Gersten Jonker

General introduction   13 1 The idea of CBME originated in the late seventies of the twentieth century when aWorld Health Organization report suggested that the output of medical training be doctors who are able to practice at a defined level of proficiency to meet local health care needs [29]. It initiated an educational evolution toward curricula that are derived from doctors’ current or future role in society and that aim to license or certify learners based on demonstrable proficiency in aspects of that role [30]. Presently, CBME is defined as “an approach to preparing physicians for practice that is fundamentally oriented to graduate outcome abilities and organized around competencies derived from an analysis of societal and patient needs. It de-emphasizes time-based training and promises greater accountability, flexibility, and learner- centeredness” [31]. In CBME, the self-regulating medical profession acknowledges the obligation to society to focus on outcome, i.e. to deliver able graduates who consistently provide safe and effective, patient-centered care [3, 32-36]. CBME “starts with the end in mind” – desired outcomes of physicians that must demonstrate to meet society’s needs [16]. Instead of concentrating (only) on knowledge, CBME emphasizes the attainment of the required abilities, framed as observable competencies synthesized from necessary technical and interpersonal skills and attitudes [34]. CBME can improve the connection between stages of education, as it builds a curriculum around the end-product it promises to deliver. Learners do not necessarily take the same amount of time to master the required competencies. Therefore, in CBME, the learner is central.With a transparent path towards clear goals, a learner should be able to complete a personally tailored program in which time and the process are secondary to the development of learner competence [34]. Assessment is important in establishing that graduates have met the outcomes. However, competencies are difficult to assess separately [37, 38]. Also, atomizing medicine into too many competencies, detached from context, is not meaningful [18]. It may reduce assessment to a check box exercise [37]. Competence, as a holistic integrated model of competencies, is not necessarily directly assessable, but can be inferred from performance [39]. Workplace assessments with a variety of tools provide subjective low-stakes data on single encounters, with the main goal of supporting learner progress. When aggregated, the data points should paint a complete, valid, and reliable picture of learner performance that can be used for high-stakes decisions. This approach to assessment is called programmatic assessment [40-42].