Building the continuum of competency-based medical education

achievement of competency milestones at variable rates, the establishment of effective mechanisms to coordinate standards and the establishment of rigorous and progressively higher levels of competency. In spite of this and other calls to action, the education community has just begun the work of describing meaningful developmental outcomes for each educational silo and has yet to effectively integrate this work across the professional career of a physician [3]. The gaps reported by Chen are not unique. Studies by Crosson and Mattar have identified similar deficiencies in resident and fellow competence at significant transitions including the transition to unsupervised practice [4, 5]. Crosson specifically commented, ‘educators, accrediting bodies and other stakeholders will need to work together to clarify gaps, prioritize them and determine which can best be addressed in medical school, residency, fellowship or clinical practice’. Given what we know about the limitations of self-assessment, and despite the low response rate observed in the Chen study, the fact that students report feeling ill-prepared in many of the core competencies needed for current and future practice is striking. The development of milestones that define the ACGME and CanMeds competencies and entrustment-based assessment utilizing the concept of entrustable professional activities (EPAs) have begun to better define this continuum [6–8]. As granular descriptions of the knowledge, skills and attitudes/ behaviours that define the competencies, milestones provide a shared understanding of competence, enhance feedback and provide greater uniformity when making promotion decisions [9, 10]. Entrustment-based assessments focus on the actual work of patient care: those discrete activities that all physicians are trusted to do. While still nascent, core EPAs at the transition from undergraduate to graduate training and beyond have already been proposed [11, 12]. However, because future physicians will need to Paul Batalden is credited with the observation that, ‘every system is perfectly designed for the results it generates’. In this volume of Perspectives in Medical Education, Chen and associates highlight the importance of this observation by describing self-reported gaps in preparedness of learners transitioning from undergraduate to graduate medical training [1]. By identifying these gaps, these authors highlight one of the most serious challenges facing the medical education community as it operationalizes competency-based medical education. Using Batalden’s axiom, learners experience a medical education system that is perfectly designed to inadequately prepare them for the next stage of their professional development and ultimately to work competently in the health care delivery system of the future. For over 100 years, medical education has been delivered along a continuum that can be characterized as a series of linked, but independent silos. While the design of these silos may vary worldwide, they typically include premedical education, undergraduate medical education, graduate medical education and continuing medical education. Historically, the alignment of learning outcomes across these silos has reflected a confederacy rather than a union of stakeholders. Recognizing this reality, in 2010, the Carnegie Foundation called for a unified roadmap for medical education across this continuum [2]. Key elements of that roadmap included standardized core learning outcomes, flexibility to allow the