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76
K. I. Voorhees et al.
immediately allocating the PGY1 funding and allowing the
PGY2 and PGY3 funding to be escrowed. This would allow
residents who are in the program to be able to have funding
to complete their program if Medicaid funding were to be
discontinued by the state legislature.
Since Medicaid GME funding is directed by the state, this
method of GME funding is a way for a state to impact their
own healthcare workforce needs. There have been a number
of instances where Medicaid GME funding has been used to
pay for the development and maintenance costs of statefunded rural track programs, helping the state meet its rural
workforce needs. This is in contradistinction to the current
national Medicare GME system where decisions are generally governed by what is in the best interest of hospitals, as
this is where the federal funding generally ows.
Teaching Health Center Funding
Teaching Health Center GME (THCGME) funding was
established through the Accountable Care Act (ACA) in
2010 and paid as an appropriation through HRSA, which
requires Congressional reauthorization, at least every
5years. This is in contrast to Medicare GME funding which
is an entitlement, providing long-term and sustainable funding, and is not subject to periodic Congressional
reauthorization.
The purpose of THCGME funding was to help produce
physicians and dentists to achieve the following aims: (1)
training is in community-based settings, (2) improve health
outcomes for the members of underserved communities, and
(3) expand health care access in underserved and rural areas.
THCGME funding is only for new residency positions in the
specialties of Family Medicine, Internal Medicine, Pediatrics,
Internal Medicine-Pediatrics (Med-Peds), OBGyn,
Psychiatry, General Dentistry, Pediatric Dentistry, and
Geriatrics [16]. The residency program must be sponsored
by a Federally Qualied Health Center (FQHC), Community
Mental Health Center, Rural Health Clinic (RHC), a Health
Center operated by the Indian Health Service, an Indian tribe
or tribal organization or an urban Indian organization, or an
entity receiving funds under Title X of the Public Health
Service (PHS) Act [68]. If an academic health center wanted
to participate in a THC program, they could do so through
the development of a legally constituted consortium, which
would be governed by a board of directors that would typically include representatives from the participating FQHC
(or other appropriate organization), the community, and the
hospital.The academic health center would have to give up
being the sponsoring institution for these resident positions
to the consortium, and the academic health center's position
on the board of directors would be just one equal voice
among the other board members.
HRSA’s National Center for Health Workforce Analysis
estimates a projected shortage of 35,260 primary care physicians by 2035, and the THCGME program is one way to help
reduce the shortage [16]. In the year 2022–2023, THCfunded residents treated over 792,000 patients and conducted
more than 1.2 million patient encounters, helping to increase
access to primary care in underserved areas. Over 2000 new
primary care physicians and dentists have completed training
and entered the workforce with the help of THCGME.This
included 1235 new family physicians, 466 internal medicine
physicians, 107 pediatricians, 21 OB/Gyn physicians, 7 geriatricians, 69 psychiatrists, and 122 advanced general dentists, with 62% training in Medically Underserved
Communities and 21% in rural areas [16]. In academic year
2023–2024, the program is funding the training of over 1096
residents in 81 community-based programs [16].
THC funding started at a PRA of $150,000/resident per
year, and increased to $160,000 per resident per year in
2023. All of these positions and amounts are subject to regular reauthorization by Congress. When the originating documents were written to describe THCGME, it was stated that
this funding would not impact a hospital’s Medicare GME
status. The legislation forbade “double dipping.” Teaching
Health Center programs could not get full THCGME funding if the hospitals were simultaneously receiving full new
program Medicare GME funding. However, the rules governing this from the THC side (HRSA funding claims) and
hospital side (required IRIS claims for THC residents) are
not yet clear. Programs that receive—or plan to apply for—
THCGME sustaining funding need to work closely with
their partner hospitals to consider how to manage these
issues given ongoing rule-setting developments in CMS and
in HRSA [4, 5, 16, 68].
The residency program must be accredited by the
ACGME at the time of the THCGME funding application.
Notications of awards are typically in November or
December, and the residents must start the following July
1, or they lose out on this funding. There have been some
programs that received accreditation but were not selected
to receive new THCGME funding. In these situations, the
program could opt to hold off on lling the positions, starting the program, and applying for funding again the next
year. However, if a residency program goes 3years without
residents, they will lose their ACGME accreditation and
will have to be re-accredited if they want to continue to
pursue THCGME funding. THCGME funding is not
allowed to support residency program startup costs, it is
only to be used to support the costs associated with resident
FTE training ([68]/Funding).
10 Graduate Medical Education Funding
77
Health Resources andServices
Administration (HRSA) Residency
Development Funding
Teaching Health Center Planning and DevelopmentTechnical Assistance Center (THCPD-TAC) is a HRSA program to provide development funding and resources to help
THCs along the path to accreditation [68, 69]. A THCPDTAC grant to develop a THC residency program is up to
$500,000 over 2years [69]. Although the funds can be used
to cover most development expenses, they cannot be used for
establishing a consortium. The grantee is provided with an
experienced advisor through the TAC Center to guide them
through the process. Grantees can also can take advantage of
20 paid consultation hours, monthly webinars, and an annual
meeting.
The Rural Residency Planning and DevelopmentTechnical Assistance Center (RRPD-TAC) is a HRSA program to support the development of rural residency programs.
Grant awards are for 3years and up to $750,000 [70]. Rural
programs must be a combined effort between an urban hospital and rural hospital in an RTT.The resources, meetings,
goals, and objectives are similar to the THCPD program,
with the exception that 30 hours of paid consulting is
available.
Veteran’s Administration GME
grams. These residents will train in other covered facilities,
and the VA will pay for certain costs of the program. The
pilot program will fund 100 individual residents (not FTEs)
at non-VA facilities. Eligible facilities include those operated
by an Indian tribe or tribal organization, the Indian Health
Service, a Federally Qualied Health Center, a health care
facility operated by the Department of Defense, or other
health care facilities the VA considers appropriate. The rst
RFP will be in the summer of 2024, and funding will be in
place for the covered facilities beginning July 2025 [72, 73].
The VA budget on Graduate Medical Education Training
in 2017 was $1.78 billion per year [27, 73].
Children’s Hospital GME (CHGME)
Children’s Hospital GME (CHGME), as with THCGME, is
funded through HRSA and is an appropriation rather than an
entitlement. CHGME was set up this way through HRSA
because children’s hospitals have a very low percentage of
Medicare patients. CHGME funds freestanding children’s
hospitals. Children’s hospitals apply for funding each summer. Using data from these applications, DME and IME payments are calculated. The total annual national CHGME
funding is a xed amount. In 2015, CHGME funding totaled
$249 million. Using data from applications DME and IME
payments are calculated [74, 75].
The VA has long-funded resident training time in VA facilities, typically for residents at programs based at other sponsoring institutions. Congress passed the Veterans Access,
Choice, and Accountability Act of 2014 (VACA), which
authorized 1500 new positions to be funded. The act prioritized primary care and mental health training along with
other specialties with documented physician shortages. By
the end of scal year 2021, 1490 positions were authorized
and 21 of the 22 VA medical centers previously without
GME activity had added residents or were planning to do so
[71]. About 42% of the residents are in primary care, 24% in
mental health, and 34% in other needed specialties. The VA
has approximately 43,000 individual resident-physicians
who receive their clinical training by rotating through about
11,000 VA-funded residency FTE positions at VA medical
clinics [72].
A VA pilot program was authorized through the MISSION
Act in June, 2018. It took a while to get all of the parts
planned but is to nally start and is to have their rst residents begin in 2025. This program is called the Pilot Program
on Graduate Medical Education and Residency (PPGMER).
It is different than the currently existing VA residency pro-
Department ofDefense
The Department of Defense (DOD) trains residents who
have a United States uniformed service obligation. Funding
for this training is through the annual Department of Defense
appropriation in the Defense Health Program budget. In FY
2017, the DOD administered residency programs at 26 DOD
hospitals and trained an estimated 1455 FTE residents in
over 100 specialties. DOD programs are accredited through
the ACGME and managed by the uniformed services with
the Air Force, Army, and Navy military branches operating
their own residency programs. There are also joint service
residency programs [27].
State Line Item Funding
A number of states including Texas, Colorado, and California
provide direct funding to residency programs. Sometimes a
governor or legislature will provide funding for the development of residency programs (e.g., Nevada). California has
interesting state-specic GME funding options:
78
K. I. Voorhees et al.
• Song-Brown Healthcare Workforce Training Program.
This funding helps to fund the training of primary care
health professionals in California. Funding is distributed
through a competitive application process, so it is not
something a program can automatically count on. The
goal of the program is to attract under-represented minor-
ities and those from underserved communities and, ulti-
mately, place residency graduates in underserved areas.
Funding is dependent on the state budget. In the
FY2021–2022 state budget, $31 million was allocated.
Funding can be used for existing programs, program
expansion, THCs, or new program start-up funding needs
[76].
• CalMedForce Graduate Medical Education Program.
This program funds new residency positions. It uses
tobacco tax revenues from Proposition 56 (2016) to fund
the training of physicians to help meet the growing physi-
cian shortage. There is a focus on medically underserved
populations. In 2020, there was approximately $38 mil-
lion available for programs in Family Medicine, Internal
Medicine, OBGyn, Pediatrics, and Emergency Medicine.
Funding is distributed through an application process
[77].
they were seeing patients themselves during that time. Even
precepting 1 upper level resident with a full schedule plus
having the faculty see a 50% schedule on their own will generate more billings. The resident is “free” to the clinical
operation with salary and benets covered by hospital GME
revenue. The resident is also “free” to the physician billing
productivity model for specialists and hospital preceptors.
Oftentimes resident care improves supervising physician
clinical productivity or, at worst, breaks even. In most family
medicine residency programs this enhanced productivity is
credited to the supervising physician and is not considered
income on the “academic” side of the budget; it can be budgeted and calculated as excess visit revenue. This additional
patient care revenue can be used for a variety of purposes,
including non-revenue generating activities such as leadership and faculty development and administrative activities. It
is possible that some excess might be of slight benet to
overall residency revenue. However, this is almost never
capable of funding the residency if other sources of funding
are not available. There have been several programs that tried
to self-fund through patient revenue that have subsequently
closed because of funding issues.
Hospital Supplemental Funding
If there is a funding shortfall, in any of the above GME payment methodologies, it typically falls to the hospital to cover
the decit. Some hospitals or academic health centers intentionally provide internal funding to expand residency programs, resulting in hospitals operating with more trainees
than their caps. The hospitals may do this for service reasons
to ensure adequate residents to handle larger volumes of
patients, or in the hope of being able to retain graduates on
the medical staff.
The nancial impact of having a residency program in a
hospital and health system can be quite positive beyond
Medicare and Medicaid GME payments, making internal
investment attractive. There are often substantial savings in
recruitment and retention of the physicians in all specialties
and signicant downstream revenue for the health system
with an expanded primary care base including the patient
panels managed by residents. Improved access and likely
improved quality of care in a teaching environment are other
benets.
Philanthropy
Philanthropic funding is often used to cover some of the
development costs of a new residency, fund special activities
not in the program’s operational budget, pay for large capital
investments, or to cover episodic shortfalls in revenue. If
funding is to help with development costs, the funding
should go to the hospital and not the program, because if it is
to the program, Medicare can consider this as community
support, decreasing their Medicare GME fundinglong term,
even if the community support funding has stopped.In some
situations, philanthropic organizations have become a longterm partner and a major funding source of a GME program.
Philanthropic funding may come from a sponsoring institution’s own foundation, community foundations, episodic
gifts from patients or graduates, or planned giving. However,
philanthropic funding carries some risk if it is relied upon for
long-term operational funding. With a change in leadership
of the philanthropic organization, new leadership may
choose to go a different direction and discontinue the funding of the residency program.
Conclusions
Patient Care Revenue
Revenue from resident care isusually billed through the faculty. If a faculty member precepts three upper level residents,
they will be able to “see” more patients and bill more than if
Through the years, many stakeholders have been critical of
the GME funding enterprise. The most recent sweeping evaluation of GME funding was published by the Institute of
Medicine (IOM, now the National Academy of Medicine,
NAM) in 2014 [7]. The forward to that report states:
10 Graduate Medical Education Funding
79
Perhaps most critically, it (GME funding system) lacks the over-
sight and infrastructure to track outcomes, reward performance,
and respond nimbly to emerging challenges.” Some of the con-
cerns included in the report were: a mismatch between the health
needs of the population and the make-up of the physician work-
force, a persistent geographic maldistribution of physicians,
insufcient diversity in the physician population, and a lack of
scal transparency. [7]
The report made the following recommendations: (1)
phase out the current GME payment system and modernize
it to make payments based on performance, (2) create a GME
policy and nancing infrastructure, (3) create a transformational fund for GME innovation, (4) replace IME/DGME
payments with a single “per-resident amount” that is adequate to totally support the academic costs of GME and is
not discounted by “percent Medicare”, and (5) improve
transparency and accountability of Medicaid GME [7].
Although the IOM report generated considerable discussion in health policy arenas, its recommendations, to date,
have not been implemented. Current GME policy agendas
include improving and expanding support for rural training,
making THCGME funding permanent, lifting the cap on
resident trainees, and coming to terms with the recent wave
of RRC reclassication of urban teaching hospitals.
A shortage of physicians in rural settings has been widely
acknowledged for some time. Rural training has primarily
been embraced by family physicians in RTPs. There are a
number of challenges to operating these programs.
Furthermore, specialties other than family medicine are
needed in rural areas but establishing rural-based training for
specialties such as psychiatry, general surgery, and internal
medicine has proven difcult. A bill to address these issues
in a comprehensive manner was rst introduced by Colorado
Senator Cory Gardner as the “Rural Physician Workforce
Production Act of 2019” (RPWPA). Key features of this bill
included exibility of payment between the rural and urban
hospitals involved in the training, ability of specialist training programs to receive payments for short stints of resident
training, and support of full payments to Sole Community
and Critical Access hospitals. The bill proposed a at per
resident rate of GME payment, similar to THC funding, but
through the Medicare GME system and not discounted by
the percentage of Medicare patients in the hospital. Similar
comprehensive bills have been introduced in every congress
since 2019 but have not garnered sufcient support. The
CAA of 2021 did address some of the challenges to training
in rural areas.
The THC “experiment” has been generally seen as a success with impressive documentation supporting the program’s ability to train physicians in needed specialties and
needed locations. Funding for the THC program has been
reauthorized several times and enjoys widespread bipartisan
support. Nevertheless, as of 2023, legislative initiatives such
as S.1958 and HR 2569 that would make THCGME funding
permanent have failed to gain enough support to pass into
law. Therefore, the current system of THC funding remains
uncertain [78].
Large-scale increases to the total hospital trainee cap system, in the neighborhood of 15,000 slots, have been a perennial bill before congress for decades, and as of 2023 it has
been introduced as Senate Bill S.1302. Such bills are often
criticized for not providing enough specicity on the geographic and specialty mix of the newly funded positions.
These bills contain no specialty workforce goals and very
limited geographic or population goals. Over the years, there
has been the creation of new residency slots on a smaller
scale.
A working knowledge of the issues and controversies that
surround GME funding can be useful for advocates of a more
balanced, equitable, and high-quality US healthcare system.
We hope that this chapter has contributed information for
support of these goals.
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ama- assn.org/system/les/2023- gme- compendium- report.pdf
50. Rural Health Information Hub > Rural Hospitals. https://www.rur-
alhealthinfo.org/topics/hospitals
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ecfr.gov/current/title- 42/chapter- IV/subchapter- G/part- 485/
subpart- F?toc=1
52. Medicare Learning Network Information for Critical Access
Hospitals, April 2023. https://www.cms.gov/les/document/
mlruraln006400- information- critical- access- hospitals.pdf
53. Federal Register 42 CFR § 413.78(g) Direct GME Payments:
Determination of the total number of FTE residents. https://
www.ecfr.gov/current/title- 42/chapter- IV/subchapter- B/part- 413/
subpart- F/section- 413.78
54. Medicare Learning Network, Medicare Payment Systems, Acute
Care Hospital Inpatient Prospective Payment System – Click
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Education/Medicare- Learning- Network- MLN/MLNProducts/
html/medicare- payment- systems.html#Acute
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subchapter- B/part- 412/subpart- G/section- 412.96
56. HRSA 340B Rural Referral Centers Eligibility. https://www.hrsa.
gov/opa/eligibility- and- registration/hospitals/rural- referral- centers
57. GME benets of rural status Dentons Lori Mihalich-Levin, Susan
Banks, and Allison M.Cohen, October 20, 2016. https://www.den-
tons.com/en/insights/newsletters/2016/october/20/gme- dentons/
gme- benets- of- rural- status#:~:text=Thus%2C%20rural%20hospitals%20enjoy%20some,new%20programs%20they%20can%20
add
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Chess Game: New Moves for Some Urban Hospitals | Hall Render.
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Billing 20.6– Criteria and Payment for Sole Community Hospitals
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64. Federal Register § 412.105 (f)(1)(iv)D The section talks about
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to an urban CBSA eCFR :: 42 CFR 412.105– Special treatment:
Hospitals that incur indirect costs for graduate medical education
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les/document/frequently- asked- questions- section- 126.pdf
66. Federal Medical Assistance Percentage (FMAP) for Medicaid and
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%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22
%7D
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funding/apply- grant/faq- thcpd
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funding/5315
70. Rural Health Information Hub; Rural Residency Planning
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funding/4533
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academicmedicine/fulltext/2022/08000/veterans_affairs_graduate_medical_education.37.aspx
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Initiatives, pp. 4–5. Heading The US Department of
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compendium- graduate- medical- education- initiatives
73. VA GME PPGMER Final Rule, Nov 17, 2023 Federal Register;
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29 Mar 2018. https://www.gao.gov/products/gao- 18- 240
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The- Teaching- Health- Center- Graduate- Medical
Part III
Curriculum Design and Assessment
Designing Assessment toMeet
theChallenge ofCompetency-Based
Medical Education
DrewKeister andVeronicaBrohm
11
Key Points
• Competency-based medical education (CBME) aims to
hold medical graduates accountable to outcomes that
meet the needs of patients and society at large.
• The American Board of Family Medicine core outcomes
dene the targets for individual graduates of family medicine residency training programs.
• A system of assessment must be designed in each FM
residency program to give continuous low-stakes feedback that guides progress toward achieving the core outcomes. Ideal systems of assessment will require more
frequent assessments than most residencies currently perform. An accumulation of low-stakes assessments can be
used to guide summative assessment.
• As FM residencies move toward CBME goals, “perfect is
the enemy of good enough.” Programs should make continuous improvement to their systems of assessment using
successful strategies shared by other residencies.
• The emergence of articial intelligence, the concept of
time-variable residency education and as yet unknown
forces will shape the future of CBME in FM.
Introduction
Health care in the United States has reached a point of crisis.
Despite increases in spending, outcomes continue to decline
in comparison to other afuent countries [29]. One proposed
solution to this crisis is to increase the number of well-trained
personal family physicians who practice in robust interdisciplinary teams in the context of health policy changes that
support primary care [51]. The 2023 changes to the
Accreditation Council for Graduate Medical Education
(ACGME) program requirements for graduate medical education (GME) in family medicine, which center the family
medicine practice as the curriculum, increase exibility in
residency scheduling, recommend participation in learning
networks, and provide more faculty time for assessment and
education, create the structure for family medicine GME that
will support the changes necessary to create the personal
physicians of the future (ACGME, [51]). However, as the
number of family medicine residency positions grows [46], it
is essential to ensure that residency graduates will be highquality family physicians who are trained adequately to meet
the future challenges of our discipline [14]. Competencybased assessment provides the structure and the tools to
allow residency programs, accrediting bodies, certifying
boards, and society at large to trust the quality of residency
graduates [53, 59].
Denition ofCompetency-Based Medical
Education (CBME)
CBME is dened as
an outcomes-based approach to the design, implementation, and
evaluation of education programs and to the assessment of learners across the continuum that uses competencies or observable
abilities. The goal of CBME is to ensure that all learners achieve
the desired patient-centered outcomes during their training. [7]
This chapter will focus on assessment within CBME.The
other portions of this denition are covered elsewhere in this
book, though they may not be specically identied as a part
of CBME therein.
D. Keister (*) · V. Brohm
Lehigh Valley Health Network Family Medicine Residency
Program, Allentown, PA, USA
e-mail: Drew_M.Keister@lvhn.org
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
R. Kellerman, G. Irwin (eds.), Graduate Medical Education in Family Medicine, Excellence in Medical Education 2,
https://doi.org/10.1007/978-3-031-70741-4_11
85
86
The History ofCMBE inFamily Medicine GME
The concept of CBME is not new. In a 1978 public health
paper for the World Health Organization, McGaghie etal.
[43] wrote an elegant description of competency-based curriculum development in medical education. Although this
early call for CBME was well-founded, it was not widely
adopted, largely due to the difculty changing culture within
medical education and to service requirements that superseded educational needs [31].
Through the 1990s, concerns about the quality of US
health care grew, leading the Institute of Medicine (IOM)
to publish To Err is Human [40] and bringing to public
attention the fact that more than 90,000 Americans died
annually due to medical errors. The subsequent IOM call to
action in Crossing the Quality Chasm [35] documented the
causes of the quality gap and analyzed healthcare systems
as complex adaptive systems, which are unpredictable and
difcult to change. “The task for clinicians and managers
(in complex systems) is not to treat all situations alike, but
to understand when specication and standardization are
appropriate and when they are not” [35]. This challenge
also will be a key to the implementation of CBME because
the process of medical education also behaves as a complex
adaptive system [75].
In response to the challenge of inadequate quality within
the complex US health system, the ACGME launched the
Outcomes Project, which aimed to implement outcomesbased GME in the USA [10]. The ACGME identied the six
core competencies that have become a familiar part of resident assessment: patient care; medical knowledge; practicebased learning and improvement; professionalism;
interpersonal skills and communication; and systems-based
practice [10]. At the heart of the Outcomes Project was the
desire to move away from proxies for competency, such as
time or completion of a given curriculum [31]. Instead, the
ACGME aimed to create a curriculum and assessment that
would lead to clearly dened competency outcomes.
Unfortunately, the competencies themselves were too broad
to be easily understood or reliably assessed in that early
form [31].
One necessary step in the measurement of CBME is to
identify a progressive sequence of skills and their developmental markers [78]. After the initial challenges in the
Outcomes Project, the ACGME launched the Next
Accreditation System (NAS), moving the ACGME from an
episodic “biopsy”-like sampling of programs through intermittent site visits to a model that requires annual data reporting about program and resident performance [49]. A critical
D. Keister and V. Brohm
component of the new system was the creation of developmental milestones for each discipline [73]. The milestones
were revised in 2020 to better reect the actual progression
of residents through the performance standards described by
Milestones 1.0 [14, 20]. The NAS also began the requirements for residency programs to create Clinical Competency
Committees and Program Evaluation Committees, which are
key components for the implementation of CBME. The
milestones and the Next Accreditation System helped residency programs to engage and understand the core competencies much moredeeply than in the decade prior to their
implementation [31].
Although milestones offer a sequence of common skill
progression among learners, CBME also requires a
description of the final goal of training. Entrustable
Professional Activities (EPAs) are critical activities in a
medical discipline that are defined “a unit of work that
should only be entrusted upon a competent enough professional.” [70] Taken together, the EPAs for any discipline are “those professional activities that together
constitute the mass of critical elements that operationally
define a profession” [70]. In addition to defining a finish
line for medical training, EPAs are intended to describe
the work that physicians actually do in practice, the language to describe them can be more concrete than theorybased milestone competency language [69]. Early efforts
to describe the family medicine EPAs [66] were refined
by the Association of Family Medicine Residency
Directors to the 20 EPAs [72] that have since been
mapped to the milestone and sub-competencies that correlate to the activities. These EPAs are used by many
residency programs as a component of their assessment
systems but their use has not been required by the
ACGME.
The nal goal of CBME is to enact a curriculum measurable by a system of assessment that allows the condent
determination of when learners are competent to complete
their training. The promise of CBME is that a structure
shared across all residencies can improve the quality of educational and clinical outcomes [31]. The natural nal step of
this process is to require that family medicine residencies
attest that their graduates meet a minimum standard of
described competency. As such, the American Board of
Family Medicine (ABFM) has advanced a set of twelve core
outcomes [51]. Residency program directors will be asked to
attest not only that their graduates have completed the curriculum but also that they are competent in each of the core
outcomes. The ve most basic core outcomes will be attested
starting in 2024, with additional outcomes being added in
each of the two following years (Table11.1).
11 Designing Assessment toMeet theChallenge ofCompetency-Based Medical Education
Table 11.1 ABFM core outcomes and schedule for attestation. (From Newton etal. [51])
In June 2024, we propose that program directors and CCCs will attest that each graduating resident is competent to:
Practice as personal physicians, providing rst contact, comprehensive and continuity care, to include excellent doctor- patient relationships,
excellent care of chronic disease, and routine preventive care and effective practice management
Diagnose and manage acute illness and injury for people of all ages in the emergency room or hospital
Provide comprehensive care of children, including diagnosis and management of the acutely ill child and routine preventive care
Develop effective communication and constructive relationships with patients, clinical teams, and consultants
Model professionalism and be trustworthy for patients, peers, and communities
We will monitor progress and seek further input, but for June 2025, we would extend attestation of assessment of competency by program
directors and CCCs for each graduating resident to include competence in:
Practice as personal physicians, to include care of women, the elderly, and patients at the end of life, with excellent rate of continuity and
appropriate referrals
Provide care for low-risk patients who are pregnant, to include management of early pregnancy, medical problems during pregnancy,
prenatal care, postpartum care and breastfeeding, with or without competence in labor and delivery
Diagnose and manage of common mental health problems in people of all ages
Perform the procedures most frequently needed by patients in continuity and hospital practices
Model lifelong learning and engage in self-reection
Then, in June 2026, with continuing monitoring of progress, we would extend attestation by the program director and CCCs to include the
following competencies for each graduating resident:
Practice as personal physicians, to include musculoskeletal health, appropriate medication use, and coordination of care by helping patients
navigate a complex health system
Provide preventive care that improves wellness, modies risk factors for illness and injury, and detects illness in early, treatable, stages for
people of all ages while supporting patients’ values and preferences
Assess priorities of care for individual patients across the continuum of care—in-ofce visits, emergency, hospital, and other settings,
balancing the preferences of patients and medical priorities
Evaluate, diagnose, and manage patients with undifferentiated symptoms, chronic medical conditions, and multiple comorbidities
Effectively lead, manage, and participate in teams that provide care and improve outcomes for the diverse populations and communities they
serve
87
CBME inMedical Schools andtheTransition
toGME
Although this chapter focuses on CBME in GME, it is
important to understand the implementation of CBME in
undergraduate medical education (UME) as a context for
learners entering residency. The Liaison Committee on
Medical Education (LCME) and the Commission on
Osteopathic College Accreditation (COCA), the accreditors
for US medical schools, have required components of
CBME for decades. In 2014, the Association of American
Medical Colleges (AAMC) identied 13 core EPAs necessary for entering residency training. These EPAs were
piloted at 10 medical schools with varying degrees of success [4]. In 2020, the Coalition for Physician Accountability
(COPA) convened the UME-GME Review Committee
(UGRC), which focused on the transition from UME to
GME.The 34 recommendations of the UGRC were organized around nine themes and [42] motivated the AAMC,
the American Association of Colleges of Osteopathic
Medicine (AACOM) and the ACGME to co-create an initiative to dene the Foundational Competencies for US medical students [25]. This initiative’s work will be disseminated
in 2024 and will guide the UME to GME transition of the
future. One critical challenge the initiative will address is to
create a process for sharing information more freely between
UME and GME programs to allow the educational continuity necessary for the success of CBME [55].
The CanMEDS Framework andCBME Outside
theUnited States
The journey toward CBME has moved at varying paces in
different health care systems. The CanMEDS Framework
[27] is the major CBME effort internationally that mirrors
the ACGME’s process. In fact, the CanMEDS Framework
predates the ACGME core competencies [74], and the implementation of the CanMEDS framework in FM is arguably
more advanced than the ACGME competencies [67].
Programs and accreditors in other nations have followed the
CanMEDS framework in creating their own path to CBME
[41, 65, 74]. However, despite its many excellent features,
the CanMEDS framework has been criticized for not yet
aligning with feasible accessibility in the workplace [6]. The
CanMEDS Framework is due to be revised in 2025in a continuing effort to respond to society’s needs [74]. CanMEDS,
the ACGME core competencies, and other international
efforts to implement CBME necessarily will coevolve as evidence of success or failure within specic frameworks
emerge [12].
What Makes CBME Dierent?
The general concept behind CBME is easy to support, but
what specically makes an educational program consistent
with CBME? Frank et al. [26] assert four main principles