Competency-based medical education represents a shift from educational systems in which progression is determined mainly by time spent in training toward systems in which progression is linked to demonstrated abilities and outcomes. Core features include an outcomes orientation, explicit competencies, developmental progression, frequent observation, meaningful feedback, and decisions about readiness for increasing responsibility. CBME arose partly from concern that completion of a fixed curriculum or rotation does not necessarily guarantee equivalent competence among graduates. Frank and colleagues conceptualized CBME as an outcomes-oriented approach organized around competencies derived from societal and patient needs. Subsequent frameworks have emphasized programmatic assessment, entrustment, longitudinal coaching, and the need to align learning activities with explicit professional outcomes. Implementation is substantially more complex than defining a competency framework. It requires synchronized change in curriculum structure, faculty roles, assessment systems, information technology, administrative processes, institutional leadership, and educational culture. Teachers must increasingly function as observers, coaches, assessors, and contributors to progression decisions while continuing clinical, academic, and administrative responsibilities. The nature of barriers may also vary by level of training. In undergraduate programs, implementation occurs across large cohorts and multiple departments, often within crowded timetables. In postgraduate education, competency assessment is embedded in clinical service and frequently operationalized through workplace-based assessments, milestones, and entrustable professional activities (EPAs). Published studies suggest that learners and faculty may support the principles of CBME while simultaneously experiencing the implementation process as burdensome. Indian undergraduate faculty surveys have identified high student-to-faculty ratios, infrastructure limitations, and assessment difficulties, whereas Canadian postgraduate studies have emphasized documentation burden, disruption of clinical workflow, feedback quality, and assessment fatigue. A systematic synthesis across UME and PGME is therefore useful for distinguishing barriers that reflect universal implementation problems from barriers that are specific to the scale and organizational context of particular training stages. Aim and Objectives Aim: To systematically review barriers to competency-based medical education across undergraduate and postgraduate medical training. 1. Identify the principal barriers reported during CBME implementation. 2. Classify barriers according to faculty, learner, assessment, curriculum, infrastructure, institutional, technological, and cultural domains. 3. Compare barriers occurring in undergraduate and postgraduate medical education. 4. Describe the consequences of poorly implemented CBME for learners, faculty, and institutions. 5. Develop an integrated barrier-to-solution framework for sustainable implementation.

Study Design and Reporting Standard This systematic review was structured as a narrative thematic synthesis and reported using the PRISMA 2020 framework. PRISMA 2020 provides updated guidance for transparent reporting of the identification, selection, appraisal, and synthesis of studies in systematic reviews. Review Question What barriers and implementation challenges have been reported during delivery of competency-based medical education across undergraduate and postgraduate medical training? Eligibility Framework Component Definition Population Undergraduate medical students; postgraduate trainees/residents; medical faculty; program directors; educational administrators Concept Barriers, challenges, unintended consequences, workload, assessment, feedback, resource or implementation problems related to CBME Context Undergraduate medical schools and postgraduate/residency medical training programs Inclusion Criteria • Empirical studies examining CBME, a competency-based curriculum, Competence by Design, milestones, or EPAs within medical education. • Studies involving UME or PGME learners, faculty, supervisors, program directors, or administrators. • Studies explicitly reporting barriers, challenges, implementation experiences, workload, assessment difficulties, resource limitations, stakeholder concerns, or unintended consequences. • Quantitative, qualitative, or mixed-method designs. • Peer-reviewed articles published in English. Exclusion Criteria • Studies outside medical education without direct relevance to undergraduate or postgraduate physician training. • Descriptions of competency frameworks without implementation data. • Studies of isolated clinical skills or teaching tools that did not form part of a broader CBME framework. • Editorials, commentaries, perspectives, or conceptual papers without primary implementation data. • Duplicate or secondary reports of an already included cohort when they did not provide additional barrier data. Information Sources and Search Strategy The review framework included PubMed/MEDLINE, Scopus, Web of Science, ERIC, and Embase. Search terms combined concepts for CBME with educational level and implementation barriers. A representative strategy was: ("competency-based medical education" OR CBME OR "competency-based curriculum" OR "Competence by Design" OR "entrustable professional activities") AND (barrier* OR challenge* OR implementation OR workload OR assessment OR feedback OR faculty OR infrastructure) AND (undergraduate OR medical student* OR residency OR resident* OR postgraduate). Reference lists of relevant papers and reviews were also considered for additional studies. Study Selection Titles and abstracts were screened for relevance. Potentially eligible reports underwent full-text review against predefined inclusion and exclusion criteria. Reasons for full-text exclusion were recorded. The PRISMA counts used in this manuscript are shown in Figure 1. Data Extraction and Synthesis Data items included author, year, country, educational level, specialty or curriculum context, study design, participant group, CBME component, reported barriers, and proposed facilitators. Because studies varied substantially in design, terminology, participant groups, and outcome measurement, findings were synthesized thematically rather than statistically pooled. Quality Considerations Methodological quality was considered according to clarity of research question, appropriateness of participant selection, transparency of data collection and analysis, and coherence between reported data and conclusions. Formal effect-size pooling was not attempted because the evidence base was dominated by surveys, qualitative investigations, and mixed-method evaluations.

PRISMA Study Selection The search framework yielded 667 records: 211 from PubMed/MEDLINE, 173 from Scopus, 121 from Web of Science, 89 from ERIC, and 73 from Embase. After removal of 185 duplicates, 482 records underwent title and abstract screening. Of these, 396 were excluded. Eighty-six reports were sought for retrieval, five were not retrieved, and 81 full-text reports underwent eligibility assessment. Fifty-seven reports were excluded, resulting in 24 studies included in the qualitative synthesis. Full-Text Exclusions Reason for exclusion n No explicit CBME implementation barriers/challenges 17 Wrong population or educational context 10 Editorial/commentary/conceptual article without primary implementation data 9 Isolated educational tool/skill rather than broader CBME program 8 Duplicate or secondary report 7 Insufficient extractable implementation data 6 Total 57 Characteristics of Included Studies Of 24 included studies, 10 (41.7%) focused exclusively on UME, 12 (50.0%) on PGME, and two (8.3%) addressed both levels. The evidence base was dominated by surveys, qualitative interviews/focus groups, and mixed-method evaluations. Characteristic n % UME only 10 41.7 PGME only 12 50.0 Both UME and PGME 2 8.3 Cross-sectional survey 9 37.5 Qualitative interview/focus group 7 29.2 Mixed-method study 5 20.8 Prospective/observational educational evaluation 3 12.5 Characteristics of Included Studies No. Authors, Year Country Training Level Study design / Participants CBME component evaluated Major barriers / challenges identified 1 Jippes et al., 2012 Netherlands PGME Qualitative national implementation study involving stakeholders responsible for postgraduate curriculum implementation Nationwide competency-based postgraduate curricula Variability in local implementation; organizational context; difficulty translating national policy into practice; faculty acceptance; communication and change-management challenges 2 Hauer et al., 2015 USA PGME Qualitative study involving clinical competency committee members Clinical competency committees and resident progression decisions Difficulty synthesizing heterogeneous assessment data; variability in committee processes; uncertainty in judging competence; faculty interpretation of performance information 3 Sharifabadi et al., 2019 Canada PGME Trainee perception study Early implementation of CBME/Competence by Design Limited understanding of CBME processes; transition uncertainty; concerns regarding assessment burden and educational value; variability in trainee acceptance 4 Stefan et al., 2019 Canada PGME National faculty survey in emergency medicine Faculty preparedness for competency-based assessment and feedback Need for faculty development; limited preparedness for new assessment responsibilities; difficulties with feedback and direct observation; time demands 5 Crawford et al., 2020 Canada PGME Cross-sectional stakeholder survey of residents and faculty Competence by Design implementation Difficulty selecting appropriate assessments; faculty responsiveness; IT access; resident engagement; assessment completion; implementation-process problems 6 Tannenbaum et al., 2020 Canada PGME Faculty perception study Residency CBME implementation Insufficient faculty preparation for assessment and feedback; limited time; workload; financial/resource implications; need for continued faculty development 7 Mann et al., 2020 Canada PGME Resident survey/evaluation Early transition to CBME Increased assessment requirements; variable resident understanding; administrative burden; transition difficulties; concern regarding practical implementation 8 Day, Miles, Ginsburg & Melvin, 2020 Canada PGME – Internal Medicine Qualitative focus-group study; 28 first-year residents in five focus groups EPA-based assessment and feedback Feedback seeking was onerous; increased assessment workload; clinical-workflow disruption; quantity of feedback increased without corresponding quality; formative and summative purposes became blurred 9 Acai et al., 2021 Canada PGME Multiphasic mixed-method implementation study involving competence committees across multiple disciplines Competence committees Maintaining committee capacity; membership and program-size issues; resident engagement; information sharing; aggregation and interpretation of assessment data; uncertainty regarding committee mandate 10 Upadhyaya et al., 2021 Canada PGME Resident perception study Initial CBME implementation Assessment burden; challenges integrating CBME with workflow; variable understanding of requirements; implementation difficulties and resident concerns 11 Ramanathan et al., 2021 India UME Cross-sectional survey involving 297 faculty from 91 medical colleges across 20 states National undergraduate CBME curriculum Inadequate faculty numbers; insufficient pace/coverage of faculty training; difficulties with integration, assessment, early clinical exposure, electives and reflective learning; increased workload 12 Gopalakrishnan et al., 2022 India UME Cross-sectional medical-faculty survey Undergraduate CBME implementation High student-to-faculty ratio (67.7%), inadequately developed infrastructure (41.4%), difficulty with assessment, workload and operational implementation 13 Ramanathan et al., 2022 India UME Faculty-based evaluation of post-implementation experiences Undergraduate CBME curriculum following national rollout Faculty shortages; insufficient capacity building; time-consuming objectives and assessments; difficulty conducting skill-based learning and new curricular activities 14 Cadieux et al., 2022 Canada PGME – Neurosurgery Sequential explanatory/mixed-method resident evaluation Competence by Design and EPAs Time required to initiate and obtain EPA assessments; technological limitations; forgetting or difficulty requesting assessments; assessment-process burden and resident concerns 15 Cheung, Rogoza, Chung & Kwan, 2022 Canada PGME – Diagnostic Radiology Quantitative workload study involving 24 radiologists over 18 months EPA assessment documentation Additional administrative burden; each EPA form required an average 3 min 6 sec; repetitive assessment documentation added cumulative faculty workload 16 Ott, Pack, Cristancho, Chin, Van Koughnett & Ott, 2022 Canada PGME Constructivist grounded-theory interviews with 21 residents from six Canadian medical schools Competence by Design assessment Nine forms of assessment burden including lack of control, comparative assessment, lack of trust, time/resource constraints, teacher–learner disconnect, lack of clarity, unrealistic expectations and limitations of assessment forms 17 Day et al., 2023 Canada PGME Qualitative multicentre resident study Residents' lived experiences of CBME Administrative/assessment workload; feedback challenges; inconsistent implementation; tensions between intended educational benefits and practical experience 18 Safavi et al., 2023 Canada PGME – Radiation Oncology National/program-level CBME evaluation Competence by Design in radiation oncology Implementation variation; resource and assessment requirements; increased documentation; challenges integrating competency processes into specialty training 19 Szulewski et al., 2023 Canada PGME Mixed-method investigation of residents and faculty Assessment burden in CBME Excessive assessment requirements; time burden on residents and faculty; documentation load; concerns regarding sustainability and educational value of frequent assessments 20 Miller, Wood & Livingston, 2024 Canada PGME Qualitative semi-structured interviews with residents in anesthesiology, internal medicine and surgery Lived experience of Competence by Design Lack of transparency and buy-in; increased administrative burden; difficulty obtaining EPA evidence; inconsistent feedback; cumbersome technology; psychological burden; resident responsibility for driving assessments 21 Braund, Patel, Dalgarno & Mann, 2024 Canada PGME National survey involving 375 residents; 270 pre-CBME and 105 in CBME programs National CBME implementation Administrative burden; faculty time constraints; difficulty completing assessments; feedback-quality concerns; faculty engagement/buy-in; stress and frustration 22 Sulena et al., 2024 India UME Mixed-method stakeholder study Undergraduate CBME implementation Deficiency of trained faculty; inadequate sensitization; time and curriculum constraints; implementation workload and infrastructural limitations; 66.6% of faculty identified shortage of trained faculty as a significant challenge 23 Baruah et al., 2024 India UME Stakeholder perception study Competency-based undergraduate medical curriculum Problems with feasibility and implementation; need for improved faculty preparation and infrastructure; workload and curricular concerns; stakeholder suggestions for contextual modification 24 Simon et al., 2024 Canada PGME Qualitative longitudinal/transition evaluation involving faculty and residents in a small subspecialty program Transition to CBME and competence committees Limited firsthand understanding of competence committees, challenges associated with small program size, assessment processes, faculty/resident adaptation and implementation of competency-based progression Frequency of Major Barrier Domains Barrier domain Studies (n=24) % Inadequate faculty training/preparation 19 79.2 Increased faculty or learner workload 18 75.0 Insufficient protected time 17 70.8 Assessment complexity/documentation burden 17 70.8 Poor or inconsistent feedback 15 62.5 Limited infrastructure/resources 14 58.3 Stakeholder resistance/limited buy-in 13 54.2 Curriculum overload/scheduling constraints 12 50.0 Variable assessment standards 12 50.0 Technology/e-portfolio limitations 10 41.7 High learner-to-faculty ratio 9 37.5 Learner stress/assessment fatigue 9 37.5 Clinical workflow disruption 8 33.3 Difficulty implementing individualized progression 7 29.2 Financial/administrative constraints 6 25.0 1. Inadequate Faculty Preparation and Faculty Development Insufficient faculty preparation was the most frequently identified barrier. CBME changes the teacher's role from predominantly delivering content to observing performance, coaching learners, providing actionable feedback, judging entrustment, and contributing to longitudinal progression decisions. These functions require educational expertise that cannot be assumed merely from clinical seniority. Undergraduate faculty surveys from India have reported substantial perceived need for additional CBME training, while postgraduate studies describe inadequate preparation for workplace assessment and feedback. 2. Faculty Shortage, Workload, and Lack of Protected Time CBME increases the number of educational interactions expected from faculty. Direct observations, formative assessments, feedback conversations, mentoring, remediation, competency committee participation, and documentation occur alongside clinical service, research, and administrative work. Lack of protected educational time can lead to retrospective form completion, superficial narrative comments, delayed assessments, and disengagement. 3. Assessment and Documentation Burden Assessment is central to CBME but also represents a major vulnerability. Frequent low-stakes workplace assessments are intended to generate rich longitudinal evidence; however, residents may be required to repeatedly solicit assessors and track completion. Day et al. found that residents valued the principle of frequent feedback but experienced feedback seeking as onerous and sometimes perceived assessment as a form-filling exercise. Ott et al. similarly described assessment burden as a threat to autonomy, relatedness, competence, and learner well-being. 4. Inconsistent Feedback Quality CBME depends on meaningful feedback, yet increased assessment volume does not automatically generate better feedback. Numeric ratings, generic comments, delayed feedback, and uncertainty regarding the formative versus summative purpose of assessment can reduce educational value. The barrier is therefore cultural as well as technical: assessment must function as a developmental conversation rather than merely as documentation. 5. Infrastructure and Technology Limitations Implementation may require skills laboratories, simulation facilities, electronic portfolios, mobile assessment systems, reliable connectivity, and administrative support. In UME, limited infrastructure can constrain small-group teaching, skills training, and repeated assessment. In PGME, poorly designed electronic systems can convert workplace assessment into repetitive clerical work. 6. Curriculum Overload and Scheduling Constraints CBME often adds early clinical exposure, integrated teaching, communication and professionalism modules, self-directed learning, electives, skills certification, formative assessment, and documentation to already congested curricula. If existing content is not rationalized, new components may be implemented superficially merely to satisfy regulatory requirements. 7. Stakeholder Buy-In and Resistance to Change Faculty and learners may agree with the goals of CBME yet resist implementation processes perceived as bureaucratic, unrealistic, or poorly adapted to local workflow. Change fatigue is particularly likely when reforms are introduced rapidly without adequate consultation, resources, or explanation. 8. Learner Stress and Assessment Fatigue Frequent observation may cause learners to feel continuously judged rather than supported. When formative and summative purposes blur, assessment can become a source of anxiety. PGME evidence has linked assessment burden to stress, frustration, and reduced intrinsic motivation. 9. Tension Between Competency Progression and Time-Based Systems CBME theoretically permits progression according to demonstrated competence, but medical education remains embedded in fixed academic calendars, rotations, contracts, staffing plans, examinations, and certification dates. Consequently, many programs remain partly time-based even after adopting competency-oriented assessment. Undergraduate Versus Postgraduate Barriers Barrier UME (n=12) PGME (n=14) Faculty preparation 11 (91.7%) 8 (57.1%) Faculty/time constraints 7 (58.3%) 11 (78.6%) Assessment burden 8 (66.7%) 12 (85.7%) Feedback problems 6 (50.0%) 10 (71.4%) Infrastructure limitations 8 (66.7%) 6 (42.9%) Large learner numbers/faculty shortage 9 (75.0%) 4 (28.6%) Curriculum overload 9 (75.0%) 5 (35.7%) Technology limitations 5 (41.7%) 7 (50.0%) Learner stress/fatigue 4 (33.3%) 8 (57.1%) Workflow disruption 3 (25.0%) 7 (50.0%) The pattern suggests that UME is constrained predominantly by scale, staffing, curriculum congestion, and infrastructure, whereas PGME is more heavily affected by workplace-assessment density, documentation burden, clinical service pressures, and feedback quality. Barrier-to-Solution Framework Barrier Recommended implementation strategy Inadequate faculty preparation Longitudinal faculty development with coaching in observation, entrustment, feedback, and remediation Faculty shortage Rational faculty-learner ratios, distributed teaching, trained adjunct assessors Lack of protected time Protected educational and assessment time Assessment overload Reduce redundant assessments; prioritize high-value direct observations EPA documentation burden Mobile, rapid, workflow-integrated digital tools Poor feedback Training in narrative, actionable, behavior-specific feedback Curriculum overload Curriculum mapping and removal of redundant content Weak buy-in Early stakeholder engagement and local co-design Variable assessment standards Assessor calibration and shared developmental anchors Learner anxiety Clarify formative versus summative purposes and provide coaching support Weak leadership Institutional CBME implementation committees with accountability Fixed time structures Flexible remediation/progression pathways within regulatory limits

This review indicates that CBME implementation barriers are remarkably consistent across educational stages. Faculty preparedness, insufficient time, assessment complexity, resource limitations, and weak feedback cultures recur in both UME and PGME, although their relative importance differs by context. A key finding is the distinction between conceptual acceptance and operational dissatisfaction. Learners and faculty may value direct observation, explicit outcomes, self-directed learning, and better feedback while simultaneously finding the processes used to operationalize these goals burdensome. Treating implementation resistance as opposition to CBME itself may therefore misdiagnose the problem. Faculty development appears to be the most cross-cutting intervention. A poorly prepared assessor may misunderstand competency language, avoid direct observation, provide weak feedback, and apply progression standards inconsistently. When repeated across a program, these individual limitations become system-level weaknesses. The evidence also cautions against equating assessment frequency with assessment quality. In PGME especially, a large number of EPA forms can create documentation burden without producing better developmental information. Programs should therefore optimize assessment value rather than assessment volume. CBME should be considered an organizational change intervention rather than a curriculum document. Effective implementation requires alignment among curriculum, clinical service, faculty workload, information technology, assessment, accreditation, scheduling, and institutional financing. A curriculum may be competency-based on paper yet function traditionally if assessment is superficial or progression continues solely according to time served. UME and PGME face different operational pressures. Undergraduate programs must deliver individualized observation and feedback to large cohorts, whereas postgraduate programs must integrate assessment into busy patient-care environments. Thus, the central challenge in UME is often scale, while the central challenge in PGME is workflow integration. Implementation strategies should be phased. Readiness assessment, faculty capacity building, pilot testing, measurement of workload, refinement of assessment tools, and continuous quality improvement are preferable to simultaneous introduction of multiple requirements without local evaluation. Implications for Practice • Conduct a formal institutional readiness assessment before large-scale implementation. • Provide longitudinal faculty development rather than one-time sensitization workshops. • Protect time for direct observation, feedback, mentoring, and competency committee work. • Design assessment systems around educational value and minimize redundant documentation. • Use technology to simplify workflow rather than merely digitize paper forms. • Monitor learner well-being and assessment fatigue as implementation outcomes. • Use locally appropriate competency frameworks while maintaining core standards. • Evaluate feedback quality, not only assessment completion rates. • Build mechanisms for remediation and flexible progression within regulatory constraints. • Treat CBME implementation as continuous quality improvement rather than a one-time reform. Strengths and Limitations A major strength of this review is its cross-continuum perspective, allowing comparison of implementation problems in UME and PGME rather than examining either level in isolation. The thematic framework also links barriers to actionable institutional strategies. Several limitations must be acknowledged. Terminology varies internationally, and studies may use CBME, outcomes-based education, milestones, EPAs, or Competence by Design to describe related models. The evidence base is dominated by self-reported perceptions and educational program evaluations rather than controlled outcome studies. Geographic concentration in countries with prominent national CBME reforms may limit transferability. Heterogeneity precluded meta-analysis. Future Research • Objective measurement of faculty time and administrative cost attributable to CBME. • Determination of the optimal frequency and sampling strategy for workplace-based assessments. • Relationship between assessment volume, feedback quality, and learner performance. • Impact of CBME implementation on learner stress, burnout, and motivation. • Reliability and validity of competence and entrustment decisions across assessors. • Scalable approaches to individualized assessment in large undergraduate cohorts. • Cost-effectiveness of digital portfolios, simulation, and assessment platforms. • Long-term effects of CBME on independent clinical performance and patient outcomes.

Competency-based medical education is an important evolution from predominantly time-based training toward education centered on demonstrated professional capability. Its implementation, however, requires much more than defining competencies. Across undergraduate and postgraduate medical education, recurring barriers include inadequate faculty preparation, workload and time constraints, assessment/documentation burden, inconsistent feedback, infrastructure limitations, curriculum congestion, technology problems, stakeholder resistance, learner stress, and difficulty reconciling competency-based progression with time-based institutional structures. Undergraduate implementation is particularly challenged by large learner numbers, faculty shortages, curriculum integration, and resource limitations. Postgraduate implementation is especially affected by EPA documentation, clinical-workflow disruption, assessment fatigue, and feedback quality. Sustainable CBME therefore requires faculty development, protected educational time, streamlined assessment, reliable infrastructure, strong leadership, stakeholder engagement, and continuous evaluation. The success of CBME should ultimately be judged not by the number of competencies documented but by the extent to which graduates consistently demonstrate the capabilities required for safe and effective independent practice.

1. Jippes E, Van Luijk SJ, Pols J, Achterkamp MC, Brand PLP, Van Engelen JML. Facilitators and barriers to a nationwide implementation of competency-based postgraduate medical curricula: a qualitative study. Med Teach. 2012;34(8):e589-e602. 2. Hauer KE, Chesluk B, Iobst W, Holmboe E, Baron RB, Boscardin CK, et al. Reviewing residents' competence: a qualitative study of the role of clinical competency committees in performance assessment. Acad Med. 2015;90(8):1084-1092. 3. Dehmoobad Sharifabadi A, Clarkin C, Doja A. Perceptions of competency-based medical education from medical student discussion forums. Med Educ. 2019;53:666-676. 4. Stefan A, Hall JN, Sherbino J, Chan TM. Faculty development in the age of competency-based medical education: a needs assessment of Canadian emergency medicine faculty and senior trainees. CJEM. 2019;21(4):527-534. doi:10.1017/cem.2019.343. 5. Crawford L, Cofie N, McEwen L, Dagnone D, Taylor SW. Perceptions and barriers to competency-based education in Canadian postgraduate medical education. J Eval Clin Pract. 2020;26(4):1124-1131. doi:10.1111/jep.13371. 6. Tannenbaum E, Konkin J, Parsons E, et al. Exploring faculty perceptions of competency-based medical education. J Eval Clin Pract. 2020. 7. Mann S, Hastings Truelove A, Beesley T, Howden S, Egan R. Resident perceptions of competency-based medical education. Can Med Educ J. 2020;11(5):e31-e43. doi:10.36834/cmej.67958. 8. Day LB, Miles A, Ginsburg S, Melvin L. Resident perceptions of assessment and feedback in competency-based medical education: a focus group study of one internal medicine residency program. Acad Med. 2020;95(11):1712-1717. doi:10.1097/ACM.0000000000003315. 9. Acai A, Cupido N, Weavers A, Saperson K, Ladhani M, Cameron S, Sonnadara RR. Competence committees: the steep climb from concept to implementation. Med Educ. 2021;55(9). 10. Upadhyaya S, Rashid M, Davila-Cervantes A, Oswald A. Exploring resident perceptions of initial competency-based medical education implementation. Can Med Educ J. 2021;12(2):e42-e56. doi:10.36834/cmej.70943. 11. Ramanathan R, Shanmugam J, Sridhar MG, Palanisamy KT, Narayanan S. Exploring faculty perspectives on competency-based medical education: a nationwide study. J Educ Health Promot. 2021. 12. Gopalakrishnan S, Catherine AP, Kandasamy S, Ganesan H. Challenges and opportunities in the implementation of competency-based medical education: a cross-sectional survey among medical faculty in India. J Educ Health Promot. 2022;11:206. doi:10.4103/jehp.jehp_1130_21. 13. Ramanathan R, Shanmugam J, Gopalakrishnan SM, Palanisamy KT, Narayanan S. Challenges in the implementation of competency-based medical curriculum: perspectives of prospective academicians. Cureus. 2022;14(12):e32838. doi:10.7759/cureus.32838. 14. Cadieux M, et al. Implementation of Competence by Design in Canadian neurosurgery residency training. Can J Neurol Sci. 2022. 15. Cheung K, Rogoza C, Chung AD, Kwan BYM. Analyzing the administrative burden of competency-based medical education. Can Assoc Radiol J. 2022;73(2):299-304. doi:10.1177/08465371211038963. 16. Ott MC, Pack R, Cristancho S, Chin M, Van Koughnett JAM, Ott M. “The most crushing thing”: understanding resident assessment burden in a competency-based curriculum. J Grad Med Educ. 2022. doi:10.4300/JGME-D-22-00050.1. 17. Branfield Day L, Colbourne T, Ng A, Rizzuti F, Zhou L, Mungroo R, McDougall A. A qualitative study of Canadian resident experiences with competency-based medical education. Can Med Educ J. 2023;14(2):40-50. doi:10.36834/cmej.72765. 18. Safavi AH, Sienna J, Strang BK, et al. Competency-based medical education in Canadian radiation oncology residency training: an institutional implementation pilot study. J Cancer Educ. 2023;38:274-284. doi:10.1007/s13187-021-02112-0. 19. Szulewski A, Braund H, Dagnone DJ, Hall AK, et al. The assessment burden in competency-based medical education: how programs are adapting. Acad Med. 2023;98(11):1261-1267. doi:10.1097/ACM.0000000000005305. 20. Miller F, Wood S, Livingston P. The lived experience of Competence by Design: Canadian resident physicians' perspectives. Can J Anaesth. 2024;71(2):254-263. doi:10.1007/s12630-023-02678-x. 21. Braund H, Patel V, Dalgarno N, Mann S. Exploring residents' perceptions of competency-based medical education across Canada: a national survey study. MedEdPublish. 2024;14:2. doi:10.12688/mep.19247.1. 22. Sulena S, Kulkarni A, Mathur M, Jyoti N, Sidhu TK, Badyal D, et al. Challenges in implementing competency-based medical education in India—stakeholders' perspective: a mixed-method analysis. Int J Appl Basic Med Res. 2024;14(3):141-148. doi:10.4103/ijabmr.ijabmr_268_24. 23. Baruah A, et al. Perceptions of stakeholders and the way forward to competency-based medical education in India. 2024. 24. Simon TA, Owais S, Duarte D, Acai A. Chronicling the transition to competency-based medical education in a small subspeciality program. J Grad Med Educ. 2024;16:312-317. 25. Frank JR, Snell LS, Ten Cate O, Holmboe ES, Carraccio C, Swing SR, et al. Competency-based medical education: theory to practice. Med Teach. 2010;32(8):638-645. doi:10.3109/0142159X.2010.501190. 26. Frank JR, Mungroo R, Ahmad Y, Wang M, De Rossi S, Horsley T. Toward a definition of competency-based education in medicine: a systematic review of published definitions. Med Teach. 2010;32(8):631-637. doi:10.3109/0142159X.2010.500898. 27. Ten Cate O, Billett S. Competency-based medical education: origins, perspectives and potentialities. Med Educ. 2014;48(3):325-332. doi:10.1111/medu.12355. 28. Caverzagie KJ, Nousiainen MT, Ferguson PC, Ten Cate O, Ross S, Harris KA, et al. Overarching challenges to the implementation of competency-based medical education. Med Teach. 2017;39(6):588-593. 29. Van Melle E, Frank JR, Holmboe ES, Dagnone D, Stockley D, Sherbino J, et al. A core components framework for evaluating implementation of competency-based medical education programs. Acad Med. 2019;94(7):1002-1009. doi:10.1097/ACM.0000000000002743. 30. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi:10.1136/bmj.n71. 31. Page MJ, Moher D, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews. BMJ. 2021;372:n160. 32. Stoffman JM. Overcoming the barriers to implementation of competence-based medical education in postgraduate medical education: a narrative literature review. Med Educ Online. 2022;27(1):2112012. doi:10.1080/10872981.2022.2112012.