You should care about Competence by Design. Here’s why.

March 3, 2020 | Author: Guest post

The rigors of training in the Canadian postgraduate residency system lead to exceptional and skilled physicians dedicated to patient care. Even years after residency, as you continue to acquire new skills and knowledge, what you learned as a resident is not forgotten. Neither are the memories of writing the exam. We are a profession of individuals committed to advancement and evolution.

We achieve great standards and serve our patients well, and yet when you look at our training model, all the way back to Flexner, it remains virtually unchanged. The resident learning environment and medicine overall have changed dramatically in the past 100 years, and the transition to Competence by Design is ensuring that Canadian residency training reflects the realities of 21st century practice.

Fundamentally, this is why Competence by Design matters. And why you should care.


The world is watching Canada

Both within Canada and across the world, there is a movement towards realigning medical education with a competency-based approach. For specialists training in Canada, this new system is called Competence by Design — a hybrid between time and competency-based systems. In a world that is constantly changing, you belong to an organization that continues to set the highest standards for cutting-edge specialty training.

Canada’s new postgraduate medical educational model outlines four stages of training, each of which have specific entrustable professional activities (EPAs) — basically, skills you should master as you progress. The stages are progressively set out as Transition to Discipline, Core, Foundations and Transition to Practice, and movement between stages is deliberate, providing a concrete framework on what a resident should be achieving in each stage. However, it’s not all about tick-boxes. With this new model comes a culture shift towards increased direct observation, coaching assessments geared towards promotion of learning, and learner-driven education. Learning rotations continue to take place in a variety of settings, including community hospitals and clinics. These frequent points of contact with mentors are also ensuring that if deficiencies do exist, they are identified early, allowing Fellows and supervisors to execute learning plans to fill these gaps in a structured way.

And you have a role to play as all disciplines convert to CBD.


Refine your observation and coaching skills

As a Fellow, you may already be directly or indirectly involved in Competence by Design. Or, perhaps you will be in the near or more distant future. Whenever it happens, it will be important for you to understand the fundamental aspects of the curriculum. For example, you may supervise residents who are under a Competence by Design model, which will require increased direct observation and familiarity with the assessments and assessment system. Eventually, as your specialty transitions to Competence by Design, there will be more exposure to trainees in this model.

Working to refine your skills in direct observation and coaching of trainees will also help you more accurately complete the assessments and give more accurate feedback to competence committees (committees under the Competence by Design curriculum that make promotion decisions for residents) and the trainees.

Eventually, all Royal College specialty Fellowship programs will transition to a competency-based model through Competence by Design.

Regardless of your current interest or involvement, we encourage you to stay informed. We will all eventually be supervising residents trained under a Competence by Design curriculum, working with those trained in this model, or involved in selecting a trainee or hiring a colleague who was trained under this model.


Change is never easy, but it is important

In Canada, we have the privilege of being stewards of our own system. With this great honour, comes great responsibility. Competence by Design is a reform designed to safeguard the calibre of our country’s postgraduate medical education system and high standards for future generations.

Our learning environment has changed dramatically since the Flexner report in 1910, with vast amounts of new information, technologies and the increased call for societal accountability. Resident expectations are also changing. They are seeking more coaching and assessments to prepare them for this rewarding, but challenging profession. Competence by Design updates our current system and standards to reflect the realities of 21st century health care, preparing the physicians of the future.

Guest authors Dr. Hall and Dr. Harris are actively involved in Competence by Design, and welcome your feedback. Please comment below or email them at

Jena Hall MD, MEd is a PGY4 OBGYN resident at Queen’s University. She has worked extensively with Queen’s residents, fellows, faculty and PGME leadership through the transition to CBME.



Kenneth A. HarrisKen Harris, MD, FRCSC, FACS, is the Royal College’s Deputy CEO & Executive Director of Specialty Education. He is a vascular surgeon who is deeply committed to health care education, particularly in the postgraduate realm.



This is the first in a four part Dialogue series dedicated to the transition to Competence by Design. If you want to learn more, stayed tuned for these future articles and visit the Royal College newsroom. For specific questions or to share feedback, contact


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