Laurel Case Lecture November 2014

Assessment strategies for competency-based medical education

Eric Holmboe, MD, FACP, FRCP

Medical education is undergoing significant change. OHSU’s YOUR M.D. curriculum will be competency-based, meaning a student will have to demonstrate competency in defined areas in order to graduate. Similarly, GME programs across the nation are implementing Milestones as a way to assess residents and fellows. Milestones are specialty-specific competency-based outcomes and are part of the Accreditation Council for Graduate Medical Education’s Next Accreditation System.

Providing safe, effective, patient-centered care is the foundation of competency-based medical education, according to Eric Holmboe, M.D., FACP, FRCP, visiting professor for the Annual OHSU Family Medicine Laurel Case Visiting Professor Lecture. Holmboe, Senior Vice President, Milestone Development and Evaluation at ACGME, presented the lecture “Moving Beyond the Multiple Choice Question: Evolving Assessment Strategies for CBME” on Nov. 19.

“Ask the question, ‘Did the patient get safe, effective, patient-centered care?’ Answer that question and then work backward,” Holmboe said. “Then decide what the trainee’s role was in that care. If they did a great job with the patient, then you can entrust them to patient care without supervision, which is our ultimate goal.”

In all competency-based medical education (CBME), the patient is the dependent variable, he said.  “Viewing the educational process through the lens of quality patient care results not only in better assessment, but better care in teaching hospitals.”

Competency-based education has been a topic of discussion since the 1960s when it was introduced in connection with teacher education.With the launch of the ACGME’s Next Accreditation System and the Milestones, the interest and need for assessment has increased significantly.

“In the traditional model of medical education, experts defined the curriculum,” Dr. Holmboe said. “That wasn’t a bad thing, but it wasn’t always in the context of a population’s health needs or the health system’s needs. The curriculum tended to be heavily focused on knowledge and not enough on skills and attitudes that are part of the newer required skills including interprofessional teamwork, quality science, system science and care coordination.”

In addition to the Laurel Case Lecture, Dr. Holmboe presented “Maximizing the effectiveness of Faculty Assessments: Lessons from the Emerging Science of Rater Cognition” at Family Medicine Grand Rounds. He also led a faculty development workshop for Family Medicine, Internal Medicine and Pediatric faculty on improving direct observation skills, met with GME program directors and coordinators and led a session on the future of GME with the Oregon Council on Graduate Medical Education.

Assessment, particularly competency-based assessment, relies on professional judgment.

“The whole purpose of an assessment program is to enhance the probability that we’re making good judgments,” Dr. Holmboe said. “That’s really what we’re after. It’s still a human process, and we’re not going to get it 100 percent right. But it would be really good if we could enhance the probability of making good judgments.”

Calling the Milestones “a huge culture shift,” Dr. Holmboe encouraged GME program leaders to send feedback to the ACGME at

Dr. Holmboe, a board-certified internist, is a Professor Adjunct of Medicine at Yale University and Adjunct Professor of Medicine at the Uniformed Services University of the Health Sciences. He is a graduate of Franklin and Marshall College and the University of Rochester School of Medicine. He completed his residency and chief residency at Yale-New Haven Hospital, and was a Robert Wood Johnson Clinical Scholar at Yale University. From 2009 until January 2014 he served as the Chief Medical Officer and Senior Vice President of the American Board of Internal Medicine and the ABIM Foundation. He originally joined the ABIM as Vice President for Evaluation Research in 2004.

View the video recording