CBME As a Philosophy of Training: Balancing Fidelity and Flexibility in Emergency Medicine

ABSTRACT

The 2025 SAEM Consensus Conference: “Competency‐Based Training and Certification: The Future of Emergency Medicine Education” provided the opportunity to further the development of competency‐based medical education (CBME) in Emergency Medicine. This perspective argues that CBME is a flexible philosophy of training rather than a fixed checklist or recipe, and as such can and should manifest variably across contexts and specialties. The authors reason that by viewing CBME as a philosophy, multiple beneficial corollaries follow: (1) CBME training will demand a balance of fidelity of philosophical implementation with necessary context‐specific flexibility. (2) Philosophies are dynamic, and as such CBME has already evolved over time and will continue to do so. (3) Medical education has agency to direct such evolution and to choose different philosophies of training if CBME is not delivering what it purports to do. Emergency Medicine is encouraged to approach their work through the philosophy of CBME by embracing CBME principles with training and reframing assessment.

Competency‐based medical education (CBME) has a growing footprint in graduate medical education (GME). CBME requires an outcomes‐based approach, focusing on preparing learners to become physicians who are ready for practice by the end of training, reliably performing the tasks and responsibilities expected of them. Training programs are increasingly adopting competency‐based assessment systems [1, 2], and accrediting and certifying bodies are also moving toward competency‐based approaches [3]. To that end, the Society for Academic Emergency Medicine (SAEM) recently held a consensus conference on competency‐based training and certification. Our author group was invited to this conference to serve as a reactor panel for presentations on current and future CBME initiatives within Emergency Medicine. We were charged with listening to the conference discourse, reflecting on what we heard, and offering critical insights and synthesis regarding the implications of these discussions for the future of CBME in Emergency Medicine. Our author group consists of multispecialty education scholars and program leaders with expertise in CBME and innovation. Our team carries varied roles and experience as former or current associate deans, residency program leadership, an associate designated institutional official, and members with leadership roles at the American Board of Medical Specialties and the Accreditation Council for Graduate Medical Education (ACGME). This manuscript brings together our perspectives and reflections based on the conference discussions, specifically with regard to CBME implementation, as this was a prominent discourse throughout the meeting.

1. CBME As a Philosophy of Training

CBME has been called a theory, framework [4], and an approach [5, 6]. We believe that all of these terms insufficiently describe CBME; instead, it can usefully be considered a philosophy of training [7, 8]. The distinction is important. A philosophy is a set of beliefs, assumptions, and principles (implicit or explicit) that guide a system of thinking (Table 1). In contrast, a theory is an abstract description of how concepts and constructs relate, and is used to better understand how the world works [9]. A framework is a structure that allows for the application of theories or ideas in a specific context or action [9]. The terms theory and framework imply more defined components and boundaries, often designed to explain or operationalize discrete phenomena. CBME, however, permeates multiple levels of the educational system including curriculum design, assessment practices, and pedagogy. Conceiving CBME as a philosophy emphasizes its role as a guiding orientation for the entire enterprise of medical education, rather than a bounded theory to test or a framework to apply, and encourages flexibility in implementation.

TABLE 1.

CBME core components and associated beliefs, assumptions, and principles.

CBME core component	Beliefs (What is held to be true)	Assumptions (Underlying premises)	Principles (Guiding commitments)
Clearly specified outcome competencies	Medicine's purpose is to serve society, and education should prepare physicians accordingly	Competencies can be systematically derived from societal needs and transparently conveyed to learners	Define, communicate, and align competencies with evolving health priorities, ensuring shared expectations across contexts
Sequenced progression	Expertise advances through developmental stages	Learning is best supported by organizing activities in a logical, progressive sequence	Provide structured experiences that scaffold the learner's trajectory from novice to unsupervised practice
Competency‐focused instruction	Readiness for practice is measured by what learners can do, not how long they have trained	Predefined standards, rather than time‐based or comparative measures, are used to determine competence	Anchor pedagogy and assessment in criterion‐referencing rather than normative comparisons
Programmatic assessment	Growth is nurtured by feedback derived from multiple, intentionally integrated assessment approaches	Competence is multidimensional and requires multiple data points	Employ diverse, integrated assessment strategies that are transparent, fair, and defensible
Tailored learning experiences	Learners thrive when their individuality is respected	Individualized education, rather than one‐size‐fits‐all, maximizes growth	Design flexible, learner‐centered pathways that adapt to diverse strengths and trajectories

An important property of a philosophy, one that allows the systematization of the core set of beliefs, is that it can manifest variably in differing contexts. One reason for this beneficial variability is that different theories and frameworks can be used to operationalize a philosophy. A nonmedical education example may be useful. While democracy is often portrayed as a system of government, it is also a philosophy of governance [10]. The philosophy of democratic governance includes beliefs that power resides with the governed, that the governed should have autonomy to choose (often via representatives) the laws and policies that govern them, and that such autonomy should be exercised without forceful coercion. The principles often imbued in democratic philosophy include freedom, justice, and participation. However, when democracy is implemented in different contexts, the same philosophy can manifest in different governing frameworks and with different theories of how such beliefs and principles should exist. Governments can adhere to the same philosophy of democracy but have very different policies and structures.

Similarly, the philosophy of CBME can be operationalized differently depending on context, and which frameworks and theories are used in implementation. For example, CBME could be operationalized in a setting where theories of self‐conscious emotions (e.g., shame) [11, 12] and psychological safety [13] are highly salient. CBME might then use assessment frameworks that minimize threat to learners and completely eliminate any normative comparisons, such as only using narrative comments in assessment [14, 15]. Alternatively, CBME could be operationalized in a way that emphasizes the social contract that the medical profession has to protect society by only graduating physicians who have been determined to be fully competent in patient care tasks required in their specialty. This approach might employ an assessment framework that centers on patient care and how much supervision a learner needs such as entrustable professional activities [16, 17, 18]. How, then, does one know if the particular approach to CBME being used within a given context is still being true to the underlying philosophy? How different can democracies be before they are no longer democracy?

2. CBME'S Core Components Framework

The relatively rapid expansion of CBME has led to a heterogeneous and inconsistent description of the philosophy's central tenets. Brydges et al. completed a critical narrative review of existing evidence underpinning assumptions about CBME [19], finding 15 core assumptions in published literature. However, several of these core assumptions would not be endorsed by many CBME experts as contributing to the overall CBME philosophy. For example, one assumption they listed was “There is a linear, progressive pathway to reach competence,” while another was “CBME frameworks are inherently clear and intuitive.” Competence attainment is rarely linear, but is instead variable and context dependent [20]. Indeed CBME frameworks often require significant training to understand and implement, addressing as they do the full complexity of modern healthcare [3]. Brydges et al.'s manuscript illustrates the necessity of parsing which assumptions and beliefs are core to the philosophy of CBME, and which are misappropriations due to misunderstanding of the philosophy.

To help with this parsing of assumptions, beliefs, and principles, van Melle et al. used consensus methodology to develop a specific framework for ensuring that implementation and evaluation of CBME programs are consistent with the overall philosophy [21]. The framework consists of five core components:

1. Clearly specified outcome competencies – the desired outcomes of training are systematically determined and communicated to the learner.

2. Sequenced progression—organizing a logical developmental sequence of instructional activities that supports growth and development of expertise

3. Competency‐focused instruction—using pedagogical and assessment practices focused on criterion‐referenced mastery rather than normative comparison or ranking

4. Programmatic assessment—integrating multiple assessment strategies together in a way that is fit for competency determination and defensible

5. Tailored learning experiences—accommodating the known variability in learner development and individualizing training accordingly

Van Melle and colleagues' framework has been incredibly useful in determining the degree of fidelity [22] of CBME implementation to the philosophy. To take a sub‐optimal example, some training programs have grafted ACGME subcompetencies or entrustable professional activities (EPAs) onto existing assessment structures and labeled it CBME implementation. However, the ACGME subcompetencies were never intended to be used as a frontline assessment tool [23], and doing so does not result in true programmatic assessment as defined in Van Melle's core components [24]. Hanging assessment frameworks onto programs like ornaments on a tree does not by itself result in tailored, sequenced, individualized instruction. Evaluating these programs with the core components framework reveals the lack of fidelity to CBME philosophy when taking such an approach. Thus, the core components framework serves as a necessary link between CBME philosophy and practice.

The core components framework does not completely standardize CBME implementation nor should this be the goal. Each of the core components can be operationalized in myriad ways. Programmatic assessment can be approached very differently across contexts and specialties [25]. Tailored learning experiences could mean variability in training duration [26], curricular content [27], or both. Multiple different competency‐based outcomes frameworks have been used, and even sometimes co‐exist within specialties and programs while being aligned with the philosophy [28, 29]. When translating a philosophy to practice, there will always be room for interpretation, flexibility, and creativity. One size does not fit all.

3. The Corollaries of CBME as a Philosophy

If CBME is a philosophy of training, and if it can manifest variably even with a core component framework to guide implementation, then multiple important corollaries follow.

3.1. Balancing Flexibility and Fidelity

Any CBME program needs to balance fidelity of implementation (i.e., alignment with the core components) with flexibility in adapting to local contexts. But how does one know when flexibility has gone too far at the expense of fidelity? There is no official arbiter of when an acceptable balance has been reached or lost. Many ACGME program requirements list aspects of CBME, but there is no official decision that says when a program is competency‐based enough. This is a balance that each program, specialty, or regulatory body must weigh on its own. However, we point out that this is consistent with the higher ambition of delivering complex care to a diversity of patients in multiple contexts.

Engaging with three key types of expertise can help navigate this process (Figure 1). First, implementation science is a field that helps with the translation of knowledge (e.g., philosophy, concepts, theory) to practice [30, 31, 32]. Implementation science approaches can help ensure alignment between program processes and intended outcomes by using the core components framework to guide implementation. Second, program evaluators can ensure that in evaluating CBME efforts, fidelity of implementation is accounted for [33, 34]. Outcomes are important, but so are the mechanisms that lead to those outcomes. Program evaluators can leverage approaches that are likely underutilized in medical education, such as realist evaluation, which seeks to answer what works for whom under which circumstances and why [35]. Finally, co‐creation with learners and frontline educators who are at the heart of CBME efforts can ensure that stakeholder experiences are part of implementation feedback. Co‐creation of CBME programs is key, and has likely been underutilized in many settings, which in certain circumstances has led to unintended outcomes [36, 37]. All three groups—implementation scientists, program evaluators, and frontline educators/learners—are needed to find a useful balance between fidelity and flexibility.

FIGURE 1.

Three expertise groups who can help find the right balance of flexibility and fidelity in implementing a CBME philosophy.

3.2. Embracing, Not Lamenting, Philosophical Drift

Philosophies are not static; they are dynamic and change over time as new theories and values are integrated. For example, theories that heavily influenced early CBME included behaviorism, systems theory, and mastery learning [7]. Behaviorism has fallen out of favor in CBME [21], and systems theory has been supplemented with more nuanced theories from psychology and sociology. Theories on learner motivation [38, 39], self‐conscious emotion [11, 12], mindset [40, 41], adaptive expertise [42], equity [43, 44], and well‐being [45] have become more prominent in medical education, and hence been infused into CBME. This philosophical drift is normal and expected as knowledge and science progress [46]. At some point, a philosophy may change to the extent that one might ask if it is still the same philosophy. An analogy for this is the Ship of Theseus, in which a ship is slowly replaced board by board, until all component parts are replaced [47]. One wonders at which point the ship loses its identity, if ever. As CBME evolves, at some point does it become a different philosophy entirely? Perhaps this is the wrong question. The goal is for CBME to continually evolve to meet the needs of learners and patients, and the overarching label is less important than whether the philosophy is delivering on the intended outcomes.

3.3. Finding Agency in Holding CBME Accountable

Philosophies are human creations; they are not immutable truths of the universe. They are grounded in human knowledge and values, and therefore are subject to human agency. CBME grew out of societal needs [7], and its core components were determined by human consensus [21]. Medical education must continually evaluate if CBME is delivering the outcomes that are expected from high fidelity implementation of such a philosophy. If it does not, we have agency to either evolve CBME or to seek out new training philosophies that hold promise to benefit the field's stakeholders. Some have framed CBME as potentially oppressive when driven or supported by regulatory bodies [48, 49]; however, medical education as a field and member organizations as advocacy bodies have agency to shift the ideology when their guiding philosophies are not serving patients and learners [50].

4. Implications for CBME in Emergency Medicine

Emergency Medicine has always demanded adaptability, rapid decision‐making, and effective communication and collaboration—all under pressure. These demands align closely with the outcomes‐based philosophy of CBME, making EM not just a fertile ground for its implementation, but also a specialty uniquely suited to demonstrate its value. When considered as a philosophy rather than a checklist or prescriptive framework, CBME offers a way to align EM training with the realities of clinical practice and the needs of learners, patients, and systems.

4.1. EM Training Already Embraces Many CBME Principles

The philosophy of CBME emphasizes progressive autonomy, individualized learning, and real time feedback—features long embedded in EM through shift‐based supervision and high frequency formative assessment [51, 52]. Tailored learning experiences, for instance, naturally emerge in EM as learners move from simple procedures to managing critical resuscitations, guided by entrustment decisions made by supervising physicians. What CBME offers EM is not reinvention, but rather language and structure to clarify and refine what the specialty already does well.

4.2. EM Can Lead in Reframing Assessment as Learning

EM's culture of “in‐the‐moment” coaching [53] can integrate with the more longitudinal coaching relationships that are central to CBME. Residents often seek diverse feedback sources not just from attending physicians, but also from nurses, senior residents, and electronic health record metrics [54]. Recognizing and legitimizing this ecosystem of learning aligns with CBME's acknowledgment that developmental cues are diverse and distributed. EM programs can lead the way in formalizing this ecosystem while guarding against feedback overload and assessment fatigue.

4.3. CBME Helps Tackle the Real Challenges of EM Training

EM residents frequently face challenges in feedback quality [55], the hidden curriculum of performance expectations [56], and the lack of clarity in non‐procedural competencies [57]. CBME's emphasis on psychological safety, learner agency, and adaptive expertise can address these issues. For example, a focus on equity in assessment [58] can attempt to mitigate known biases in EM evaluations, especially those faced by women, trainees from underrepresented groups in medicine, or international graduates [59].

4.4. A Systemic Philosophy for a Systems‐Oriented Specialty

EM is deeply embedded in healthcare systems—it is where social determinants, clinical urgency, and systemic gaps converge. CBME encourages educators to link assessment and education with patient outcomes and system‐level impacts. The philosophy urges us to ask, “Are we graduating residents who can adapt to chaos, respond to shifting clinical demands, and center patient care in fragmented environments?” A CBME approach allows us to build assessments and curricula that answer this question affirmatively, fostering both clinical excellence and moral clarity.

4.5. EM'S Opportunity—and Responsibility—to Shape CBME

As CBME evolves, EM has an opportunity to not only participate but also to shape its trajectory. The specialty can model how to balance fidelity to core CBME principles with local flexibility: shift‐based environments, varied case presentations, disparate resource settings, and rapid task‐switching all challenge traditional models of progression and assessment. EM can pioneer approaches to mitigate assessment burden while preserving educational value, to develop coaching cultures amidst workflow demands, and to tie training more directly to patient and system outcomes.

5. Conclusion

In sum, CBME provides a philosophy to elevate and evolve EM training. The principles of CBME are already present to varying degrees in EM training. Explicitly naming the organizing philosophy provides a way to articulate and enhance what EM educators have long valued: competent, adaptive, humanistic physicians trained for the real world.

Author Contributions

B.K., S.A.S., T.M., and M.P. were all involved with the initial conceptualization of the manuscript. B.K. wrote the initial draft. S.A.S., T.M., M.P., and H.C.‐W. were all involved in multiple rounds of editing and revision. All authors approve the final version of the manuscript.

Funding

The authors have nothing to report.

Disclosure

Dr. Murano is a member of the Accreditation Council for Graduate Medical Education Residency Review for Emergency Medicine and a volunteer for the American Board of Emergency Medicine. Dr. Santen serves on a committee for the National Board of Medical Examiners, the American Board of Emergency Medicine oral board examiner, and a consultant for the American Medical Association. Dr. Pusic is an associate professor of Pediatrics and Emergency Medicine at Harvard Medical School and is the Director of the Research and Education Foundation at the American Board of Medical Specialties.

Kinnear B., Santen S. A., Murano T., Caretta‐Weyer H., and Pusic M., “ CBME As a Philosophy of Training: Balancing Fidelity and Flexibility in Emergency Medicine,” AEM Education and Training 10, no. 3 (2026): e70196, 10.1002/aet2.70196.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.