In Response to “Implementing Competency-Based Medical Education in Family Medicine: A Narrative Review of Current Trends in Assessment”

We applaud Dr Danilovich and colleagues for their well-researched review of current trends in assessment in family medicine competency-based medical education (CBME). The authors state that the most common concern for learners was “the need for better constructive feedback.”1 We believe it is noteworthy that in the more than 30 years since academic family medicine launched discussion of CBME, the primacy of effective feedback, an essential element of formative assessment, remains.

In the 1980s, the STFM Task Force on Residency Education for the Future called for a transition to a competency-based curriculum. The work of the Task Force on CBME was largely informed by leaders in the field of mastery learning: Block, Airasian, Bloom, Carroll and others.2 Two major themes that were brought forward by the Task Force were a redefinition of aptitude that embraced the time variability by which learners achieve mastery, and second, the central role of formative evaluation and its focus on timely, nonjudgmental, competency-based feedback. The Task Force highlighted the importance of the teacher-learner relationship and the need to create a safe and respectful learning environment in order to facilitate mastery learning.

As follow-up to this effort, the STFM Task Force on Competency-Based Education in Family Medicine published its findings, which included the following recommendations: (a) a clear definition of competencies that must be mastered for successful completion of the curriculum, (b) use of formative evaluation instruments that help learners and teachers assess interval mastery, (c) allowance of sufficient time for learners to attain mastery, and (d) availability of a variety of teaching strategies for those who require additional instruction.3

Formative evaluation, particularly when coupled with encouragement and direction, sends a powerful message that the purpose for the interaction between teacher and learner is for the teacher to provide objective information to the learner with the intention of initiating a conversation about learning that is driven by the learner’s self-examination of their current level of competence. It is an educational gift from teacher to learner that values the teacher-learner dyad and elevates learner safety while exposing weaknesses and areas for growth to the forefront. Tools, such as the gap analysis method, exist to enable teachers to create these safe educational relationships.4 The value of this approach, and the reason that lifting the method of CBME, beyond simply stating outcome competencies, is that it emulates highly effective medical care where the practitioner provides objective information to the patient to motivate a safe and respectful conversation of health within the patient, without judgment, bias, or prejudice. It is hypothesized that students who experience this method of education may then have a higher likelihood of practicing medicine with this attitude. Further work in CBME must include attention to the process of CBME in addition to a stating and assessing outcome competencies.

We believe that the time is right for the family medicine education research community to study the content of feedback, the process by which it is delivered, and the perceived quality of teacher-learner relationship on educational and clinical outcomes.