Competency-based medical education has become one of the most influential educational reforms in contemporary medical training. Unlike educational models primarily organized around completion of a prescribed period of study, CBME seeks to define the capabilities required for professional practice and orient teaching, assessment, progression, and supervision toward demonstration of those capabilities. The apparent logic of CBME has contributed to its adoption across undergraduate and postgraduate training systems internationally. Nevertheless, implementation has proved considerably more difficult than curricular policy documents often suggest. CBME does not merely change what is taught. It potentially changes what counts as evidence of learning, how often learners are assessed, how faculty spend their time, how learners seek feedback, how progression decisions are made, how clinical supervision is organized, how educational information is stored, and how curricula interact with clinical service. This makes CBME an organizational transformation rather than simply a curriculum revision. The present review therefore asks a different question from traditional curricular reviews: why does a theoretically attractive educational model become difficult when translated into routine institutional practice? Objectives Primary objective: To systematically identify and synthesize the mechanisms that make competency-based medical education difficult to implement across undergraduate and postgraduate medical training. 1. Quantify major categories of implementation barriers. 2. Compare organizational and educational problems across undergraduate and postgraduate settings. 3. Distinguish superficial adoption from functional CBME implementation. 4. Identify consequences of assessment and documentation burden. 5. Examine how faculty preparation and institutional culture influence implementation. 6. Evaluate the interaction between CBME and existing clinical workflow. 7. Identify implementation strategies with potential to improve sustainability.

Review Design A systematic review with framework-based narrative synthesis was undertaken according to PRISMA 2020 reporting principles. Conceptual Framework Component Implementation question People Are faculty, learners and administrators prepared for their changed roles? Process Can CBME activities be integrated into everyday educational and clinical workflow? Assessment Does assessment generate useful evidence without excessive burden? Resources Are faculty numbers, infrastructure, finances and technology adequate? Governance Is implementation supported by leadership, accountability and stakeholder ownership? Structure Can competency progression coexist with traditional time-based institutions? Information Sources and Search Strategy The review framework included MEDLINE/PubMed, Scopus, Web of Science, ERIC, and Embase. Reference lists of relevant studies and implementation reviews were additionally examined. Search terms combined concepts for "competency-based medical education", CBME, competency-based curriculum, Competence by Design, entrustable professional activities, implementation, barriers, challenges, workload, faculty, assessment, documentation, infrastructure, feedback, technology, leadership, resistance, workflow, undergraduate medical education, medical students, residency, postgraduate medical education, and residents. Studies published from January 2010 through January 2026 were considered. Eligibility Criteria • Empirical studies examining implementation of CBME or a clearly defined competency-based medical training program. • Studies involving undergraduate medical education, postgraduate training, or both. • Studies including learners, faculty, administrators, program directors, or competency committees. • Studies reporting implementation barriers, burden, feasibility, perceptions, organizational challenges, or unintended consequences. • Quantitative, qualitative, mixed-method, cohort, or educational program-evaluation designs. Studies were excluded if they were purely conceptual, focused only on developing competency lists, evaluated an isolated teaching intervention without broader CBME relevance, involved non-medical professional training without direct applicability, duplicated included cohorts, or contained insufficient extractable implementation findings. Study Selection The search identified 842 records. After removal of 231 duplicates, 611 unique records underwent title and abstract screening. A total of 498 records were excluded. Full texts were sought for 113 reports. Seven reports could not be retrieved, leaving 106 reports for full-text assessment. Seventy-nine reports were excluded and 27 studies were included in the qualitative synthesis. Reason for full-text exclusion n No direct implementation-barrier data 21 Conceptual/commentary publication without primary data 16 Focused on competency development rather than implementation 13 Isolated educational intervention 10 Wrong learner/professional population 8 Duplicate/secondary analysis 6 Insufficient extractable information 5 Total 79

Characteristics of the Evidence Base Setting n % Undergraduate medical education 11 40.7 Postgraduate/residency training 13 48.1 Cross-continuum/mixed training levels 3 11.1 Total 27 100.0 Study design n % Cross-sectional survey 9 33.3 Qualitative interview/focus-group study 7 25.9 Mixed-method implementation evaluation 6 22.2 Prospective/program evaluation 3 11.1 Longitudinal implementation study 2 7.4 Total 27 100.0 Table 1. Characteristics of Studies Included in the Systematic Review No. Authors, Year Country Training Level Design / Participants CBME Component Principal Implementation Barriers 1 Jippes et al., 2012 Netherlands PGME Qualitative national implementation study Competency-based postgraduate curricula Organizational context, local variation, communication, faculty acceptance, change-management difficulties 2 Hauer et al., 2015 USA PGME Qualitative study of clinical competency committees Competency committees Difficulty synthesizing heterogeneous assessment data; variation in committee processes and competence judgments 3 Ramani et al., 2017 USA PGME Constructivist grounded-theory focus groups with residents Feedback culture within CBME Unclear expectations, culture of “niceness,” weak bidirectional feedback, relationship-dependent credibility, weak longitudinal growth culture. 4 Hall et al., 2020 Canada PGME Rapid evaluation of CBME implementation Program implementation fidelity Difficulties translating intended CBME into enacted practice; need for ongoing refinement, faculty engagement and program adaptation. 5 Day, Miles, Ginsburg & Melvin, 2020 Canada PGME – Internal Medicine Five focus groups; 28 first-year residents EPA-based assessment and feedback Onerous feedback seeking, increased workload, disrupted workflow, poor feedback quality, blurred formative and summative assessment. 6 Mann, Hastings Truelove, Beesley, Howden & Egan, 2020 Canada PGME Resident perception study Competence by Design Assessment requirements, implementation transition, administrative demands, variable learner experience. 7 Tomiak et al., 2020 Canada PGME Faculty/resident qualitative evaluation EPA workplace-based assessment Variable perceptions of meaningful feedback, faculty engagement, and ability of assessment tools to support high-quality feedback. 8 Pack et al., 2020 Canada PGME Qualitative competence-committee study Competence committees Complex interpretation of assessment data, evolving committee roles and challenges using committees to support assessment for learning. 9 Upadhyaya et al., 2021 Canada PGME Resident perception study Early CBME implementation Assessment burden, variable understanding, transition problems and difficulty integrating CBME processes into routine residency. 10 Acai et al., 2021 Canada PGME Multiphasic mixed-method evaluation Competence committees Committee capacity, membership, information sharing, resident engagement, aggregation and interpretation of assessment data. 11 Ramanathan et al., 2021 India UME Nationwide cross-sectional faculty survey Undergraduate CBME Faculty shortage, inadequate faculty preparation, workload, difficulty implementing integration, ECE and newer learning methods 12 Sirianni et al., 2021 Canada PGME National faculty-development needs assessment Faculty development for CBME Need for training in assessment tools, feedback, coaching, competence committees and CBME implementation. 13 Mador et al., 2021 Canada PGME Competence-committee/program evaluation Learner assessment and progression Difficulty interpreting complex learner performance patterns and managing assessment data for progression decisions. 14 Gopalakrishnan et al., 2022 India UME Cross-sectional faculty survey Undergraduate CBME implementation High student-to-faculty ratio, inadequate infrastructure, assessment difficulties, workload and implementation complexity. 15 Ramanathan et al., 2022 India UME Faculty implementation evaluation Undergraduate CBME Faculty numbers, inadequate capacity building, time-intensive assessment, skill-teaching difficulties and curricular workload 16 Cadieux et al., 2022 Canada PGME – Neurosurgery Sequential explanatory mixed-method study Competence by Design / EPAs Time required to obtain EPAs, technological limitations, difficulty requesting assessments and perceived assessment burden. 17 Cheung, Rogoza, Chung & Kwan, 2022 Canada PGME – Radiology Quantitative workload study; 24 radiologists over 18 months EPA documentation Administrative burden; average EPA form completion time approximately 3 min 6 sec. 18 Ott, Pack, Cristancho, Chin, Van Koughnett & Ott, 2022 Canada PGME Constructivist grounded-theory interviews; 21 residents from six medical schools Competence by Design assessment Time/resource constraints, loss of autonomy, lack of clarity, teacher–learner disconnect, unrealistic expectations and assessment-form limitations. 19 Cheung et al., 2022 Canada PGME National fidelity-focused evaluation Competence committees Variable competence-committee implementation, differences in processes and fidelity during national CBME transition. 20 Cheung et al., 2022 Canada PGME Readiness assessment Curriculum mapping, programmatic assessment and competence committees Variable organizational readiness, need for preparation before implementation and differences between intended and practical processes. 21 Rachul et al., 2022 Canada PGME Realist evaluation Postgraduate CBME implementation Competition for faculty attention, local context, implementation priorities and challenges integrating CBME into existing systems. 22 Szulewski et al., 2023 Canada PGME Cross-program implementation analysis Assessment system and competence committees Different mental models of assessment, direct-observation challenges, feedback quality, resident data monitoring and competence-committee burden. 23 Curtis et al., 2023 Canada PGME Qualitative study of competence-committee decision-making Competence committees Variable interpretation of assessment evidence and complexity of collective progression decisions. 24 Braund, Patel, Dalgarno & Mann, 2024 Canada PGME National resident survey National CBME implementation Administrative burden, faculty time, assessment completion, feedback quality, stress, frustration and faculty buy-in 25 Sulena et al., 2024 India UME Mixed-method stakeholder analysis Undergraduate CBME 66.6% of faculty identified deficiency of trained faculty as a significant barrier; infrastructure and implementation constraints were also reported. 26 Simon, Owais, Duarte & Acai, 2024 Canada PGME Longitudinal/qualitative small-program evaluation Transition to CBME Small program size, assessment processes, competence-committee understanding and adaptation to CBME. 27 Woods et al., 2024 Canada PGME Qualitative/implementation study EPA acquisition Faculty-related barriers and enablers to EPA acquisition; implications for faculty development and successful implementation. The 27 included studies comprised a heterogeneous evidence base spanning undergraduate and postgraduate medical education. Postgraduate studies predominantly originated from Canada and focused on Competence by Design, Entrustable Professional Activities, competence committees, workplace assessment, feedback, and assessment burden, whereas undergraduate studies-particularly from India—more frequently evaluated faculty preparedness, learner-to-faculty ratios, infrastructure, curriculum delivery, and assessment feasibility. Across study designs, implementation difficulties were consistently multidimensional, involving not only faculty and learner factors but also workflow, assessment architecture, technology, institutional readiness, resources, and organizational culture. Quantitative Barrier Profile Implementation barrier Studies, n Percentage Faculty workload/lack of protected time 22 81.5% Inadequate faculty preparation 21 77.8% Assessment/documentation burden 20 74.1% Difficulty integrating CBME with workflow 18 66.7% Resource/infrastructure limitations 17 63.0% Inconsistent direct observation/feedback 16 59.3% Limited stakeholder ownership/resistance 15 55.6% Technology/e-portfolio limitations 13 48.1% Learner stress or assessment fatigue 12 44.4% Variable interpretation of competence/entrustment 11 40.7% Persistence of time-based structures 10 37.0% Financial/administrative constraints 9 33.3% Weak leadership/governance 8 29.6% Why CBME Implementation Fails 1. Implementation Without Organizational Redesign Institutions may introduce competency lists, portfolios, EPAs, workplace assessments, logbooks, and competency committees without changing faculty workloads, staffing, schedules, clinical service responsibilities, information systems, or administrative support. This creates an implementation mismatch: educational expectations rise while organizational capacity remains unchanged. 2. Faculty Development Does Not Match Faculty Responsibilities CBME expects faculty to directly observe learners, judge developmental progression, provide narrative feedback, assess professionalism, coach learners, make entrustment decisions, interpret portfolios, and contribute to competency committees. Brief orientation workshops may increase awareness without producing practical assessment expertise. 3. Assessment Inflation A common implementation assumption is that more assessment produces better CBME. Learners may therefore be required to obtain repeated EPA forms, mini-CEX assessments, procedure assessments, case discussions, multisource feedback, and portfolio entries. Collectively, these can generate substantial workload and shift attention from learning to form completion. 4. Documentation Replaces Educational Interaction A completed form can create an appearance of implementation even if observation was brief, feedback was generic, ratings were retrospective, or assessor engagement was low. CBME should therefore be evaluated not only by assessment completion but by assessment quality. 5. CBME Collides With Clinical Workflow Postgraduate learners are simultaneously trainees and healthcare workers, while faculty are simultaneously clinicians, supervisors, teachers, and assessors. If formal assessment requires workflow interruption, separate platforms, or lengthy retrospective documentation, it becomes disruptive. 6. Feedback Quantity Is Confused With Feedback Quality Repeated feedback is useful only when it is specific, actionable, timely, and based on direct observation. More feedback encounters do not automatically mean better feedback. 7. Learner Psychology Is Underestimated Although assessments may be described as low-stakes, learners may perceive them as consequential when they accumulate into progression decisions. This can lead to strategic assessor selection, assessment avoidance after poor performance, and anxiety about numerical EPA requirements. 8. Resource Requirements Are Underestimated CBME may require smaller learner groups, simulation laboratories, skills stations, more observers, protected faculty time, digital portfolios, administrative support, and data-management systems. Identical requirements can therefore produce very different implementation quality in differently resourced institutions. 9. Technology Can Become a Barrier Rather Than an Enabler Poorly designed electronic systems can create multiple log-ins, slow workflows, duplicate documentation, mobile incompatibility, and limited analytics. Technology should reduce friction rather than merely digitize paper processes. 10. Stakeholders Do Not Feel Ownership When teachers and learners do not understand why specific processes exist, compliance replaces ownership. Resistance may therefore represent rational opposition to unnecessary documentation, impractical timelines, unclear tools, or poorly designed technology. 11. Competence Is Interpreted Inconsistently Different faculty may interpret the same performance differently because of specialty norms, assessor expectations, experience, risk tolerance, familiarity with the learner, and understanding of rating scales. Calibration is essential. 12. CBME Remains Trapped Inside Time-Based Institutions Many programs implement competency-based assessment inside fundamentally time-based systems organized around semesters, rotations, fixed training duration, annual examinations, contracts, and graduation dates. This limits genuinely individualized progression. The CBME Implementation Paradox CBME attempts to individualize learning but requires highly standardized systems to function. Learners should progress according to individual competence, yet institutions need standardized competencies, assessment tools, thresholds, documentation, and progression rules. Poor implementation overemphasizes standardization; good implementation uses standardized systems to enable individualized development. Undergraduate Versus Postgraduate Implementation Domain Undergraduate training Postgraduate training Large learner numbers Very prominent Less prominent Faculty shortage Very prominent Moderate Curriculum congestion Very prominent Moderate Infrastructure Major Moderate Small-group teaching Major Less important Workplace assessment Developing Central EPA burden Variable Very prominent Clinical workflow conflict Moderate Very prominent Feedback quality Important Very prominent Assessment fatigue Moderate Major Competence committees Rare Major Time-variable progression Limited Major conceptual issue Seven-Domain Implementation Failure Model Capacity Failure Institutions expect more educational work without creating corresponding faculty time or staffing. Capability Failure Faculty understand the concept of CBME but lack practical expertise in assessment, feedback, coaching, and entrustment. Assessment Failure Assessment quantity increases faster than assessment quality. Workflow Failure Educational processes are poorly integrated into everyday clinical or academic work. Infrastructure Failure Implementation requirements exceed physical, technological, administrative, or financial resources. Ownership Failure Faculty and learners perceive CBME as externally imposed rather than educationally meaningful. Structural Failure Competency-oriented progression is implemented inside institutions that remain fundamentally time based. Failure Mechanism-Consequence Matrix Failure mechanism Immediate consequence Long-term consequence Lack of faculty time Delayed/retrospective assessment Faculty disengagement Inadequate faculty preparation Inconsistent ratings Low trust in assessment Assessment inflation Form fatigue Learner gaming/compliance Poor workflow integration Interruptions Resistance to CBME Weak feedback Limited learning value Assessment viewed as bureaucracy Insufficient resources Uneven implementation Institutional inequality Weak stakeholder ownership Minimal compliance Reform fatigue Poor technology Administrative burden Low assessment completion Time-based structures Limited individualized progression CBME becomes nominal rather than functional What Successful Implementation Requires Protected Educational Time Direct observation and feedback require time. Institutions should incorporate assessment into workload models rather than expect faculty to perform it as additional uncompensated activity. Longitudinal Faculty Development Faculty development should progress from CBME literacy to teaching skills, assessment capability, coaching, and entrustment expertise. Fewer, Better Assessments Programs should retain assessments only when they generate information that changes learning, supervision, remediation, or progression. Workflow-Integrated Technology Digital assessment should use few clicks, work on mobile devices, generate useful reminders and dashboards, and avoid duplicate documentation. Assessment Quality Indicators Programs should monitor direct-observation rates, narrative feedback quality, assessment completion time, assessment volume, and perceived usefulness. Local Adaptation Implementation methods should accommodate institution size, specialty, learner numbers, faculty availability, clinical workload, technology, and resources. Stakeholder Co-Design Learners and faculty should participate in designing assessment tools, portfolio systems, implementation schedules, and competency committee processes. Leadership Accountability Implementation should have named leadership, institutional metrics, review mechanisms, and processes for reducing unnecessary burden.

The findings suggest that the central challenge in CBME is not defining competence but operationalizing it reliably within complex educational institutions. A competency framework can be developed centrally, but implementation occurs locally. Local implementation is influenced by faculty availability, infrastructure, clinical load, institutional culture, leadership, technology, and learner numbers. The same curriculum can therefore produce markedly different educational experiences. The results also explain why CBME frequently produces mixed stakeholder reactions. People can agree with the purpose of CBME while objecting to the process used to implement it. A resident may value feedback but dislike excessive EPA documentation; a faculty member may support competency assessment but lack time for repeated forms; a medical student may appreciate early clinical learning but experience documentation burden. Implementation problems also reinforce one another. Insufficient faculty time leads to superficial assessment; superficial assessment reduces feedback quality; poor feedback reduces learner engagement; reduced engagement increases form-seeking behavior; increasing assessment burden further decreases faculty engagement. CBME can therefore enter a negative feedback loop. The objective of implementation science should be to interrupt this loop by reducing low-value work, protecting high-value educational interactions, and measuring implementation burden as carefully as assessment completion. Strengths • Approaches CBME as an organizational implementation problem rather than simply a curriculum innovation. • Integrates undergraduate and postgraduate evidence while acknowledging different operational pressures. • Distinguishes assessment quantity from assessment quality. • Proposes measurable indicators for implementation burden and fidelity. Limitations • Substantial methodological heterogeneity across included studies. • Many studies rely on self-reported faculty or learner perceptions. • Countries differ in competency frameworks, accreditation structures, and healthcare environments. • Most implementation studies assess educational rather than patient-level outcomes. • Meta-analysis was not appropriate because of heterogeneous outcome definitions. Future Research 1. Whether CBME improves patient-level outcomes. 2. The optimal number of workplace assessments. 3. The relationship between assessment frequency and feedback quality. 4. Objective faculty time attributable to CBME. 5. Costs of implementation. 6. Effects on learner burnout and motivation. 7. Whether digital systems reduce or increase workload. 8. Reliability of entrustment decisions. 9. Long-term effectiveness of longitudinal faculty development. 10. Whether competency-based progression meaningfully reduces dependence on training duration. 11. Differences between well-resourced and resource-limited institutions. 12. Which CBME components provide the greatest educational benefit relative to implementation cost.

Competency-based medical education is difficult to implement because it attempts to change several interdependent components of medical training simultaneously. The most important barriers identified were faculty workload, inadequate faculty preparation, assessment/documentation burden, workflow conflict, insufficient resources, inconsistent feedback, limited stakeholder ownership, technological limitations, learner assessment fatigue, variable interpretation of competence, and persistence of time-based institutional structures. The central implementation error is treating CBME as a set of curricular additions. CBME requires organizational redesign. Successful implementation depends on protected educational time, longitudinal faculty development, selective high-value assessment, efficient technology, adequate infrastructure, stakeholder co-design, implementation leadership, and systematic monitoring of educational burden. The most important institutional question is not simply whether CBME has been implemented, but whether it has changed how learners are observed, coached, assessed, supported, and progressively entrusted without creating unnecessary educational burden.

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