Postgraduate clinical assessment systems are intended to ensure that physicians entering independent practice are competent to deliver safe, high-quality care. Yet despite extensive reform, there is limited empirical evidence linking changes in assessment during training to subsequent patient outcomes. This gap raises a fundamental question for medical education regulators: do contemporary assessment systems meaningfully predict future performance in practice?
Competence by Design (CBD), introduced by the Royal College of Physicians and Surgeons of Canada, represents a system-level reform of postgraduate medical education encompassing curriculum structure, assessment design, and progression decisions. CBD replaces time-based training with an outcomes-focused model emphasizing longitudinal workplace-based assessment, entrustment decisions, and competence committee review to support more defensible judgments of readiness for independent practice. While CBD has reshaped training and assessment processes, its predictive validity beyond graduation remains largely unexamined.
This population-based study evaluates whether implementation of CBD is associated with differences in patient outcomes among newly independent surgeons in Ontario. Using linked administrative health data housed at ICES, adult surgical patients will be deterministically linked to their operating surgeons across early-adopting surgical specialties (urology, obstetrics and gynecology, general surgery, and orthopedic surgery). Surgeons will be classified as CBD-trained or pre-CBD based on year of entry into independent practice relative to specialty-specific rollout timelines.
The primary research question is whether surgeons trained under CBD demonstrate equivalent or improved patient outcomes compared to those trained under pre-CBD systems. Primary outcomes include 30-day postoperative mortality; secondary outcomes include readmission, emergency department visits, reoperation, and length of stay. A quasi-experimental, multilevel difference-indifferences design with event-study analyses will estimate associations between exposure to a restructured curriculum and assessment system and outcomes, adjusting for patient, surgeon, hospital, and temporal factors.
This study empirically tests whether a national shift in postgraduate curriculum and assessment predicts early-career clinical performance, directly addressing the Medical Council of Canada’s (MCC) priority on outcomes measurement and predictive assessment.
