January 5, 2021

Guidance Statement on Competency-Based Medical Education during COVID-19 Residency and Fellowship Disruptions

(originally posted September 2020; updated January 2022)

Due to the disruption in the educational components of some graduate medical education (GME) programs caused by the COVID-19 pandemic, competency-based medical education (CBME) is even more crucial in assessing the clinical competence of residents and fellows. The ACGME partnered with the certifying Boards to develop the following recommendations grounded in core CBME principles for programs, program directors, and Clinical Competency Committees (CCCs) to follow while facing COVID-19. 

The ACGME will share this information with the GME community and work with programs, program directors, CCCs, Review Committees, and certifying Boards during this period of disruption to learn about what works for the implementation of CBME over time.

Recommendations for Competency-Based Medical Education (CBME) during COVID-19

  1. Resident/fellow assessment must address all six Core Competencies and the pertinent subcompetencies within the specialty. Table 1 provides examples of a minimal set of assessment methods that could be used to support an entrustment decision in the context of disrupted education and training during COVID-19.

  2. The curriculum should be mapped to the Competencies by using the subcompetency milestones. (IV.A.2., IV.B.*)

  3. The programs of assessment must be mapped to the Competencies by using the subcompetency milestones to ensure all Core Competencies are assessed. (V.A.1.c))

  4. Review Committees will focus on the quality of educational programs:

    a. The specialty- and subspecialty-specific Program Requirements define the necessary and appropriate educational experiences (IV.C.)  and assessments for promotion in or completion of a residency or fellowship. (V.A.) Each program, through the authority of the program director with input from the Clinical Competency Committee (CCC), determines whether a resident or fellow has achieved the competence to practice safely and without supervision. 

    b.
     The ACGME recognizes that certifying Boards in each specialty will define, describe, and communicate the amount of time and number of patients or procedures (if applicable) they will require of a resident or fellow to meet Board eligibility standards. 

    c.
     Review Committees and the respective Boards will coordinate this work so that the specialty- and subspecialty-specific Program Requirements work hand-in-glove with the certification eligibility requirements of the certifying Boards to promote the best interests of residents, fellows, other health care providers, and patients.

  5. Each residency and fellowship program’s CCC should review the current status and progress of residents and fellows scheduled to graduate in June each year. By no later than December 31 of the graduation year, program leadership should assess the current state of progress in the program for each individual resident or fellow and then work with each resident or fellow not meeting milestones to create an individual learning plan (ILP) for the remaining time in the program. The ILP should include an identification of the remaining competency gaps. The individual and the program should have the opportunity to address those gaps with an increase of observations and feedback before the end of the academic year. (V.A.1.d))

* The ACGME program requirement supporting each recommendation is noted in parentheses. The Common Program Requirements can be accessed on the ACGME website, here.

The ACGME offers these recommendations as residency and fellowship programs anticipate continued disruptions to education and training during the COVID-19 pandemic. This is a time of extraordinary pressure for everyone in health professions education. Despite this pressure, it is vital to keep the public interest in mind. These recommendations are offered as the minimum set of program criteria for guiding decisions about learner progression and readiness for graduation during this COVID-19 pandemic.

Traditional time-based or volume-based measures may not be fully achievable during this period. The current environment is not “normal,” and each program should use the principles of CBME and the guidance below to make informed decisions about advancement, graduation, and Board eligibility. Educational experiences may be modified or disrupted through alternative forms of education, such as virtual learning, deployment to another clinical rotation or activity (e.g., ICU, ED, wards, telemedicine), or by missing a traditionally required rotation. Also, qualifications for some specialty Boards may not be program requirements, but they are typically completed during a residency or fellowship (e.g., Fundamentals of Laparoscopic Surgery (FLS) or a research thesis) and each specialty should check with the respective certification board regarding any changes. Programs should work to ensure these important activities are also completed.

CBME principles and activities have grown over the years and are used to support an entrustment decision-making process that determines whether individual residents or fellows are ready to progress to the next stage in their professional career (Table 2). “Entrustment decision-making” focuses on the conscientiousness, trustworthiness, discernment, and competence of the resident or fellow. The demonstration of conscientiousness, trustworthiness, and discernment supports confidence in assessment outcomes. Entrustment is grounded in the patient and educational outcomes that a graduate can deliver on the Quadruple Aim. The Quadruple Aim simultaneously improves patient experience of care, population health, and health care provider work life, while lowering per capita cost.

Summary
GME programs continue to be disrupted by COVID-19. The ACGME recognizes that typical metrics, such as time, volume, and specific rotations completed, may be unavailable for all residents and fellows. The principles provided are the minimum required to make a defensible, high-stakes entrustment decision for an individual to complete a residency or fellowship and advance to the next stage of one’s professional career during this period of disruption. It is possible that these principles will inform future CBME decisions using more robust and deeper data. The ACGME will work with programs, CCCs, the Review Committees, and ABMS certifying Boards during this disrupted period to learn about what works for the implementation of CBME over time.

Table 1. Core Competencies and Examples of Minimal Required Competency-Based Assessments that Could be Used during COVID-19 Disruption

Competency

Competency-Based Assessment Options

Medical Knowledge

  • In-training exam
  • Feedback from multiple faculty evaluations

Patient Care

  • Work-based clinical assessment through direct observation of the individual during care delivery
  • Feedback from multiple faculty and peer evaluations
  • External structured curriculums, standardized assessments, and simulation

Professionalism

  • Informed self-assessment
  • Feedback from multiple faculty and peer evaluations
  • Multi-source feedback, such as a 360-degree evaluation

Communication

  • Patient-reported feedback
  • Feedback from multiple faculty and peer evaluations
  • Multisource feedback, such as a 360-degree evaluation, especially regarding interprofessional care

Practice-Based Learning and Improvement

  • Evaluation of knowledge, skills, and attitudes from participation in systematic efforts to improve the quality, safety, or value of health care services

Systems-Based Practice

  • Feedback from multiple faculty evaluations regarding ability to practice in a complex health care system
  • Multi-source feedback, such as a 360-degree evaluation, especially regarding interprofessional care

 

Table 2. Van Melle Framework for Competency-Based Medical Education1

Component

Description

An Outcomes-Based
Competency Framework

  • Desired outcomes of training are identified based on societal needs
  • Outcomes are paramount so that the graduate functions as an effective health professional

Progressive Sequencing of Competencies

  • In CBME, competencies and their developmental markers must be explicitly sequenced to support learner progression from novice to master clinician
  • Sequencing must consider that some competencies form building blocks for the development of further competence
  • Progression is not always a smooth, predictable curve

Learning Experiences 
Tailored to Competencies in CBME

  • Time is a resource, not a driver or criterion
  • Learning experiences should be sequenced in a way that supports the progression of competence
  • There must be flexibility to accommodate variation in individual learner progression
  • Learning experiences should resemble the practice environment
  • Learning experiences should be carefully selected to enable acquisition of one or many abilities
  • Most learning experiences should be tied to an essential graduate ability

Teaching Tailored
to Competencies

  • Clinical teaching emphasizes learning through experience and application, not just knowledge acquisition
  • Teachers use coaching techniques to diagnose a learner in clinical situations and give actionable feedback
  • Teaching is responsive to individual learner needs
  • Learners are actively engaged in determining their learning needs
  • Teachers and learners co-produce learning

Programmatic Assessment
(i.e., Program of Assessment)

  • There are multiple points and methods for data collection
  • Methods for data collection match the quality of the competency being assessed
  • Emphasis is on workplace-based assessment
  • Emphasis is on providing personalized, timely, meaningful feedback
  • Progression is based on entrustment
  • There is a robust system for decision-making
  • Good assessment requires attention to issues of implicit and explicit bias that can adversely affect the assessment process.

1E. Van Melle, J.R. Frank, E.S. Holmboe, D. Dagnone, D. Stockley, and J. Sherbino (International Competency-Based Medical Education Collaborators). 2019. "A Core Components Framework for Evaluating Implementation of Competency-Based Medical Education Programs." Academic Medicine 94 (7):1002-1009.

 

ACGME Resources to Support Competency-Based Medical Education Assessment

Milestones Guidebook (Second Edition)

Milestones Guidebook for Residents and Fellows (Second Edition)

Clinical Competency Committee Guidebook (Third Edition)
See also the CCC Guidebook Executive Summaries

Milestones Implementation Guidebook

Faculty Development in Assessment

ACGME Developing Faculty Competencies in Assessment course
Courses will be offered in May, October, and November 2022.

Developing Faculty Competencies in Assessment Online Mini-Course

National Milestones Reports

2021 Milestones National Report
This report contains descriptive data about Milestones ratings across all programs by specialty.

2021 Milestones Predictive Probability Values Report
This report provides predictive probability value (PPV) tables for almost all specialties with instructions on proper use of PPVs.

Milestones Bibliography

Contains research to date (updated annually).

ACGME Milestones and Assessment Resources web page

Open-Access Assessment Tools

The ACGME provides two open-access assessment tools that may be of use for programs:

Media Contact Information
Susan White

Susan White

Vice President, Communications
312.755.5066