Context Matters: Lessons from Piloting the Five Core Components of CBE in Emergency Medicine

By: Holly Caretta-Weyer, MD, MHPE “Context matters.” This phrase has become a mantra in the world of competency-based education (CBE). But, what does it really mean for those of us on the frontlines of implementation? In my experience leading implementation of CBE in emergency medicine in US-based postgraduate training programs, it translates to acceptable variability within and among programs as we navigate the challenges of adopting CBE across a highly diverse specialty. Emergency medicine training in the United States is as varied as Ben & Jerry’s ice cream flavors. With over 280 programs, we see a rich tapestry of training environments. Approximately 75% of programs are three years in duration, while the other 25% are four. The primary training site may be an academic institution, a community hospital, or a county hospital. You may have rural rotations or experience in the Indian Health Service, spend time at the Veterans Administration Hospital, or you may never leave your primary training site. You may have a very small program with six trainees per year or a large program with more than twenty trainees per year or truly anything in between. Given this diversity, why do we expect a one-size-fits-all approach to CBE implementation? Yet, many countries, accreditation bodies, and certifying organizations have taken precisely this top-down approach. Our grassroots pilot of CBE across a dozen U.S. Emergency Medicine programs1 has yielded invaluable insights through rigorous realist evaluation.2 We’ve learned what works, for whom, in what context, and why. These lessons are guiding us towards offering a variety of options as we consider expanding this work across the entire specialty. Let’s explore how context impacts each of the five core components of CBE: Outcome Competencies: While our specialty-wide advisory board agreed on 22 Entrustable Professional Activities (EPAs) for emergency medicine,3 implementation varies: Some programs expect faculty to consider all EPAs during every resident shift. Others focus on specific subsets of EPAs on certain days with rotating EPAs based on a variety of factors. A few programs, inspired by the Canadian model, include program-specific “bonus” EPAs beyond the original 22. Progressive Sequencing: EPAs are linked to subcompetencies and milestones to track development. However, educational opportunities and autonomy levels differ across programs: Some programs thrust junior residents into leading resuscitations early while others reserve this for senior residents alone. Other programs reserve specific procedures for different stages of training such as intubation of multi-system trauma patients for senior residents alone. The advisory board tiered the EPAs for these purposes; however, some programs needed flexibility across tiers due to contextual differences in access to specific educational opportunities. Competency-Focused Instruction Our grant focused on implementing formal coaching programs, revealing diverse approaches: Some programs separated coaches from formal assessors. Others, due to resource constraints, had program leadership double as coaches. One program deliberately made coaches serve on competency committees and present their coaches while subsequently delivering competency committee feedback, linking formal assessment directly to coaching. Each model showed merits and potential pitfalls, with varying levels of resident engagement. Tailored Learning Experiences We piloted an individualized learning plan across participating programs, resulting in creative adaptations: Some used it to track learner wellbeing. Others integrated it with performance coaching. Many employed it for career guidance. A few incorporated it into competency committee meetings as a resident input tool akin to a faculty promotion packet. Programmatic Assessment While all programs implemented workplace-based EPA assessments using a supervisory scale model, variations emerged in how programs built out additional data streams: Some leveraged electronic health record data for assessment, while others used it only for formative feedback, A few used simulation for assessment purposes, Competency committees aggregated and weighted data differently, Decision-making processes varied, though all adhered to best practices for robust outcomes, In conclusion, context profoundly influenced each pilot program’s implementation. Factors such as resource availability, program priorities, educational opportunities, assessment weighting, and decision-making drivers all played crucial roles. Yet, all five core components were successfully implemented across programs, with residents progressing through robust coaching and meeting core patient-centered outcomes. This experience suggests that as we support specialties in broader CBE implementation, we should focus on identifying the essential elements of CBE while embracing and encouraging acceptable contextual variability. By doing so, we can ensure that CBE adapts to the unique needs of each program while maintaining its core principles and effectiveness.nsensus study, take a few moments to consult ACCORD or DELPHISTAR. You may find that the checklist doesn’t constrain your work at all—it just makes it stronger. About the Author: Holly Caretta-Weyer, MD, MHPE is Associate Professor of Emergency Medicine and Associate Dean for Admissions and Assessment at the Stanford University School of Medicine. Her work focuses on leveraging precision education principles in selection and assessment across the continuum of medical education with an eye to patient and learner outcomes as well as the implementation of competency-based education within emergency medicine training. References Caretta-Weyer HA, Schnapp BH, Brown CA, et al. Implementing the 5 core components of competency-based medical education in US emergency medicine residency programs. J Grad Med Educ. 2025 May;17(2 Suppl):57-63. Ellaway RH, Kehoe A, Illing J. Critical realism and realist inquiry in medical education. Acad Med. 2020 Jul;95(7):984-988. Caretta-Weyer HA, Sebok-Syer SS, Morris AM, et al. Better together: A multistakeholder approach to developing specialty-wide entrustable professional activities in emergency medicine. AEM Educ Train. 2024 Mar;8(2):e10974.