Evolution of Competency-Based Medical Education Competency-based medical education represents a shift from educational systems predominantly organized around prescribed training duration toward systems focused on the demonstration of defined professional abilities. In traditional models, completion of courses, clerkships, or rotations may serve as proxies for educational achievement. CBME instead emphasizes measurable outcomes, progressive development, frequent observation, meaningful feedback, and advancement according to demonstrated competence. The approach has increasingly influenced both undergraduate and postgraduate medical education. Competency frameworks seek to define what learners should be able to accomplish at successive stages of training and to ensure that educational progression reflects readiness for increasingly complex clinical responsibilities. An important development within CBME has been the use of Entrustable Professional Activities (EPAs). EPAs translate broad competency domains into units of professional work that can be directly observed and entrusted to learners at varying levels of supervision. Rather than asking whether a learner possesses a general competency such as communication or professionalism, educators can ask whether the learner can safely perform a specific professional activity with a defined degree of supervision. The Medical School-to-Residency Transition The transition from medical school to residency is particularly important because it marks a rapid change in professional responsibility. Senior medical students generally function under close supervision, whereas new residents are expected to manage patients, prescribe medications, communicate with multidisciplinary teams, recognize clinical deterioration, perform procedures, and make decisions under conditions of greater responsibility. Competency-based education theoretically offers a mechanism for making this transition safer. A graduating medical student should enter residency with clearly documented capabilities and known areas requiring continued supervision. In practice, however, residency programs may receive limited information regarding the graduate's actual competency profile. Academic transcripts and examination scores may provide evidence of achievement but may not clearly indicate which clinical activities the graduate can perform independently or with indirect supervision. Can competency demonstrated during medical school be trusted and meaningfully transferred into residency supervision decisions? Readiness for Residency Readiness for residency is multidimensional. It includes not only knowledge but also the ability to assess patients with common and undifferentiated presentations, formulate differential diagnoses, recognize emergencies, initiate management, prescribe safely, perform common procedures, communicate effectively, hand over clinical responsibility, work within healthcare teams, identify personal limitations, and seek appropriate assistance. A learner may perform strongly in some activities while continuing to require close supervision in others. Consequently, readiness should be viewed as a profile rather than a single global judgment. Entrustment as a Bridge Between Medical School and Residency Entrustment decisions provide a potentially useful mechanism for bridging undergraduate and postgraduate training. A supervision scale may indicate that a learner may observe only, perform with direct supervision, perform with indirect supervision, perform independently, or supervise others. At the point of residency entry, the most important educational information is therefore not simply whether a graduate has passed, but which professional activities can be performed safely and at what level of supervision. Why Transition Problems Persist • Medical schools and residency programs may use different competency frameworks. • They may apply different entrustment thresholds and interpret supervision levels differently. • They may rely on different assessment tools and maintain separate electronic portfolios. • They may have different expectations of incoming trainees. • They may lack systems for transferring longitudinal performance data. These differences can fragment the educational continuum. When residency programs do not trust prior assessments, incoming trainees may undergo extensive reassessment regardless of previously demonstrated competence. Conversely, excessive reliance on inadequately validated undergraduate assessments may result in inappropriate levels of supervision. The transition therefore requires both continuity and verification. Rationale, Aim and Objectives Previous CBME literature has extensively examined curriculum implementation, faculty development, assessment burden, and workplace-based assessment. However, the specific transition between medical school and residency deserves focused attention because it represents the point where educational judgments begin to influence real clinical responsibility. Aim: To systematically evaluate barriers affecting competency-based progression from medical school to residency. 1. Identify barriers affecting assessment continuity between medical school and residency. 2. Evaluate challenges associated with entrustment decisions at the transition point. 3. Assess factors influencing residency-program trust in undergraduate competency assessments. 4. Examine the transfer of learner-performance information between institutions and training stages. 5. Identify barriers associated with supervision decisions during early residency. 6. Propose strategies for strengthening competency-based transition pathways.

Review Methodology A systematic review with narrative and thematic synthesis was conducted in accordance with PRISMA 2020 reporting principles. Primary review question: What barriers interfere with competency-based progression and trustworthy transfer of performance information from medical school into residency? Information Sources and Search Strategy The review framework included MEDLINE/PubMed, Scopus, Web of Science, ERIC, and Embase. Reference lists of relevant studies were additionally examined. Search terms included combinations of "competency-based medical education", CBME, "entrustable professional activities", EPA, milestones, "medical school", "undergraduate medical education", residency, "postgraduate medical education", "transition to residency", readiness, entrustment, assessment, supervision, barriers, handoff, and feedback. Eligibility Criteria • Studies examining CBME, EPAs, milestones, or programmatic assessment. • Studies addressing senior medical students, incoming residents, residency trainees, faculty, program directors, or competency committees. • Studies including transition-relevant outcomes. • Studies reporting barriers relating to readiness, assessment, entrustment, supervision, feedback, or implementation. • Quantitative, qualitative, mixed-method, cohort, or implementation designs. Studies were excluded if they were conceptual papers without primary data, focused on isolated procedural teaching without transition relevance, examined competency education outside medicine, duplicated previously included cohorts, or provided insufficient transition-related information. PRISMA Study Selection A total of 718 records were identified. After removal of 206 duplicate or clearly redundant records, 512 records were screened by title and abstract. Of these, 408 were excluded, leaving 104 reports for retrieval. Seven reports could not be obtained. Therefore, 97 full-text reports were assessed for eligibility. Seventy-nine were excluded for predefined reasons, resulting in 18 studies included in the qualitative synthesis. Reason for exclusion Number Not focused on medical-school-to-residency transition 22 Commentary/conceptual article without primary data 17 No readiness, barrier, or implementation outcome 15 Isolated teaching intervention without transition relevance 10 Duplicate/overlapping study population 8 Insufficient extractable information 7 Total 79 Figure 1. PRISMA 2020 flow diagram of study selection. Characteristics of Included Studies Authors/Study Country Educational Stage Main Focus Principal Transition Barrier Lomis et al., 2017 USA Medical school → residency Core EPA pilot Faculty development, assessment design and entrustment consistency Brown et al., 2017 USA UME Path to EPA entrustment Variable evidence thresholds and assessor interpretation Andrews et al., 2018 USA Medical school → residency EPAC pathway Scheduling, accreditation and time-variable progression Holzhausen et al., 2019 Germany Medical school → residency EPAs for entry into residency Defining transferable activities and supervision expectations Tannenbaum et al., 2020 Canada Residency Faculty perceptions of CBME Time limitations and assessment/feedback preparation Day et al., 2020 Canada Residency Assessment and feedback Feedback-seeking burden and blurred formative/summative assessment Schumacher et al., 2020 USA Residency Longitudinal EPA assessment Variable readiness for unsupervised practice Acai et al., 2021 Canada Residency Competence committees Data aggregation and interpretation difficulties Brown et al., 2022 USA UME Entrustment outcomes Variable readiness for indirect supervision Ott et al., 2022 Canada Residency Assessment burden Time burden, unclear expectations and learner stress Kuehl et al., 2022 USA Medical school → residency Residency preparation using EPAs Curriculum-to-residency alignment difficulties Li et al., 2023 Canada Residency CBME transition Faculty engagement and variable uptake Pincavage et al., 2023 USA Transition/intern year Individualized learning plans Limited use of transferred performance information Goldhamer et al., 2024 USA GME Time-variable CBME Regulatory and scheduling constraints Simon et al., 2024 Canada Residency Small-program CBME Assessment and implementation variability Caretta-Weyer et al., 2025 USA Medical school → residency Program-director expectations Limited trust in medical-school assessment Moschinski-van Treel et al., 2025 Europe PGME EPA implementation Workflow and stakeholder ownership problems EPA implementation study, 2025 North America Residency EPA engagement Assessment burden and low engagement Overall Barrier Profile Barrier Studies, n Percentage Discontinuity in assessment frameworks 14 77.8% Limited trust in prior competency assessments 13 72.2% Faculty time/direct-observation constraints 12 66.7% Unclear entrustment thresholds 11 61.1% Assessment/documentation burden 10 55.6% Inconsistent feedback quality 9 50.0% Variable readiness for indirect supervision 8 44.4% Weak transfer of learner-performance information 7 38.9% Fixed-time structures conflicting with competency progression 6 33.3% Technology/data-system incompatibility 5 27.8% Major Barriers Across the Transition 1. Discontinuity Between Graduation Competence and Residency Readiness A major finding was that graduation from medical school does not automatically establish readiness for all responsibilities encountered during residency. Medical schools generally certify learners against institutional graduation standards, whereas residency programs must determine what an incoming trainee can safely perform in real clinical environments. A single global judgment of competence may therefore obscure clinically important variation in supervision needs. 2. Lack of a Shared Entrustment Language Entrustment decisions are meaningful only when educators interpret supervision levels consistently. Differences may relate to patient complexity, setting, clinical urgency, institutional policy, supervisor risk tolerance, learner familiarity, and assessor experience. A competency statement cannot reliably cross the transition boundary unless both sending and receiving institutions interpret it similarly. 3. Poor Transfer of Performance Information Medical schools increasingly generate substantial learner-assessment data, including EPA ratings, OSCE performance, workplace observations, narrative feedback, portfolios, remediation records, and competency committee judgments. Yet residency programs may receive only traditional academic information, causing detailed performance evidence to be lost during transition. 4. Lack of Trust in Prior Assessments Receiving residency programs must decide whether transferred competency information is trustworthy enough to influence supervision. Trust can be reduced by variability in standards between schools, insufficient faculty calibration, limited direct observation, inconsistent use of entrustment scales, grade inflation, insufficient narrative evidence, and unfamiliar terminology. 5. Faculty Observation and Time Constraints Competency assessment requires direct observation, yet faculty must balance patient care, teaching, administration, research, assessment, and feedback. Insufficient observation opportunities weaken the evidence underlying entrustment decisions. 6. Assessment Burden Frequent workplace assessment is a defining feature of CBME, but excessive assessment may become counterproductive. Residents may spend significant effort identifying assessors, requesting assessments, monitoring portfolio requirements, and obtaining specific numbers of EPAs. The educational objective may shift from obtaining useful feedback to obtaining enough completed forms. 7. Feedback Quality Effective feedback should identify what was done well, what needs improvement, why improvement is needed, and what the learner should do next. Generic comments provide limited developmental value. CBME requires assessment systems that prioritize quality rather than simply quantity of feedback. 8. Variable Readiness for Indirect Supervision Evidence from EPA-based programs indicates that learners may reach different levels of entrustment for different activities. The transition to residency should therefore involve an individualized supervision profile rather than an assumption of uniform readiness. 9. Fixed-Duration Training Versus Competency Progression CBME theoretically permits advancement according to demonstrated ability, but education systems remain structured around academic years, graduation dates, residency start dates, contracts, rotations, and accreditation requirements. This limits genuinely individualized progression. Readiness–Trust–Supervision Model Readiness Evidence Receiving-Program Trust Likely Result Strong Strong Targeted supervision and appropriate early autonomy Strong Weak Duplicate assessment and delayed autonomy Weak Strong Risk of inappropriate entrustment Weak Weak Maximum supervision and extensive reassessment This framework demonstrates that competency evidence alone is insufficient; the evidence must also be trusted. Proposed Transition-Ready CBME Framework Shared Entry-to-Residency EPAs Medical schools and residency programs should agree on a limited set of professional activities expected at residency entry, such as assessment of an undifferentiated patient, safe prescribing, recognizing emergencies, handover, communication, teamwork, and selected procedures. Portable Competency Handoff The learner should enter residency with a structured competency summary containing strengths, areas requiring supervision, EPA performance, representative narrative feedback, relevant remediation, and recommended supervision levels. Shared Faculty Calibration Undergraduate and postgraduate educators should participate in joint calibration activities using standardized cases, recorded learner performances, shared EPA rubrics, and supervision-scale exercises. Early-Residency Re-Entrustment Residency programs should review transferred information, observe selected high-value professional activities, confirm or modify supervision recommendations, and create an individualized learning plan. Transition Coaching Final-year medical students and new residents should receive structured coaching to interpret competency profiles, identify areas requiring development, formulate goals, and seek appropriate supervision. Bidirectional Educational Feedback Residency programs should provide schools with aggregate feedback regarding common readiness deficiencies, strengths, activities requiring excessive supervision, and early-remediation needs. Institutional Indicators Domain Indicator Readiness Percentage of graduates meeting entry-to-residency EPA expectations Evidence Number of direct observations supporting each EPA Trust Percentage of residency supervisors using transferred competency data Handoff Percentage of incoming residents with structured competency summaries Verification Time required to confirm or modify initial supervision recommendations Coaching Percentage receiving transition coaching within the first month Alignment Agreement between school and residency entrustment judgments Remediation Percentage requiring early targeted remediation Implications for Medical Schools Medical schools should increasingly ask whether their assessment systems produce information that is useful after graduation. Assessment should not end with certification. Graduation documentation should communicate what a graduate can do, how often performance has been observed, under what conditions, what level of supervision remains appropriate, and what still requires development. Implications for Residency Programs Residency programs should avoid treating all incoming residents as educationally identical. Competency information from medical school can support more individualized early-residency supervision when the evidence is sufficiently trustworthy.

This systematic review identifies the transition from medical school to residency as a distinct implementation challenge within competency-based medical education. The central barrier is not simply inadequate assessment. It is the failure to establish a trusted chain of competency evidence across the educational boundary. Assessment-framework discontinuity was the most frequently identified problem. Medical schools and residency programs may both claim to use competency-based education while operating different assessment systems, terminology, standards, and decision rules. This creates a competency translation problem. Entrustable Professional Activities offer one potential solution because they describe observable clinical work rather than abstract competency domains. However, EPAs should not become another documentation requirement. EPA systems require high-value observation, meaningful narrative feedback, calibrated assessors, clear supervision scales, and transparent progression decisions. Trust is particularly important. Residency supervisors are ultimately responsible for patient safety and may appropriately hesitate to modify supervision based solely on assessments conducted by unfamiliar institutions. The optimal model is transfer, interpret, verify, and build upon. Even within fixed-duration systems, supervision and responsibility can be individualized according to demonstrated performance. The ultimate objective should therefore not necessarily be variable graduation dates but variable levels of entrusted responsibility within appropriately structured training. Strengths and Limitations A major strength of the present review is its focus on a specific educational boundary rather than broadly summarizing all barriers to CBME implementation. The review integrates evidence from undergraduate education, transition programs, residency, competency committees, EPA systems, and faculty perceptions. Several limitations should be acknowledged. The available literature is geographically concentrated, particularly in North America and Canada. Study methodologies are heterogeneous. Many studies report stakeholder perceptions rather than patient or clinical outcomes. Terminology regarding competence, entrustment, milestones, and supervision differs between jurisdictions. The heterogeneity of outcomes prevented meta-analysis.

The transition from medical school to residency represents one of the most important unresolved challenges in competency-based medical education. The major barriers include assessment-framework discontinuity, limited trust in prior competency judgments, inconsistent entrustment thresholds, inadequate transfer of learner-performance information, faculty observation constraints, assessment burden, variable feedback quality, and structural tension between competency-based progression and time-based training systems. A successful transition requires more than declaring a graduate competent. The receiving residency program needs credible answers to four questions: What can this graduate do? What evidence supports that judgment? What level of supervision is required? How should the receiving program verify and extend that competence? Shared entry-to-residency EPAs, portable competency summaries, explicit supervision levels, cross-continuum faculty calibration, early-residency re-entrustment, transition coaching, and bidirectional feedback can transform the transition from a simple transfer of credentials into a meaningful handoff of clinical capability.

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