This article is a sequel to one published in 2002 only a few years after the initiation of the shift to competency-based medical education (CBME). The authors reflect on the major forces that have influenced the movement and tipped the balance toward widespread adoption of CBME in the United States, primarily in graduate medical education. These forces include regulatory bodies, international counterparts, and the general public. The authors highlight the most important lessons learned over the decade. These include (1) the need for standardization of language to develop a shared vision of the path ahead, (2) the power of direct observation in assessment, (3) the challenge of developing meaningful measures of performance, (4) desired outcomes as the starting point for curriculum development, (5) dependence on reflection in the development of expertise, (6) the need for exploiting the role of learners in their learning, and (7) competent clinical systems as the required learning environment for producing competent physicians.The authors speculate on why this most recent attempt to shift to CBME differs from previous aborted attempts. They conclude by explaining how the recent lessons learned inform the vision of what successful implementation of CBME would look like, and discussing the importance of milestones, entrustable professional activities, and an integrated, rather than a reductionist, approach to assessment of competence. The fundamental question at each step along the way in implementing CBME should be "How do we improve medical education to provide better care for patients?"

Although health professions worldwide are shifting to competency-based education, no common taxonomy for domains of competence and specific competencies currently exists. In this article, the authors describe their work to (1) identify domains of competence that could accommodate any health care profession and (2) extract a common set of competencies for physicians from existing health professions' competency frameworks that would be robust enough to provide a single, relevant infrastructure for curricular resources in the Association of American Medical Colleges' (AAMC's) MedEdPORTAL and Curriculum Inventory and Reports (CIR) sites. The authors used the Accreditation Council for Graduate Medical Education (ACGME)/American Board of Medical Specialties six domains of competence and 36 competencies delineated by the ACGME as their foundational reference list. They added two domains described by other groups after the original six domains were introduced: Interprofessional Collaboration (4 competencies) and Personal and Professional Development (8 competencies). They compared the expanded reference list (48 competencies within eight domains) with 153 competency lists from across the medical education continuum, physician specialties and subspecialties, countries, and health care professions. Comparison analysis led them to add 13 "new" competencies and to conflate 6 competencies into 3 to eliminate redundancy. The AAMC will use the resulting "Reference List of General Physician Competencies" (58 competencies in eight domains) to categorize resources for MedEdPORTAL and CIR. The authors hope that researchers and educators within medicine and other health professions will consider using this reference list when applicable to move toward a common taxonomy of competencies.

The decision to trust a medical trainee with the critical responsibility to care for a patient is fundamental to clinical training. When carefully and deliberately made, such decisions can serve as significant stimuli for learning and also shape the assessment of trainees. Holding back entrustment decisions too much may hamper the trainee's development toward unsupervised practice. When carelessly made, however, they jeopardize patient safety. Entrustment decision-making processes, therefore, deserve careful analysis.Members (including the authors) of the International Competency-Based Medical Education Collaborative conducted a content analysis of the entrustment decision-making process in health care training during a two-day summit in September 2013 and subsequently reviewed the pertinent literature to arrive at a description of the critical features of this process, which informs this article.The authors discuss theoretical backgrounds and terminology of trust and entrustment in the clinical workplace. The competency-based movement and the introduction of entrustable professional activities force educators to rethink the grounds for assessment in the workplace. Anticipating a decision to grant autonomy at a designated level of supervision appears to align better with health care practice than do most current assessment practices. The authors distinguish different modes of trust and entrustment decisions and elaborate five categories, each with related factors, that determine when decisions to trust trainees are made: the trainee, supervisor, situation, task, and the relationship between trainee and supervisor. The authors' aim in this article is to lay a theoretical foundation for a new approach to workplace training and assessment.