Competence by Design: The Role of High-Stakes Examinations in a Competence Based Medical Education System.

Competency based medical education is developed utilizing a program of assessment that ideally supports learners to reflect on their knowledge and skills, allows them to exercise a growth mindset that prepares them for coaching and eventual lifelong learning, and can support important progression and certification decisions. Examinations can serve as an important anchor to that program of assessment, particularly when considering their strength as an independent, third-party assessment with evidence that they can predict future physician performance and patient outcomes. This paper describes the aims of the Royal College of Physicians and Surgeons of Canada's ("the Royal College") certification examinations, their future role, and how they relate to the Competence by Design model, particularly as the culture of workplace assessment and the evidence for validity evolves. For example, high-stakes examinations are stressful to candidates and focus learners on exam preparation rather than clinical learning opportunities, particularly when they should be developing greater autonomy. In response, the Royal College moved the written examination earlier in training and created an exam quality review, by a specialist uninvolved in development, to review the exam for clarity and relevance. While learners are likely to continue to focus on the examination as an important hurdle to overcome, they will be preparing earlier in training, allowing them the opportunity to be more present and refine their knowledge when discussing clinical cases with supervisors in the Transition to Practice phase. The quality review process better aligns the exam to clinical practice and can improve the educational impact of the examination preparation process.