Although competency-based medical education (CBME) has attracted renewed interest in recent years among educators and policy-makers in the health care professions, there is little agreement on many aspects of this paradigm. We convened a unique partnership – the International CBME Collaborators – to examine conceptual issues and current debates in CBME. We engaged in a multi-stage group process and held a consensus conference with the aim of reviewing the scholarly literature of competency-based medical education, identifying controversies in need of clarification, proposing definitions and concepts that could be useful to educators across many jurisdictions, and exploring future directions for this approach to preparing health professionals. In this paper, we describe the evolution of CBME from the outcomes movement in the 20th century to a renewed approach that, focused on accountability and curricular outcomes and organized around competencies, promotes greater learner-centredness and de-emphasizes time-based curricular design. In this paradigm, competence and related terms are redefined to emphasize their multi-dimensional, dynamic, developmental, and contextual nature. CBME therefore has significant implications for the planning of medical curricula and will have an important impact in reshaping the enterprise of medical education. We elaborate on this emerging CBME approach and its related concepts, and invite medical educators everywhere to enter into further dialogue about the promise and the potential perils of competency-based medical curricula for the 21st century.

The introduction of competency-based postgraduate medical training, as recently stimulated by national governing bodies in Canada, the United States, the United Kingdom, The Netherlands, and other countries, is a major advancement, but at the same time it evokes critical issues of curricular implementation. A source of concern is the translation of general competencies into the practice of clinical teaching. The authors observe confusion around the term competency, which may have adverse effects when a teaching and assessment program is to be designed. This article aims to clarify the competency terminology. To connect the ideas behind a competency framework with the work environment of patient care, the authors propose to analyze the critical activities of professional practice and relate these to predetermined competencies. The use of entrustable professional activities (EPAs) and statements of awarded responsibility (STARs) may bridge a potential gap between the theory of competency-based education and clinical practice. EPAs reflect those activities that together constitute the profession. Carrying out most of these EPAs requires the possession of several competencies. The authors propose not to go to great lengths to assess competencies as such, in the way they are abstractly defined in competency frameworks but, instead, to focus on the observation of concrete critical clinical activities and to infer the presence of multiple competencies from several observed activities. Residents may then be awarded responsibility for EPAs. This can serve to move toward competency-based training, in which a flexible length of training is possible and the outcome of training becomes more important than its length.

Cognitive Load Theory (CLT) builds upon established models of human memory that include the subsystems of sensory, working and long-term memory. Working memory (WM) can only process a limited number of information elements at any given time. This constraint creates a "bottleneck" for learning. CLT identifies three types of cognitive load that impact WM: intrinsic load (associated with performing essential aspects of the task), extraneous load (associated with non-essential aspects of the task) and germane load (associated with the deliberate use of cognitive strategies that facilitate learning). When the cognitive load associated with a task exceeds the learner's WM capacity, performance and learning is impaired. To facilitate learning, CLT researchers have developed instructional techniques that decrease extraneous load (e.g. worked examples), titrate intrinsic load to the developmental stage of the learner (e.g. simplify task without decontextualizing) and ensure that unused WM capacity is dedicated to germane load, i.e. cognitive learning strategies. A number of instructional techniques have been empirically tested. As learners' progress, curricula must also attend to the expertise-reversal effect. Instructional techniques that facilitate learning among early learners may not help and may even interfere with learning among more advanced learners. CLT has particular relevance to medical education because many of the professional activities to be learned require the simultaneous integration of multiple and varied sets of knowledge, skills and behaviors at a specific time and place. These activities possess high "element interactivity" and therefore impose a cognitive load that may surpass the WM capacity of the learner. Applications to various medical education settings (classroom, workplace and self-directed learning) are explored.

Article Citation: Olle ten Cate (2013) Nuts and Bolts of Entrustable Professional Activities. Journal of Graduate Medical Education: March 2013, Vol. 5, No. 1, pp. 157-158. doi: http://dx.doi.org/10.4300/JGME-D-12-00380.1

Curriculum development for the workplace using Entrustable Professional Activities (EPAs): AMEE Guide No. 99. . ???aop.label???.