Competence by Design FAQ

Below are some commonly asked questions. If your question is not answered here, please do not hesitate to contact your program or email us at

Q: What is CBD?

Competence-by-Design (CBD) is the Royal College’s version of Competency-Based Medical Education (CBME). CBME is an outcomes-based approach to physician development that focuses on the demonstration of core competencies required to train. CBD is a hybrid model that de-emphasizes time and emphasizes demonstration of key skills, feedback, and coaching.

Q: What is the value of CBD?

CBD is a multi-benefit initiative that defines competencies within an organized framework, helps learners identify areas of improvement, tracks learner progress, and focuses on teaching and learning based on individual needs. It provides the opportunity for residents to get timely, formative feedback.

Q: What are the stages of the competence continuum?

There are four developmental stages in the competence continuum: Transition to Discipline (TTD), Foundations of Discipline (FOD), Core of Disciple (COD), and Transition to Practice (TTP). Each program has outlined the length of each stage as part of their CBD curriculum.

Q: What is an EPA?

Entrustable Professional Activities (EPAs) are key tasks in the clinical setting that a resident can be expected/trusted to perform without supervision, e.g. carrying out a procedure, leading a family meeting, etc. EPAs are used for improved teaching, learning, and evaluation and increases in complexity through the stages.

Q: What is a milestone?

A milestone is a component of an EPA. Each discrete milestone must be accomplished to allow for successful completion of the overall task (the EPA). For residents who are progressing well, identifying the specific milestones may not be necessary, but for residents who are finding challenges in completing a specific EPA, breaking it down into the component parts (milestones) may allow the faculty member and learner to see which area needs additional study/practice/exposure.  On ELENTRA – each EPA lists the milestones that are considered part of the overall task.

Q: Are EPAs the only way that residents are assessed?

EPAs are one tool that the Competence Committee uses to assess resident progress.  Other types of assessments are procedure logs, OSCEs, STACERs, multisource feedback, teaching portfolios, and written examinations. The In Training Assessment Report (ITAR) is the summative tool used at the end of each rotation and should factor in the various assessments used during the rotation.

Q: Who can initiate an EPA?

Either a resident or a faculty can initiate an EPA assessment.

Note: Faculty initiating assessments require a user account. Please contact your Program Administrator or if you do not have an account.

Q: How often should EPAs be completed?

Each program sets EPA requirements for their residents to meet to make progression/promotion decisions. If you have any questions, please contact your Program Director, CBME Lead, or the Program Administrator for your program.

Q: When should the EPAs be completed?

It’s best to complete an EPA assessment shortly after the encounter. While we understand that may not always be possible, EPAs must be completed within 48 hours after the encounter. Requests for faculty to complete an EPA are taken off ELENTRA 1 week after they are posted.

Q: What are some tips to completing EPAs during the COVID-19 pandemic?

The health and safety of yourself and others always come first. Be mindful of passing mobile phones between the assessee and assessor. An EPA can be started and contextual variables filled in and then emailed to the assessor for completion later in the day. Making notes of the cases during the day and completing and submitting the form later in the day is another way to have EPAs completed.

Q: Do I need a University of Toronto user ID (UTORID) to access Elentra?

Yes, a UTORID is required to sign in to the Elentra platform. If you don’t know your UTORID, please contact your Program Administrator or

Q: Is there any guidance to providing constructive feedback?

Yes, we have a brief document that provides some useful tips and a previous newsletter had a section devoted to this.