Competency-based medical education (CBME) is now the standard for physician education, highlighted by the implementation of competency-based Milestones1 at the graduate medical education level for all specialties by July 1, 2014. However, transitioning to CBME has been both difficult and bewildering, particularly as a student seeking assurance that my medical school education is preparing me to succeed in a competency-focused residency program. Even understanding CBME literature is difficult for a newcomer to the education field. Terms, such as competence and competency-based medical education are frequently used, but lack consistent definitions.2,3 What is really meant when my attending tells me I am competent or even, dyscompetent or starts talking about Milestones? Scholars also recognize this problem—individual authors and collaborators have worked to review term usage and promote universal definitions.46 However, those definitions have not been widely adopted, as evidenced by the continued reframing of terms in subsequent articles. To address this issue, we first identified “key elements” of commonly used CBME terms and used those elements to create a succinct definition for each term.

We used a 2-step approach: (1) we conducted a literature search for terms and associated definitions within CBME manuscripts, and (2) we identified frequently cited articles, key term elements, and associated definitions.

Step 1: Survey and Search Strategy for CBME Terms

A preliminary literature review on CBME using the terms competency and competency-based education yielded a set of repeatedly used terms. Those terms were used to frame our formal literature search. The period searched for each term depended on the presence of review articles containing compiled definitions from the preceding literature: competency and competency-based medical education4,5 were searched starting from January 1, 2010, with the search frame ending for all terms on December 31, 2012.

Each term was searched individually (table 1) in the following databases: CINAHL with Full Text, MEDLINE, Health Source: Nursing/Academic Edition, Academic Search Premier, Education Research Complete, Educational Administration Abstracts, ERIC, and MasterFILE Premier.3,4 Use of Boolean phrases narrowed the search to the field of medical education. Four article inclusion criteria were selected to create a feasible review strategy given the explosion of literature in CBME: (1) published in a peer-reviewed, English-language journal; (2) retrievable without cost (eg, medical college library, interlibrary access); (3) set in the continuum of medical education (undergraduate, graduate, or continuing); and (4) included the definition of the term under consideration (whether original or citing another source). Relevant articles from the literature on nursing and physician assistant education retrieved during the literature search were also included.

TABLE 1

Competency-Based Medical Education (CBME) Search Terms Presented by Number of Articles Meeting Inclusion Criteria and Unique Definitions

Competency-Based Medical Education (CBME) Search Terms Presented by Number of Articles Meeting Inclusion Criteria and Unique Definitions
Competency-Based Medical Education (CBME) Search Terms Presented by Number of Articles Meeting Inclusion Criteria and Unique Definitions

Definitions from articles fitting the inclusion criteria were extracted from the original text and compiled into a Word document. If review articles presented multiple definitions from previous literature, those definitions were also extracted. Competency and competence, although different terms, were often defined interchangeably in the literature, with only a few authors specifically addressing the difference.2 Thus we used the search term competenc* to include definitions for both words, and compiled them under the term competency.

Step 2: Key Terms and Definitions

We examined the definitions for each term extracted from the literature to create a key elements list for each term.

To serve as benchmarks for growth of the field, we identified frequently cited articles using Google Scholar “cited by” data as of December 31, 2012, which included citations by scholarly articles, educational programs, curricula, and journals that may not have been indexed using other search engines. Articles were considered frequently cited if they were cited 70 times or more.

Eight CBME terms consistently appeared in the literature: competency, competency-based medical education, dyscompetence, enabling competency, entrustable professional activities, facet of competency, meta-competency, and Milestone (table 1). Although multiple articles were retrieved for each term, only a few contained definitions (inclusion criteria No. 4). Four terms had definitions that drew on previous literature: competency-based medical education, entrustable professional activities, meta-competency, and Milestone. For example, the search for the term Milestone returned 32 articles without duplication, 5 of which fit the inclusion criteria (eg, had definitions). Although 3 of those 5 articles (60%) drew on a single reference7 to define Milestone, more typically authors defined terms without reference to previous work.

We identified 7 frequently cited articles (≥ 70 citations) as of December 31, 2012, including 2 review articles. Frequently cited articles were distributed across 5 journals with Academic Medicine and Medical Teacher each publishing 2 articles (table 2). To confirm that those articles continued to have impact after our key elements abstraction, we completed a second Google Scholar citation search, dated December 31, 2013, for comparison. We found an increase in the number of article citations, ranging from 35 to 249 new citations in a 1-year period (19%–107% increase).

TABLE 2

Comparison of Citation Frequency for Frequently Cited Articles From Initial Search Containing Competency-Based Medical Education (CBME) Term Definitions to 1 Year Later

Comparison of Citation Frequency for Frequently Cited Articles From Initial Search Containing Competency-Based Medical Education (CBME) Term Definitions to 1 Year Later
Comparison of Citation Frequency for Frequently Cited Articles From Initial Search Containing Competency-Based Medical Education (CBME) Term Definitions to 1 Year Later

From the retrieved definitions for each term, we identified key elements, drawing on only the 2010–2012 search results. Terms possessed between 3 and 7 elements. We used an iterative process to coalesce the key elements for each term to form a succinct definition (table 3).

TABLE 3

Competency-Based Medical Education Terms, Associated Key Elements, and Proposed Term Definition

Competency-Based Medical Education Terms, Associated Key Elements, and Proposed Term Definition
Competency-Based Medical Education Terms, Associated Key Elements, and Proposed Term Definition

As a medical student, I am surrounded by educational programs claiming to be “competency-based.” Yet our study showed that, although CBME terms were frequently used in the literature, they were rarely defined. When authors did attempt to define terms, they often promoted their own definitions without citing those that had been previously proposed, adding to the confusion. The lack of clear, cogent definitions for CBME terms is confusing to established educators, as well as medical students, who are seeking to judge whether a residency has “the competencies” and “Milestone” assessments in place.

Our search and analysis of definitions resulted in several key elements for each term, reflecting a wide breadth of inherent meaning. We sought to create succinct definitions for each term based on key elements to help establish a glossary for commonly used CBME terms. Adding the advanced beginner's8 perspective on the key elements associated with CBME terms further enriches the definitions.

Our approach has several limitations. By design, our definitions were limited to the peer-reviewed literature, thereby excluding definitions in other educational materials. The accuracy of the term's key elements and definitions are limited because they were analyzed only by the authors. These would be strengthened through confirmation from independent reviewers, an expert panel, and/or a Delphi process to achieve consensus. That said, we recognize the original intent of a term often evolves with practice because language has both descriptive and constructive functions.9 

We present time-stamped definitions for selected CBME terms to expedite the volition toward a common terminology. As we embark on the Next Accreditation System and the educational Milestones, periodic redefinition of commonly used CBME terms will enhance our ability to examine and communicate our underlying assumptions and strategies to trainees, faculty, program directors, and other stakeholders.10 As a soon-to-be resident, I look forward to hearing my staffing physician say, “Congratulations, you are competent, moving to proficient” with assurance that those terms mean the same to both of us.

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Author notes

Britlyn D. Orgill, BS, is a Third-Year Medical Student who completed this work as part of the Elsa B. & Roger D. Cohen MDs Fellowship in Medical Education, Children's Hospital of Wisconsin & Medical College of Wisconsin; and Deborah Simpson, PhD, is Director of Medical Education Programs, Aurora University of Wisconsin Medical Group, and Professor of Family & Community Medicine (Clinical Adjunct), Medical College Wisconsin and University of Wisconsin School of Medicine & Public Health.

Funding: Partial funding support was provided to the first author through the Elsa B. & Roger D. Cohen, MDs Fellowship in Medical Education at the Children's Hospital of Wisconsin & Medical College of Wisconsin.

This study was presented as a poster at the 39th Annual Society of Teachers of Family Medicine Conference on Medical Student Education, in San Antonio, TX, January 25, 2013.