for acceptance. Three vNGT rounds were conducted. Accepted EPAs were further refined by assigned primary editors. Results: The expert panel produced 15 core EPAs spanning four established domains: Administration, education, sonography skills, and scholarship. Professionalism was designated as its own domain. Panel deliberations focused on feasibility within a one‐year fellowship, post‐graduation scope of practice, and variability in program resources. The group endorsed a modified entrustment scale tailored to AEMUS to guide assessment across EPAs. Conclusion: Using a structured consensus process, we developed the first EPA‐based framework for AEMUS fellowship training. These EPAs provide a foundational curriculum and assessment structure intended to support program rigor, promote national consistency, and prepare fellows for independent advanced practice and leadership in clinical ultrasound.

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: 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: Competency‐based medical education (CBME) focuses on the attainment of defined skills independent of the time spent in training. Emergency Medicine (EM) is starting the long process of CBME implementation. Methodology: In preparation for the 2025 Society for Academic Emergency Medicine (SAEM) Consensus conference whose goal is to define the research agenda around CBME, a diverse workgroup of expert educators convened. They conducted a literature review and developed a large roster of potential research questions. Analysis: Through a modified Delphi process, they prioritized 10 research questions related to CBME implementation. The final group of questions fell into three broad categories: (1) Program evaluation, (2) Change management, and (3) System needs and resources. Implications: Implementation of CBME in EM will require intentional incorporation of change management strategies and systematic development of program evaluation. This will minimize the risk of negative outcomes resulting from ineffective implementation strategies and promote the successful uptake of CBME within the specialty.

The 2025 SAEM Consensus Conference: “Competency‐Based Training and Certification: The Future of Emergency Medicine Education” provided the opportunity to further the development of competency‐based medical education (CBME) in Emergency Medicine. This perspective argues that CBME is a flexible philosophy of training rather than a fixed checklist or recipe, and as such can and should manifest variably across contexts and specialties. The authors reason that by viewing CBME as a philosophy, multiple beneficial corollaries follow: (1) CBME training will demand a balance of fidelity of philosophical implementation with necessary context‐specific flexibility. (2) Philosophies are dynamic, and as such CBME has already evolved over time and will continue to do so. (3) Medical education has agency to direct such evolution and to choose different philosophies of training if CBME is not delivering what it purports to do. Emergency Medicine is encouraged to approach their work through the philosophy of CBME by embracing CBME principles with training and reframing assessment.

Purpose: Patient care is inherently collaborative, yet traditional assessment methods often emphasise individual performance. This study explores how the concept of interdependence can be used for assessment within clinical settings by examining how faculty in Emergency Medicine (EM) and Paediatrics identify interdependence and distinguish between the different types when assessing residents. Methods: We employed a mixed‐methods survey design, recruiting board‐certified faculty from EM and Paediatrics across Canada and the United States. Participants watched three different videos, each ranging from 3 to 7 minutes that depicted interdependent performances. After watching the videos, participants completed relevant Entrustable Professional Activity (EPA) assessments. Then, each video was broken down into smaller clips for participants to watch again. After watching each of the individual video clips, participants answered questions regarding their observations of interdependence, which included the type and appropriateness. After watching all the videos and their associated clips, participants provided Milestone ratings. Results: A total of 126 faculty members participated, evenly split between EM and Paediatrics. Descriptive statistics revealed that participants were able to precisely identify interdependence, but notable differences in distinguishing between supportive and collaborative interdependence existed based on specialty. Open‐ended responses support the notion that faculty conceptually understand the interdependence they observed in clinical scenarios. Correlation analyses indicated various relationships between interdependence assessments, EPAs and Milestone ratings. Conclusion: This study highlights the complexities of assessing interdependence. Although faculty demonstrated an understanding of interdependence and were able to identify it, challenges remain with classification during real‐time assessments. These findings underscore the need for faculty development and reflection on how to best use assessments of interdependence to measure residents' performance and contributions to collaborative patient care.