MENTORING, EDUCATION, AND TRAINING CORNER
John Del Valle, Section Editor
Competency-Based Education, Feedback, and Humility
Larry D. Gruppen
University of Michigan Medical School, Ann Arbor, Michigan
O ver the past 2
decades, com-
petency-based edu-
cation (CBE) has
rapidly become the
predominant frame-
work for medical
education innovation
and change. It forms
the core of graduate
medical education ac-
creditation in North
America and much
of Europe, and is
making inroads into
undergraduate edu-
cation. CBE is an approach to preparing physicians for
practice that is fundamentally oriented toward graduate
outcomes and organized around competencies derived from
an analysis of societal and patient needs. It deemphasizes
time-based training and promises greater accountability,
exibility, and learner centeredness.1,2 Although it is based
on solid educational principles, CBE is too new to have yet
demonstrated efcacy in improving educational or clinical
outcomes. Nonetheless, it is a potent tool to reconsider
many of the assumptions we have made about medical
education.
The contrasts between CBE and traditional or structure-
based education are numerous.3 The most frequently
highlighted contrasts include an outcomes focus rather than
content focus, a recognition that learners will become
competent at variable times rather than on a xed schedule,
and that outcomes assessment must be conducted against a
xed criterion or denition of competence rather than on
comparisons with other learners. These contrasts have
considerable practical implications for organizing learning
programs, scheduling educational events, and structuring
assessments.
The salience of these particular aspects of CBE tend to
overshadow some other important but less discussed con-
trasts. One of these, on which this commentary will focus, is
that CBE is fundamentally learner centered rather than
teacher centered.3 The learner must take responsibility for
attaining competence, using the learning opportunities and
resources available to them, and changing their perfor-
mance and practice on the basis of formative feedback.
Although competence must be dened by the program
Gastroenterology 2015;148:47
through statements and acceptable forms of evidence, CBE
requires learners to actively participate in their individual
learning process by setting short-term learning goals and
selecting and pursuing learning activities. Learners are also
responsible for seeking out feedback and applying it to their
own learning.
The institutional concerns about offering a feasible and
efcient educational program do not always align with this
principle of learner centeredness. It is much more efcient
for faculty to schedule learning events at set times, which
coordinate well with clinic schedules and the faculty mem-
bers other responsibilities. Similarly, assessment, even when
intended for formative feedback, often gets hijacked by the
programs need to evaluate learners and assign grades.
Feedback in Competency-Based
Education
For a specic example of how challenging it can be
to align institutional educational practices with CBE goals,
we can consider the problem of feedback. To do so, it
is helpful to set it in a conceptual framework that helps
us to understand the complex dynamics that surround
feedback. One of the theoretical underpinnings of CBE is
self-regulated learning, and one of the best known theories
of self-regulated learning is that developed by Zimmerman.4
Self-regulated learning can be conceptualized as a learning
cycle consisting of 4 stages: (1) learning, (2) assessment of the
results of the learning (eg, ones performance), (3) subse-
quent adjustment of ones goals or strategies for learning, and
(4) planning learning activities and marshaling resources (eg,
time).5 Mastery of this learning cycle is part of learning to
learn and a critical component of lifelong learning. Feedback
plays its most important role in the second phase of the cycle,
when the learner assesses her or his performance and iden-
ties gaps or deciencies that need subsequent attention.
Such feedback on the quality of ones performance can come
from internal or external sources.
Internal feedback typically comes in the form of self-
assessment, which is based on a comparison of ones own
Abbreviations used in this paper: CBE, competency-based education;
EPAs, entrustable professional activities.
2015 by the AGA Institute
0016-5085/$36.00
http://dx.doi.org/10.1053/j.gastro.2014.11.021
 MENTORING, EDUCATION, AND TRAINING CORNER
performance with ones understanding of performance
standards. If ones performance meets or exceeds those
standards, all is well; if not, the decit needs to be diagnosed
and remedied through subsequent learning. Unfortunately,
this apparently simple process is actually very complex and
frequently awed. Research from multiple domains consis-
tently indicates that self-assessment is generally very un-
reliable as a guide to performance quality.6,7 The inaccuracy
of self-assessment is particularly problematic for those who
need it the mostthe less skilled or experienced, because
the knowledge needed to make accurate self-assessments is
often the very knowledge that the individual lacks. Self-
assessment can also fail through inappropriately high or
low internal standards for performance. These internal
standards may be biased by ones experience, critical in-
cidents of success or failure, and by role modelswe cannot
assume that everyone shares the same standards.
External feedback comes from other people, who also
make judgments about the quality of a learners perfor-
mance against the judges standards. External feedback
avoids many of the pitfalls of self-assessment, but has its
own limitations. Because it is less subjective than self-
assessment, it has the potential for being more accurate.
When formatted effectively and delivered by a knowledge-
able faculty member, feedback may include valuable guid-
ance for improvement, not just the identication of the
deciency. However, externally generated feedback is much
more difcult to obtain than is self-assessment. It is often
delayed, often general (good job) rather than specic to
the performance, and may be based on a limited and biased
sample of learner performances.
External feedback is where the faculty and the program
leadership focus their attention, because it is more or less
under their control. It is part of their educational re-
sponsibilities and they seek to understand feedback and
deliver it effectively. As a result of research, we know of a
number of ways to improve feedback: it needs to be deliv-
ered frequently; it needs to be linked to behavior and spe-
cic parameters, not generalities; it should be formative,
directed toward improving performance, not summative (ie,
for determining grades or graduation decisions); and it
should balance the identication of deciencies and
strengths in performance.8 These are frequently the focus of
faculty development workshops and educational policies,
yet many faculty and educational leaders are frustrated by a
sense of futility that their feedback is being misinterpreted
or even willfully ignored.9
Why Feedback Fails
Although there is ample evidence that internal feedback
is inaccurate (and often fails to identify deciencies) and
that external feedback is delivered poorly, it is important to
recognize that feedback is fundamentally a social trans-
action that takes place in the context of an interpersonal
relationship and is modied by the self-image of the learner.
Both self-directed learning and faculty development efforts
to improve feedback tend to neglect this psychosocial
context, seeing the failure of feedback as either a deciency
in the individual learner or in the faculty member. There is
growing evidence, however, that giving and receiving feed-
back are tied together in intricate ways that inuence how
feedback translates into behavior change.1012 There are 3
domains of obstacles that we educators should consider:
within people, between people, and in the learning/practice
environment.
Within People
Learners at all levels want feedback (How am I doing?).
Often, however, this only amounts to seeking reassurance.
They fear disconrming information, information that does
not t with their self-image. Although disconrming feed-
back is likely to be the most useful in terms of making im-
provements to ones performance, it is also the most difcult
to accept because of the psychological discomfort it creates.
There is an intricate interplay between ones self-image,
self-condence, and feedback. Having self-condence is
not only emotionally positive, but also desirable; condence
fosters action whereas a lack of it leads to inaction and risk
avoidance. Individuals need a basic level of self-condence
to even entertain feedback that indicates a gap or de-
ciency; too little condence can lead to hesitancy and pa-
ralysis. In contrast, too much condence is likely to lead to
ignoring the validity of disconrming feedback. Condence
is something of a paradox in that it enables learners to ask
for and accept feedback but also (inappropriately) buffering
them against feedback that might be critical in nature. Thus,
the extent to which feedback is deemed valuable is depen-
dent, in part, on the degree to which the feedback can be
reconciled with ones condence in ones self-assessments.
Between People
Most externally generated feedback comes from people
with whom we have a relationshippersonal, professional,
or both. Feedback affects and is affected by these relation-
ships in several ways. One is the desire to seem competent
to others, which makes it difcult to openly acknowledge
failures or even uncertainty. The likelihood that external
feedback will be utilized depends on the perceived credi-
bility of the source and the perceived accuracy of the
feedback. We also tend to support another persons self-
image by more readily giving praise rather than criticism.
Indeed, giving someone corrective feedback places stress on
the relationship. Unless the relationship is strong, this stress
may damage the relationship, thus producing a reluctance to
provide relevant corrective feedback. Providing feedback
requires a strong relationship that is characterized by trust
and safety. Such relationships are not built quickly, which
means either that feedback in new relationships will be
shallow, general, and biased toward afrmation, or criticism
will be easy because there is no investment in and value
placed on the relationship.
In the Learning/Practice Environment
The work and learning environments have their own
inuences. The workplace may have a feedback culture or
a blame culture. There may be few opportunities to be
5
MENTORING, EDUCATION, AND TRAINING CORNER
observed and thus receive relevant feedback. There may be
little time for learners to reect on the feedback received so
they can interpret it and translate it into action. The stated
and the hidden priorities of the institution may clash, as
often happens between emphases on clinical productivity
and educational excellence. Finally, there may be a greater
emphasis on evaluation than on feedback, leaving learners
reluctant to expose any ignorance.
The complexity of giving, receiving, and using feedback,
whether internal or external, is not unique to CBE. However,
the reliance of CBE on an active learner who takes re-
sponsibility for his own learning and performance
improvement places greater importance on how he uses
feedback. Given the powerful psychological mechanisms
that protect our self-concept from possible injury from
negative feedback, even at the expense of our long-term
effectiveness, we need a psychological countermeasure to
help us honestly consider this feedback. One candidate for
this role may be humility.
Humility
Humility is a willingness to acknowledge the possibility
that you are fallible and may be wrong, that you need
guidance or help from others on occasion, that you can
benet from feedback, and that you need to make changes
in your performance. Many of us nd humility more or less
difcult. In North America, we typically practice in an
environment that rewards hubris rather than humility.
Indeed, striving for excellence motivates people toward
achievement and advancement, but it also engenders
competition and striving for preeminence. However, the
benets of humility are real. At an institutional level,
acknowledging errors and making appropriate apology has
been demonstrated to improve patient relations and reduce
litigation.13 At a personal level, it makes it easier to recog-
nize the need for continuing improvement, to seek and
accept feedback that can foster that improvement, and to
make relevant changes.
Thus, humility should be treated as a professional and
personal value that needs to be learned and constantly prac-
ticed.14 Indeed, a commitment to humility is built into modern
versions of the Hippocratic Oath (such as the Lasagna
Oath)I will not be ashamed to say I know not, nor will I 4. Zimmerman BJ. Dimensions of academic self-regulation:
fail to call in my colleagues when the skills of another are
needed for a patients recovery.15 Instilling humility is not
done best by humiliation, but by demonstration. In other
words, learners must see humility in their faculty as role
models. However, this requires all of us as faculty to come to a
healthy appreciation for the pervasive presence of uncer-
tainty, the reality of our own limitations, and a willingness to
express these issues more openly with each other.
In summary, the adoption of CBE and the explicit de-
nition of competencies, entrustable professional activities
(EPAs) and milestones16 has several implications for feed-
back in medical education. On the one hand, it claries what
goals faculty members should be addressing when they
provide feedback. Explicit milestones and EPAs can provide
the specicity that is too often lacking in feedback. It can
6
also foster corrective actions to take in response to feed-
back. On the other hand, the very centrality of feedback in
CBE will likely accentuate the impact of the barriers to
delivering and receiving feedback, as described. Overcoming
these barriers requires action by faculty, learners, and the
organization.
Faculty members can take advantage of program mile-
stones and EPAs to not simply evaluate trainees, but to
provide a few words of feedback about the individuals
actual performance. Faculty should explicitly identify it as
feedback so that trainees do not hear it as evaluation and
neglect opportunities for changing their performance. Fac-
ulty also should discuss and model the ways they them-
selves seek out and use feedback, particularly when it
identies a correction that they need to make.
Trainees must recognize that their learning is a life-long
process and that they need to acquire the ability to
constantly appraise their knowledge, skills, and perfor-
mance, always seeking ways to improve. They must accept
the discomfort inherent to this healthy level of skepticism
applied to themselves and take on the work of seeking out
feedback rather than avoiding it.
The organization needs to work on building an educa-
tional culture in which feedback is routine, and takes place
in an atmosphere of trust and a sense of safety, so that er-
rors, improvements, and working relationships can be
openly discussed. Effective implementation of CBE requires
this coordinated effort by all involved to realize the poten-
tial of educating physicians who constantly strive to
improve themselves and the health care they deliver.
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Reprint requests
Address requests for reprints to: Larry D. Gruppen, PhD, Department of
Medical Education, University of Michigan Medical School, G1111 Towsley
Center, Ann Arbor, Michigan 48109-0201. e-mail: lgruppen@umich.edu; fax:
(734) 936-1641.
Conicts of interest
The author discloses no conicts.