Monitoring plans and the probability of higher-intensity learning plans in competency-based medical education: a...

Competency-based medical education (CBME) emphasizes low-stakes interventions to support learner development. Yet, limited empirical evidence exists on whether such formative program-delivered supports mitigate the need for later high-stakes remediation. This study used structural equation modelling to examine direct and indirect (mediated) pathways, testing the hypothesis that lower-stakes interventions are negatively (inversely) associated with the probability of receiving higher-intensity learning plans.

This retrospective cohort study used secondary data from 470 residents enrolled in 42 postgraduate specialty programs at an institution in Canada across six academic years (July 2019- June 2025). Learning plans were classified as monitoring, minor, or major. Structural equation modelling, specifically path analysis, was used to model hypothesized directional relationships among plan types while controlling for program size and academic year. Cluster analysis identified naturalistic groups of programs with similar patterns of learning plan use.

Monitoring plans were associated with a significantly lower probability of also receiving both minor (β = -0.264, p < .001) and major plans (β = -0.174, p < .001). Within the model, minor plans were not significantly associated with major plans (β = -0.035 p = 0.324). The indirect pathway from monitoring to major plans via minor plans was small and not statistically significant. Larger program size was associated with a slightly higher probability of minor learning plan use, while later academic years were associated with greater use of major learning plans. Cluster analysis revealed four distinct program profiles, ranging from those emphasizing frequent monitoring to those relying heavily on more intensive learning plans.

The model suggests that low-stakes learning plans are associated with a lower probability of higher-intensity interventions, suggesting their potential formative value. Program variation suggests local culture, faculty practices, and implementation norms influence realizing CBME's intent to provide individualized and supportive assessment processes.