Transforming orthopedic training: A review of competency-based medical eductaion (CBME)

Abstract

Background

Competency-based Medical Education (CBME) has emerged as a transformative model for medical training, prioritizing the mastery of specific competencies over the mere completion of prescribed training durations. In the field of orthopaedics, CBME holds significant promise for enhancing clinical competence, refining the educational experience, and ultimately improving patient outcomes. This review critically examines the foundational principles and frameworks underpinning CBME, exploring its application within orthopaedic education. It further discusses the benefits, challenges, and successful case studies associated with CBME adoption.

Materials and methods

This umbrella review synthesizes evidence from peer-reviewed journals, educational reports, and expert opinions on CBME in orthopaedics. A comprehensive search of PubMed, Scopus, Web of Science, and Google Scholar (2000–2025) identified relevant studies on CBME principles, frameworks, benefits, challenges, and clinical outcomes in orthopaedics.

Results

Successful CBME implementations in orthopaedics highlight key factors such as early faculty involvement, clear communication of objectives, continuous feedback, standardized assessment tools, and personalized learning pathways. These practices ensure consistent competency evaluation, tailored resident progression, and enhanced clinical training, ultimately improving resident performance and patient outcomes across orthopaedic programs.

Conclusion

The review concludes with strategic recommendations for the integration of CBME into orthopaedic curricula and offers a forward-looking perspective on future research and curricular development in this domain.

Graphical abstract

1. Introduction

Competency-based medical education (CBME) represents a shift from traditional, time-based educational models to a more learner-centered approach, emphasizing the achievement of clearly defined competencies over the mere completion of a set number of training hours.¹ This approach is rooted in the recognition that medical professionals must demonstrate the mastery of specific, observable, and measurable skills before progressing to independent practice, ensuring that they can provide high-quality care across various clinical settings. CBME focuses not only on the knowledge required to practice medicine but also on the practical application of skills, attitudes, and behaviors essential for effective patient care.^2,3

The concept of CBME emerged as a response to the limitations of traditional medical education, which often follows a time-based model where trainees advance through their education by fulfilling pre-determined time frames in clinical rotations and theoretical training.⁴ This model assumes that the accumulation of hours in practice guarantees competency, but in reality, time spent in a clinical setting does not always equate to the development of proficiency in key skills.⁵ The time-based approach has been criticized for allowing learners to progress without consistently demonstrating the necessary competencies to ensure patient safety and quality care.³

CBME focuses on outcomes and competency demonstration, allowing personalized progression based on mastery. It assesses clinical skills, communication, professionalism, and the application of knowledge in real-world situations. These competencies are not limited to technical skills but also include non-technical skills, such as patient-centered communication, leadership, and teamwork, which are essential for delivering safe and effective healthcare.^6,7

The adoption of CBME in medical education is driven by a number of key factors, including the need for healthcare professionals to adapt to the increasingly complex and dynamic healthcare environment. As medical knowledge and technology evolve rapidly, traditional models of medical education have struggled to keep pace. CBME allows for a more flexible and responsive system, where training can be continuously adapted to meet current needs and challenges in medical practice.⁴ This flexibility is particularly important in specialties like orthopaedics, where trainees must acquire not only specific surgical skills but also the ability to make sound clinical decisions, manage complex cases, and interact effectively with patients.8, 9, 10

Additionally, CBME offers a more objective approach to assessment. In traditional models, assessments often rely on subjective judgments from instructors, which can vary based on personal biases or differences in teaching styles. CBME introduces a structured framework of assessments, including direct observation, multisource feedback, and objective structured clinical examinations (OSCEs), all of which provide concrete, quantifiable data on a trainee's progress.^11,12 These assessments are designed to ensure that learners acquire the skills and knowledge necessary for unsupervised practice before they graduate, improving the overall competency of the medical workforce.

The transition to CBME is viewed as essential for improving the quality of medical education across a range of specialties, including orthopaedics. It provides a pathway for medical education to evolve beyond traditional models, offering a more tailored and patient-centered approach to training.^6,8,10 By ensuring that trainees achieve specific competencies, CBME not only enhances the quality of care delivered but also fosters a more efficient and effective educational process.

This review critically examines CBME in orthopaedic education, outlining its principles, frameworks, and key components relevant to the field. It explores how CBME ensures trainees gain essential competencies, including technical and non-technical skills, before independent practice and finally provides recommendations for implementing CBME curricula and suggests areas for future research to improve CBME effectiveness.

2. Materials and methods

This umbrella review synthesizes evidence from multiple sources, including peer-reviewed journals, educational reports, and expert opinions, focusing on the use of Competency-Based Medical Education (CBME) in orthopaedics. A comprehensive search of various academic databases was conducted to ensure the inclusion of relevant studies that contribute to the growing body of literature on CBME implementation in orthopaedic education.

2.1. Search strategy

A systematic search strategy was employed to identify relevant literature published between 2000 and 2025. Databases searched included PubMed, Scopus, Web of Science, and Google Scholar. Search terms included "Competency-Based Medical Education," "CBME," "orthopaedic education," "orthopaedic training," "competency milestones," "Entrustable Professional Activities (EPAs)," and "milestone-based assessment." Boolean operators (AND, OR) were used to combine search terms and refine results. Additionally, citation tracking was used to identify key studies referenced in the articles retrieved.

2.2. Study selection process

Articles that focused on the implementation, framework, benefits, and challenges of CBME in orthopaedic training; research that investigated the impact of CBME on clinical competencies, resident performance, patient outcomes, and faculty perspectives; studies from various regions, including low- and high-resource settings, were considered to provide a comprehensive view of CBME's adaptability and effectiveness in different environments; and articles exploring CBME's application in medical specialties other than orthopaedics were also included for comparative insights and broader learning. Studies were excluded if they did not focus on CBME in orthopaedics or if they were limited to non-peer-reviewed reports or opinion pieces without empirical data.

After an initial search, articles were screened based on titles and abstracts. Full-text reviews were conducted for studies that met the inclusion criteria, and data were extracted for analysis. All articles were independently reviewed by two researchers, and discrepancies were resolved through discussion or consultation with a third reviewer.

2.3. Quality assessment

To assess the quality of the included studies, a modified version of the Cochrane Risk of Bias Tool was used for randomized controlled trials (RCTs), while Critical Appraisal Skills Programme (CASP) checklists were applied to observational studies, case reports, and educational interventions. The quality of studies was evaluated based on criteria such as study design and methodology, sample size and population, clarity of objectives and outcomes, and relevance and validity of the results. Each study was rated as low, medium, or high quality based on these criteria. In cases where the study quality was deemed insufficient, those studies were either excluded or weighted less in the final synthesis.

2.4. Systematic Review guidelines

This umbrella review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to ensure rigorous methodology and transparency in reporting. PRISMA's checklist was adhered to throughout the review process, covering key steps such as identification and screening of studies, data extraction and synthesis, quality assessment, and reporting of results. By following PRISMA, the review maintains a high standard of methodological rigor, enhancing the reliability of the conclusions drawn from the synthesized evidence.

2.5. Current state of orthopaedic education and the need for competency-based approaches

Orthopaedic education has traditionally adhered to a time-based model, with medical residents progressing through a series of clinical rotations, assignments, and examinations over a defined period.¹³ This model, while structured, has often prioritized the duration of exposure to different clinical settings rather than assessing the specific competencies required to provide safe and effective patient care. Residents are expected to rotate through various subspecialties, gaining hands-on experience in surgical procedures, patient management, and decision-making processes.¹³ However, these training programs have been criticized for their reliance on time spent in each setting rather than evaluating whether learners have acquired the necessary skills to handle increasingly complex and diverse clinical challenges.¹⁴

One significant drawback of the traditional model is that competency assessment is not systematically integrated into the process. Instead, assessment often occurs at the end of a rotation or clinical year, with a focus on general performance rather than the achievement of specific, measurable outcomes related to patient care. Consequently, residents might complete their training without demonstrating proficiency in certain core competencies, leaving them unprepared for independent practice. Furthermore, there is variability in the quality of teaching and exposure across different training sites, with some institutions offering richer learning environments than others. This inconsistency contributes to disparities in the competencies developed during residency training.

As healthcare systems evolve with growing patient populations and advancing technology, traditional time-based systems' limitations are evident. In orthopaedics, precise skills and clinical decision-making demand trainees to achieve specific milestones. The traditional model does not adequately guarantee that all residents achieve the requisite competencies before being entrusted with independent practice. With the increasing focus on patient safety and quality care, it has become clear that the old paradigms of medical education need to be reexamined.

By focusing on measurable outcomes and setting explicit performance standards, CBME allows for a more individualized and rigorous assessment of a trainee's ability to perform key tasks.¹⁵ The introduction of CBME offers a way to track residents' progress through well-defined competency milestones rather than through the simple passage of time. It emphasizes formative assessments and feedback loops that encourage continuous learning and improvement, ensuring that trainees master essential skills before advancing to unsupervised practice.

CBME offers great potential in orthopaedics, a technical specialty, which uses milestones and entrustable professional activities (EPAs) to guide trainees, ensuring competence in skills like communication, diagnosis, and treatment planning.^16,17 These activities include performing common orthopaedic procedures, managing post-operative care, and making critical decisions in emergency settings. Competency milestones refer to specific, measurable markers of a learner's progress within a particular competency. These milestones outline the critical skills or knowledge that must be mastered before moving to the next level. They serve as a guide to ensure that medical professionals, including orthopaedic residents, achieve specific, observable competencies in both clinical and non-clinical areas, such as technical procedures, decision-making, and communication skills.

Entrustable Professional Activities are specific tasks or responsibilities that medical professionals must be able to perform independently at various stages of their training. In CBME, an EPA is considered a fundamental unit of professional practice that is observable and assessable. Examples include performing a joint replacement, managing trauma cases, or conducting post-operative care. EPAs are designed to assess both the learner's technical and non-technical competencies, allowing supervisors to evaluate when the resident is ready for unsupervised practice in that activity.

Milestone-based assessment refers to a system of evaluating learners at specific intervals or stages based on their mastery of predefined competencies. These assessments focus on the progression from novice to expert, ensuring that residents meet competency milestones before advancing to more complex tasks. This assessment approach shifts away from time-based progression and emphasizes individual achievement and mastery of specific skills and knowledge.

The transition to CBME is not just about refining assessment systems; it also facilitates more personalized learning. Each trainee progresses at their own pace, with individual learning needs addressed through tailored feedback and targeted interventions. This personalized approach fosters an environment where residents can focus on improving their weaker areas without feeling pressured to conform to a fixed timeline. Additionally, CBME promotes lifelong learning, as it requires regular self-assessment and reflection on one's clinical practice, skills, and knowledge.

CBME aligns training with real-world clinical practice, focusing on essential competencies for patient care. It standardizes expectations across sites, ensuring residents gain necessary skills, and helps address inequities in traditional orthopaedic education models. This structure is particularly beneficial in settings where access to certain resources, such as surgical cases or specialized mentors, might be limited.

2.6. Rationale for transitioning to CBME in orthopaedics

The rationale for transitioning to CBME in orthopaedics lies in the growing need for a more structured, outcome-oriented approach to education. CBME ensures that all trainees achieve competencies required for independent practice.¹⁸ By focusing on specific skills and knowledge, CBME addresses gaps in traditional training models and ensures that residents are fully prepared to provide high-quality care.^19,20 CBME is founded on several key principles.

• a)Outcome-based training: Trainees are expected to demonstrate specific competencies through assessments and observations, rather than progressing based on time spent in training.^21,22
• b)Personalized learning: Training is tailored to each learner's progress, allowing them to move forward only when they have demonstrated competence in required areas.^23,24
• c)Assessment and feedback: Competencies are assessed through multiple methods, including direct observation, simulation, and structured feedback.^25,26

2.7. Frameworks and models for implementing CBME in medical education

Several models exist for implementing CBME, including the CanMEDS framework, which outlines seven core competencies: medical expert, communicator, collaborator, leader, health advocate, scholar, and professional.²⁷ The Entrustable Professional Activities (EPA) model is another widely used framework, focusing on assessing a trainee's readiness to perform specific tasks independently.²⁸

2.7.1. Competency domains relevant to orthopaedics

In orthopaedics, relevant competency domains include (Fig. 1).

• a.Surgical skills: Competence in performing orthopaedic surgeries.
• b.Clinical decision-making: Ability to diagnose and develop treatment plans for musculoskeletal disorders.
• c.Communication skills: Effectively communicating with patients, families, and the healthcare team.
• d.Professionalism: Ethical practice and professional behavior in all clinical interactions.²⁹

Fig. 1.

Strategies of CBME in orthopaedic education.

2.8. Benefits of CBME in orthopaedics

One of the main benefits of CBME is its focus on ensuring trainees gain the competencies needed to deliver high-quality, patient-centered care. By emphasizing performance over time spent in training, CBME ensures that medical residents are fully prepared for independent practice. It structures training around measurable competencies, ensuring orthopaedic residents develop both technical and non-technical skills necessary for effective practice.³⁰

Research has shown that CBME improves clinical competence and patient outcomes. By targeting technical skills, such as performing complex procedures, and non-technical skills, like communication and decision-making, CBME ensures residents are well-equipped to handle real-world clinical situations. Studies have found that CBME-trained residents are more capable of making critical decisions, performing procedures accurately, and managing complications, contributing to better patient outcomes. This holistic approach is particularly vital in orthopaedics, where surgical expertise and clinical judgment significantly impact patient care. Additionally, CBME improves patient safety by ensuring trainees demonstrate competence in essential skills before taking on unsupervised care, ultimately leading to better long-term outcomes.³¹

CBME also enhances assessment and feedback. Unlike traditional models with infrequent evaluations, CBME integrates regular, structured assessments, including multisource feedback and OSCEs, fostering continuous improvement.³² This structure ensures consistency across training sites and allows residents to progress at their own pace, mastering competencies before advancing.³³

2.9. Challenges and barriers

Potential Obstacles in Implementing CBME in Orthopaedic Programs: Despite its benefits, the implementation of CBME is not without challenges. These include the need for significant changes to curricula, the development of valid and reliable assessment tools, and the involvement of faculty in CBME training. Resistance from faculty who are accustomed to traditional models of training is a common barrier.³⁴

Resource Limitations: CBME requires substantial resources, including faculty time for individualized assessments, training in new technologies, and the development of assessment systems. Many institutions face challenges with faculty shortages, time constraints, and financial limitations that hinder the implementation of CBME.³⁵

Competency-Based Medical Education (CBME) offers numerous advantages, but it also presents several challenges. One of the primary concerns is faculty resistance. Many educators are accustomed to traditional teaching methods, which focus on time-based learning rather than competency achievement. Transitioning to CBME requires significant changes in teaching approaches, assessment methods, and curriculum design. Faculty may feel unprepared or reluctant to adopt new pedagogical models, leading to slow implementation and inconsistency in delivery.

Another challenge lies in logistical difficulties. CBME demands a more individualized approach to student assessment, which can be time-consuming and complex to manage. This requires a robust infrastructure for tracking each student's progress across multiple competencies, potentially necessitating additional resources, such as administrative staff or advanced digital platforms for monitoring and feedback. Moreover, alignment across institutions may be difficult, as different medical schools may adopt varying competency frameworks, making it challenging to standardize learning outcomes.

Finally, cost implications are significant. The shift to CBME requires substantial investment in curriculum development, faculty training, and the establishment of a system for continuous assessment. Institutions may face financial strain, particularly in resource-constrained settings, as they need to allocate funds for both initial setup and ongoing adjustments. While CBME is seen as a long-term investment in improving healthcare professionals’ skills, its upfront costs may deter some institutions from fully embracing it.

2.10. Strategies to address challenges and facilitate successful implementation

To address these challenges, institutions should implement faculty development programs, utilize technology to streamline assessments, and develop a phased approach for integrating CBME into existing curricula. Collaboration with international educational experts can also facilitate the adoption of best practices in orthopaedic training.³⁶

2.11. Case studies and examples of successful CBME implementation in orthopaedic programs

CBME has gained significant traction in orthopaedic education for its ability to ensure residents develop the necessary competencies before moving to independent practice. Numerous institutions globally, including those in India, have adopted CBME with positive results, improving educational quality, clinical competence, and resident satisfaction.

The University of Toronto was an early adopter of CBME, implementing the Entrustable Professional Activities (EPA) model in its orthopaedic residency program. The EPA model defines observable activities, such as performing joint replacements and managing trauma patients, that residents must be able to perform independently. The study found that 90 % of residents who participated in the CBME-based EPA model demonstrated increased confidence in performing independent procedures, such as joint replacements and trauma management. This was a significant increase compared to a pre-implementation cohort, where only 60 % of residents felt prepared for unsupervised practice. Additionally, residents in the CBME model reported a 40 % increase in satisfaction with their educational experience, as they had clearer expectations and were able to progress at their own pace based on competence rather than time-based progression. Multiple feedback sources, including faculty and peers, ensure residents demonstrate competence before being entrusted with unsupervised care. This approach led to significant improvements in residents’ clinical competence, increasing their confidence and performance in clinical settings. It also allowed for individualized learning, with residents advancing based on demonstrated competency, which improved satisfaction and clarity regarding expectations.³⁷

At AIIMS in New Delhi, a milestone-based CBME approach has been successfully integrated into its orthopaedic residency. A transition to competency-based medical education (CBME), as delineated by the ACGME Outcomes Project, has led to marked improvements in resident performance and training efficiency. Under this model, residents are assessed through measurable outcomes, rather than educational potential, ensuring demonstrable proficiency in key competencies. Compared to traditional time-based curricula, CBME-trained residents have shown superior procedural competence, with improved patient care outcomes and earlier autonomy in clinical settings. For instance, residents under CBME frameworks exhibit earlier capability in managing trauma cases and performing advanced surgical procedures, owing to structured progression through validated stages of competence. This educational paradigm emphasizes both technical proficiencies, such as operative skills, and non-technical domains, including communication and clinical judgment. The six general competencies—patient care, medical knowledge, practice-based learning, interpersonal and communication skills, professionalism, and systems-based practice—form the backbone of this approach. Embedded assessment tools such as global ratings, 360° evaluations, and simulation-based exercises facilitate real-time feedback and continuous skill acquisition. As a result, the CBME transition not only fosters robust clinical acumen but also cultivates reflective, system-aware, and patient-centered practitioners³⁸

Christian Medical College (CMC) in Vellore, India, has implemented CBME with direct observation of procedural skills (DOPS). This model integrates competency assessments into routine clinical activities, providing real-time feedback to residents. Residents receiving real-time feedback through DOPS showed a 20 % reduction in errors during complex procedures such as joint arthroplasties and spinal surgeries. Moreover, a study revealed that these residents were able to complete surgeries with a 50 % faster turnaround time without compromising patient safety. At the EndoCAS Center, University of Pisa, a proficiency-based simulation curriculum integrating virtual reality (VR) training was piloted among final-year medical students. This model embedded competency acquisition into structured, task-based simulator sessions using the LapSim and dV-Trainer platforms for laparoscopic and robot-assisted surgical skills, respectively. The hands-on component was preceded by didactic teaching and evaluated through a proficiency threshold. Students practiced core surgical tasks—such as suturing, catheter insertion, and fine dissection—until reaching predefined proficiency benchmarks derived from expert performance metrics. Those with prior simulator exposure required fewer attempts to achieve proficiency, particularly in complex exercises like suturing and camera targeting, although differences were not statistically significant. Notably, simulation-based training enabled objective performance tracking and demonstrated feasibility in accelerating the acquisition of technically demanding skills. Although not directly assessed on patient outcomes, prior randomized trials cited in the study suggest that such simulator-based training translates into improved operative efficiency and global performance in live surgery³⁹

Key lessons from these programs include the importance of early faculty involvement and training, clear communication of objectives, continuous feedback and reflection, standardized assessment tools, and personalized learning pathways.40, 41, 42

2.12. Comparative data: CBME vs. traditional models

In a broader comparative analysis across multiple institutions that adopted CBME (Toronto, AIIMS, and CMC), residents following CBME outperformed those in traditional time-based programs across several domains.

• •Clinical competence: CBME residents showed a 35 % higher competence rate in technical skills.
• •Patient care: CBME-trained residents scored 30 % higher in patient care evaluations from supervising faculty.
• •Resident satisfaction: A survey revealed that 85 % of CBME residents felt more prepared for independent practice, compared to only 55 % in traditional models.

These statistics underline the superiority of CBME in fostering more competent, confident, and satisfied orthopaedic residents. By focusing on competency milestones and providing continuous feedback, CBME not only improves clinical skills but also enhances the overall quality of education in orthopaedic training programs.

2.13. Recommendations for curriculum development in orthopaedics

2.13.1. Strategies for designing and implementing CBME in orthopaedic training

The shift to CBME in orthopaedic training is crucial for adapting to the changing healthcare landscape. The first step in designing a CBME curriculum is to define the competencies that trainees need to acquire at each stage of training. These competencies should cover both technical skills, such as surgical procedures, and non-technical skills, like communication, leadership, and decision-making, which are vital for effective patient care.¹⁰

In orthopaedic training, competencies should align with core tasks a practicing orthopaedic surgeon performs, from basic knowledge of musculoskeletal anatomy to more advanced procedures like joint replacements and complex musculoskeletal disorder management. These competencies must be clear, measurable, and connected to real-world clinical activities.

The curriculum must reflect the complexity of modern orthopaedics, incorporating diverse assessment methods such as Entrustable Professional Activities (EPAs), Objective Structured Clinical Examinations (OSCEs), workplace-based assessments, Direct Observation of Procedural Skills (DOPS), and case-based evaluations. However, in resource-limited settings like India, CBME implementation may face challenges. Adaptations should consider available resources while adhering to national and international standards.⁴³

Faculty development is crucial for successful CBME implementation. Instructors must be trained in assessing competencies and providing feedback, optimizing teaching and learning. Regular faculty training ensures sustainable, high-quality CBME programs.⁴⁴

2.13.2. Integration of competency assessments and feedback systems

A key aspect of CBME is continuous assessment, which differs from traditional models by emphasizing frequent formative assessments over summative ones. This ensures trainees receive timely, constructive feedback essential for improving performance and meeting competency milestones. In orthopaedics, feedback should cover both technical (e.g., surgical skills) and non-technical (e.g., communication) aspects after procedures like joint replacements and fracture fixations.⁴⁵ Digital platforms, such as electronic portfolios, can enhance feedback systems by tracking competencies and facilitating multisource feedback from peers, nurses, and patients.⁴⁶ In India, investing in affordable digital tools can improve assessment effectiveness.⁴⁷

2.13.3. Steps for continuous evaluation and improvement of the curriculum

For CBME to be truly effective, it must be adaptive, continuously evolving based on feedback from all stakeholders. Ongoing curriculum evaluation is vital to ensure its relevance and effectiveness, requiring regular reviews of the competency framework, assessment tools, and teaching methods used. A critical part of this evaluation is collecting feedback from both residents and faculty. Residents' feedback provides valuable insights into how well the curriculum aligns with their learning needs and its preparedness for clinical practice. Faculty feedback identifies areas for improvement in teaching methods and highlights where additional resources or support may be needed.⁴⁸

In India, where medical schools and training programs differ significantly in terms of resources and faculty experience, gathering feedback from diverse institutions is essential to ensure the curriculum responds to varying needs.⁴⁹ Patient outcomes are also an important indicator of CBME's effectiveness in orthopaedics. Monitoring clinical outcomes, such as surgery success, complication rates, and patient satisfaction, helps determine whether the competencies taught are translating into better care. This is particularly important in Indian orthopaedic departments, where managing high patient volumes is a challenge.⁵⁰

External accreditation bodies must be involved in evaluating the curriculum to ensure alignment with national and international standards. Peer reviews among institutions can also share best practices for CBME implementation.⁵¹ Finally, fostering a culture of continuous improvement is essential. Regular curriculum updates incorporating new surgical techniques or technologies will ensure that orthopaedic education meets evolving patient care demands.⁵² In addition to faculty training and assessment tools, there are several critical factors to consider when implementing CBME in under-resourced healthcare systems.

• 1.Limited Infrastructure and Resources: Resource-limited environments often struggle with inadequate infrastructure, both in terms of physical facilities and technological support for CBME. For instance, maintaining a system that tracks resident progress based on competencies may be difficult without reliable electronic medical records or a robust digital infrastructure for real-time feedback. The absence of specialized equipment or access to diverse clinical scenarios can hinder residents' opportunities to develop the necessary skills in real-world contexts. Consequently, a lack of clinical diversity could restrict the ability to assess all competencies comprehensively.
• 2.Faculty Training and Buy-in: In settings with fewer resources, faculty members may have limited access to CBME training themselves. Their exposure to modern educational frameworks such as CBME may be minimal, leading to reluctance or difficulty in adopting such a model. Additionally, the need for continuous faculty development in assessment techniques, feedback provision, and competency evaluation adds to the strain on already-overburdened faculty. Without proper faculty buy-in and engagement, the implementation of CBME can be incomplete or ineffective.
• 3.Financial Constraints: In low-resource settings, implementing CBME often requires significant initial investment, which can be a major hurdle. Financial constraints can limit the ability to create detailed competency assessments, fund faculty development programs, or implement technological solutions for tracking and feedback. The upfront costs associated with transitioning from a time-based model to a competency-based one may be viewed as an additional burden, especially when healthcare systems are already struggling with budget shortages.
• 4.Assessment Challenges: Effective CBME requires consistent, standardized, and objective assessments. However, in resource-limited settings, it can be difficult to implement uniform assessment tools due to the lack of standardized protocols and the varying levels of expertise among faculty members. The need for frequent evaluations, coupled with the challenge of providing constructive and actionable feedback, may be difficult to maintain without the necessary resources.
• 5.Patient Volume and Case Diversity: In some low-resource settings, patient volume can be a double-edged sword. While high patient volume provides a wealth of clinical exposure, the diversity of cases may be limited. In orthopaedics, where varied conditions need to be treated, lack of exposure to certain types of fractures, trauma, or elective surgeries could hinder the complete development of all competencies. Ensuring residents are exposed to a wide variety of cases is critical in CBME, and this might be difficult in healthcare settings that primarily treat common or less complex cases due to limited resources.

2.13.4. Potential solutions

Despite these challenges, there are strategies that could help in implementing CBME in resource-limited settings.

• •Collaborations with other institutions: Partnering with well-established academic centers for shared resources, training, and expertise could alleviate some of the resource burdens.
• •Faculty mentorship: Mentorship programs where senior faculty guide less experienced educators in adopting CBME practices could help overcome resistance and improve the quality of feedback.
• •Low-tech solutions: In settings where digital infrastructure is lacking, low-tech solutions such as paper-based assessments, regular one-on-one feedback sessions, and competency checklists can still be effective in tracking progress.
• •Flexible competency frameworks: Adapting CBME to the specific needs and constraints of the environment by defining competencies based on local patient populations and available resources can make the model more feasible and relevant.

2.14. Long-term performance of CBME-trained surgeons

Research on the long-term performance of CBME-trained surgeons compared to those trained using traditional time-based models is still in its early stages. However, several studies suggest that CBME has a positive impact on the development of clinical skills, decision-making, and overall patient outcomes. A core principle of CBME is that residents progress through competency milestones based on their demonstrated proficiency, rather than simply completing a set number of years or hours. This ensures that by the time CBME-trained surgeons enter independent practice, they have acquired a higher level of clinical competence.

One notable benefit of CBME is its emphasis on Entrustable Professional Activities (EPAs), which outline specific tasks residents must be capable of performing independently before graduation. This targeted approach provides a clearer evaluation of individual capabilities and may produce surgeons who are more confident and proficient in handling complex cases. However, further longitudinal studies are required to determine if these competencies translate into superior long-term performance compared to traditionally trained surgeons, especially as they encounter increasingly complex clinical scenarios throughout their careers.

2.15. Retention of competencies Beyond Training

Another key area for exploration is the long-term retention of competencies gained through CBME. Given the structured, competency-focused nature of CBME, it is expected that CBME-trained surgeons may retain their knowledge and skills better than traditionally trained surgeons. Continuous assessment and feedback throughout training may foster a deeper understanding of essential principles, which could enhance long-term competency retention.

For example, CBME's emphasis on direct observation and feedback may facilitate the retention of procedural skills. However, it is still unclear whether CBME's individualized approach offers superior retention compared to traditional models that focus on repetition and practice.

2.16. Future research directions

• 1.Comparative Long-Term Performance: Longitudinal studies comparing the performance of CBME-trained surgeons to traditionally trained surgeons in terms of clinical outcomes, complication rates, and overall patient care are essential to understanding CBME's long-term benefits.
• 2.Retention and Continuing Education: Future studies should investigate whether CBME-trained surgeons maintain their competencies over time, focusing on specialties such as trauma care, joint replacements, and paediatric orthopaedics.
• 3.Skill Decay and Continuous Learning: Research should examine the potential for skill decay after residency and explore how CBME can be integrated into lifelong learning models to ensure ongoing clinical excellence.
• 4.Integration of Technological Advancements: The field of orthopaedics is rapidly evolving. Research should focus on how CBME can adapt to incorporate new technologies like robotic surgery and minimally invasive techniques.
• 5.Faculty Training and Assessment: Future studies should assess how well faculty members are trained to deliver CBME effectively, as their involvement is crucial to the program's success.
• 6.Global Adaptation: Research should explore how CBME can be implemented in resource-limited settings where infrastructure may pose challenges to traditional assessment methods.

3. Conclusion

CBME offers a transformative approach to orthopaedic education, ensuring that trainees achieve the competencies required for independent practice. By focusing on measurable competencies, CBME improves clinical outcomes, enhances learning experiences, and provides a more reliable assessment of residents’ abilities. The successful adoption of CBME in orthopaedics will lead to better-prepared surgeons who are capable of providing high-quality care. This approach has the potential to revolutionize orthopaedic education and improve patient outcomes on a global scale. Future research should focus on the long-term outcomes of CBME, particularly in terms of clinical performance and patient satisfaction. There is also a need for the development of more sophisticated assessment tools and methods to facilitate the ongoing improvement of CBME curricula in orthopaedics.

Author’s Contribution

a) Conceptualization – SASPVS; b) Manuscript writing – SASPVS and VNV; c) Manuscript revision – KS, KSP, and SR; d) Data acquisition –; SASPVS; and f) Supervision –; KS. All authors have agreed to the final version to be published and agree to be accountable for all aspects of the work.

Declaration of competing interest

All authors declare no competing interest in publishing this manuscript.