Exploring the Intentions, Experiences, and Adaptations of Postgraduate Internal Medicine Programs in the Implementation of Competence by Design.

Abstract

Competence by Design (CBD) is a Canadian competency-based medical education (CBME) initiative aiming to enhance residency training through clearly defined outcome competencies, sequenced progression, tailored learning experiences, competency-focused instruction, and robust programmatic assessment. Internal medicine (IM) residency programs nationwide transitioned to CBD in 2019, prompting early evaluation of implementation fidelity. We aimed to examine CBD implementation in four IM programs approximately 18 months post-launch to identify key successes and challenges. A rapid evaluation study was conducted with four IM residency programs in Canada. Data were collected via interest holder interviews and focus groups with residents and faculty at each site. Qualitative thematic analysis was guided by the CBME Core Components Framework to explore intended versus actual implementation, and identify program-level adaptations. Key successes included more frequent feedback and direct observation of trainees, enhanced coaching relationships, and proactive curricular review to align training with outcome competencies. However, challenges were also prominent, including unclear expectations of trainees and faculty regarding required performance at different training stages, reflecting gaps in shared understanding of sequenced progression. Technological limitations of electronic assessment systems hindered efficient use of data for tracking progress, and the increased assessment burden contributed to assessor fatigue. Early evaluation of CBD implementation in IM programs in Canada has yielded notable improvements in feedback culture, direct observation, and curriculum alignment. Significant cultural and logistical challenges persisted, including confusion about expectations and high assessment workload suggesting areas for improvement. Ongoing program refinements, faculty development, and technological support are needed to realize CBD's full potential in IM training.