Competence by Design: Emergency Medicine

Welcome to the Emergency Medicine Competence by Design webpage. If you are resident interested in learning about CBD, please visit the EM Residence Resource - CBD Residents webpage. 

If you are the faculty member looking for CBD resources, we have categorized this page the main sections for easy access.  If you don't find what you are looking for on this page or if you have any questions, please do not hesitate to contact us at  


    Nazanin Meshkat Picture 2016.jpeg
    Competence by Design (CBD) is here! As of July 2018 all incoming FRCP EM residents will be entering the CBD stream of training. The residents who entered residency before 2018 will not be in the CBD stream. Following the 2021-22 academic year (i.e. when the current PGY 1s complete residency) all our residents will be in the CBD stream.

    Planning has been ongoing for two years. I want to thank the CBD Committee Members who have put in, and continue to put in, an incredible amount of work into the planning and implementation. Here is a link to our CBD Faculty Development events.

    Please do not hesitate to ask us questions. Tag “CBD Questions” at We appreciate your assistance during this landmark change in postgraduate medical training.

    Dr. Nazanin Meshkat, Program Director


    What is CBD?


    Competence by Design (CBD) is a Royal College of Physicians and Surgeons of Canada (RCPSC) initiative to transition postgraduate medical education and professional practice in Canada into a model of competency-based medical education.

    What does that mean to you? There is a shift towards a coaching model of training in lieu of the current performance model. In the coaching model residents will be required to complete formative assessments called Entrustable Professional Activities (EPAs). EPAs are tasks of the discipline that can be delegated to a resident and observed by a supervisor. These are low-stakes assessments. You will learn more on EPAs in the Assessment Section. Here is a link to a CBD Terminology Page for more information

    CBD Stages

    Residency will continue being 5 years. It will be split into 4 stages:

    • Transition to Discipline (TTD) 3 Months in PGY 1
    • Foundations of Discipline (FOD) 9 Months in PGY 1
    • Core of Discipline (COD) 3 years PGY 2-PGY4
    • Transition to Practice (TTP) 1 year PGY 5

    The Royal College Exam will take place after the Core stage at the end of PGY 4 (instead of at the end of residency). The RCPSC will be providing more information in the coming years.


    Entrustable Professional Activities (EPAs) and other assessments

    Entrustable Professional Activities (EPAs) are a CBD requirement. Each stage has specific EPAs that are assigned to it (determined by the Royal College Emergency Medicine Specialty Committee), and successful completion at each stage will be required to move from one stage to another. Here is a link to a list of all EPAs across all stages. Here is a link to the Royal College document for a detailed breakdown.  You will notice a number of milestones under each EPA. We will not be using the milestones for assessment purposes, but you can refer to them should you need more information.

    Special Assessments are non-EPA assessments that are requirements of the Royal College as well. Each tool is different, and you will be provided detailed information on their completion under each stage.

    Other assessments are called “Notes to File” and “Professional Behavioural Monitoring Form”. You can use these documents to provide information and feedback on resident performance that is not captured in the EPAs. “Notes for File” are confidential and are only shared with the PD and Competence Committee. The end of shift evaluation card will no longer be used for our CBD residents.

    The assessments above will be completed on the Elentra e-platform, and can be initiated by you or the resident. In general we expect that the resident complete at least 1 EPA (or SA tool if applicable) per shift on EM rotations. For more details on stage specific EPA and SA tool completion please refer to the specific sections below.

    Entrustment Scale

    EPAs are assessed using the Entrustment Scale. We expect that most EPAs will be given an “Intervention”, “Direction” and “Supervision” category, and only a few will be given “Autonomous” and “Excellence” especially in the early phase of a stage, and in early years of residency.

    Elentra (assessment platform)

    Click here to access Elentra and log in with your UTORid. For a step-by-by guide to Elentra, please see the user guide.  

    EPA Completion Guides

    Tipsheet on how to complete an EPA

    Faculty Development Video-EPA completion-TTD EPA 1

    Faculty Development Video-EPA Completion-Core EPA 4

    Faculty Development Video- EPA Completion- Core EPA 15

    1. TTD Primers
      The Royal College requires that you complete the assessment requirements for 3 EPAs (TTD 1-3) and one special assessment (TTD SA 1) in Transition to Discipline (TTD). For a detailed guideline please refer to TTD 1-3 EPA Assessment Completion Guide and TTD SA Assessment Completion Guide.
    2. FOD PrimersFOD EPA 1 - 4 and Core EPA 14 Assessment Completion Guide and Shining a Light on FOD EPAs
    3. Core PrimersCore EPA 1-13 & 15, and FOD EPA 4 Assessment Completion Guide
    4. TTP Primers – Coming in Spring 2022

    Competence Committee

    The Competence Committee (CC) is responsible for making overall assessments for each resident, and recommendations regarding promotion, coaching and remediation, at multiple time points throughout residency (CC Terms of Reference).  The committee is made up of faculty members from each of the core sites (link to CC members). The PD also sits on this committee. They use all the assessments described above (e.g. EPAs, ITARs, exams, notes to file etc.), as well as other relevant criteria (e.g. attendance records, emails to the PD), to make decisions.  Every resident will be reviewed by the CC at least two times per year.  The CC provides their overall assessment and recommendations to the EMRTC and PD. The PD will meet with the resident (after the CC meeting) to review these recommendations.

    How to Provide Feedback

    Moving towards a coaching model will entail being able to provide feedback and coaching. Here is link to the document on feedback and coaching.

    Feedback can trigger negative reactions on the part of the receiver if it is perceived as a judgment on personal worthiness. Here is a growth mindset Infographic that delineates those with a fixed mindset and a growth mindset. For a good source of how to give feedback please refer to “Difficult Conversations” by Douglas Stone, Bruce Patton & Sheila Heen.


    Other (Rotation Plans, ITARS)

    Rotation Plans

    We have made a number of changes to our rotation schedule to align with CBD and also to address some identified gaps. For example, CBD residents will be doing more EM rotations in their PGY 1 year.

    Here is a link to the Master Rotation Schedule for all 5 years. (may be modified). Below are links to Rotation Plans

    1. TTD Rotation Plans
    2. FOD Rotation Plans 
    3. COD Rotation Plans
    4. TTP Rotation Plans 


    1. TTD ITARs
    2. FOD ITARs 
    3. COD ITARs
    4. TTP ITARs