The recent survey of the College of Family Physicians’ of Canada (CFPC) Certificates of Added Competence (CAC) program directors is an important paper for our field. The paper by Nath and colleagues speaks to our specialty’s commitment to ensuring that graduates of both EM training programs in Canada are fully competent on the first day of their practice [1]. The CAC program now joins the Royal College Emergency Medicine program as a fully Competency-Based Medical Education (CBME) program [2].

We have spent many years focusing intently on the first 6–9 years of emergency medicine training. While this is an exciting milestone, the CBME era brings in new challenges for the learning we must do beyond residency. Now that our training programs have been aligned with CBME, it is now time to turn our attention to education beyond training—or, continuing professional development (CPD). At the individual level, the Future of Medical Education in Canada CPD (FMEC CPD) report suggests that physicians should (1) be engaged in CanMEDS/CanMEDS-FM aligned competency-based CPD; (2) be provided with tools and strategies to document and at times revise their scope of practice; (3) focus on competencies related to team functioning and collaboration; (4) be skilled lifelong learners; and (5) engage in continuous practice improvement based on their individual or aggregate practice data. And yet, will this be sufficient? Do we know what it means to be competent in practice? To maintain that competence over time?

The fork in the road

Critics of CPD to date have included various arguments against routine testing for maintenance of certification [3]. And yet, CPD is still an ill-defined zone with regard to CBME, and often absent from discussions around education change. In the wake of a global pandemic, we must take some time to rethink what it will mean for us to fulfill the recommendations from the FMEC CPD and move our field from simply focusing on undergraduate and postgraduate education, into the complexities of workplace-based learning that is integrated within our health systems and alongside our colleagues [4].

As leaders in CBME and CPD, we see that going forward we must face a fork in the road. While ensuring competence of our medical and surgical graduates surely is the mandate of undergraduate and postgraduate training, ‘maintaining competence’ is much less of an alluring construct to those fully qualified docs who are in practice. If we only seek to ‘maintain competence’, what does this mean when the next global pandemic hits and we all need to learn new things? What does it mean for a new surgeon who trains to be competent at one centre, but realizes at a new institution that the rest of her team is unfamiliar with the procedure, rendering her competence null and void?

Indeed, it may very well be hard enough for our field to “maintain” the competence of those currently in practice. By asking all practitioners to maintain their competence, are we merely preventing failure? Should we focus on remediation of colleagues who are not maintaining or are in trouble? How might we support that more? Would it be too audacious for us to chase excellence? Each of these questions will result in a different end-state and require different investment from organizations and individuals.

Beyond competence

While going all in on CBME during training is laudable, one of the core promises of CBME is a continuum of training and practice. In light of this construct of a continuum, there have been numerous conversations about what to do about the erosion of competence over time in various domains as well as how we must address gaps in training or novel practice challenges as they emerge. And how do we do this in such a way that it is adaptable to what each practicing physician requires as those working solo coverage in rural areas have different learning needs than those working with a multitude of trainees in an urban academic environment?

We must then not only consider training and practice as a continuum but also competence itself as such. Thus, competence must be addressed at each step. Simply completing training as a competent trainee prepared for initial unsupervised practice is not sufficient. We must scaffold the post-residency environment for both maintenance of competence and acquisition of new knowledge and skills. We must aim beyond competence. However, if considering medical education and practice as a continuum, initial and maintenance of certification should become a blended and flexible system aligned with CBME.

A way forward

There is an abyss off the edge of a cliff for those who have completed their training prior to the competency-based era. This is a nuanced conversation that involves consideration to the individual, team, and practice-based environment or ‘the system’. Competency-based education and assessment provides real time feedback on knowledge, skills, and attitudes.

Individuals may benefit from competency based continuous professional development for many reasons: acquisition of new skills and procedures, remedial work, return from prolonged absences from work, and more senior members of departments who spend significant amounts of time on administrative duties. Interprofessional teams can benefit from competency-based education through improving interprofessional competencies and forming communities of practice. This concept, in turn, can result in benefits to the clinical care environment and help individuals and teams improve the systems issues they have control over.

Keegan and Lahey’s deliberate development organizations concept has been proposed as a method to align organizations developmentally with CBME to create: “The Edge”—aspirational mindset of growth in a unit; “The Groove”—providing tools and practices to achieve the growth; “The Home”—creating a culture in a unit to promote the edge and the groove [5]. Digitizing data and then digitalizing the organization of these data sets for seamless delivery to stakeholders is key to DDO success [6]. Investment will be required. Maybe it is time to start raising the bar for ourselves in a way that role models and reflects how we teach our learners. It, in fact, may make us all better teachers and clinicians.