Lost in translation? How context shapes the implementation of Competence by Design in operative settings

BACKGROUND: Given the complexity of the transition to competency-based medical education (CBME) and the diversity of systems and learning contexts, the literature has acknowledged the need for principled yet contextual approaches to implementation. There is a need for research that examines these adaptations and their consequences, both intended and unintended. METHODS: We performed a constructivist grounded theory study to explore how the theory of CBME translated to practice in operative settings in a Canadian approach to CBME: Competence by Design (CBD). RESULTS: Program contexts both enabled and hindered how CBD translated into practice. The operative context was aligned with the principles of competency-focused instruction and allowed for frequent, direct observation and formative feedback. Time, personnel, and technology constraints unique to the patterns of practice in operative settings hindered programmatic assessment. CONCLUSION: Adaptations to CBME that are responsive to the context of programs can support the intended conceptual learning conditions of CBME.