In 2017, the Royal College of Physicians and Surgeons of Canada launched Competence by Design, the most consequential reform of Canadian residency training in a generation.
The premise was simple: we can define all the elements that a graduating physician should know or do in practice, and we should only graduate them when a supervisor has actually watched them do the work competently and safely. The framework broke training into discrete clinical tasks, such as managing a patient with chest pain, that a trainee must be observed performing before a supervisor signs off.
Nearly a decade later, the architecture is in place. The observation is not.