Competency-based medical education, including the Canadian version known as Competence by Design, was built on a compelling promise: training should align tightly with the observable tasks of a discipline, and assessment should capture what trainees can actually do. Entrustable Professional Activities, or EPAs, define the essential tasks of each specialty and anchor workplace-based assessment. The framework has improved clarity, feedback, and the connection between training and independent practice. But the perspective argues that implementation has created a practical incentive with an unintended consequence: programs now prioritize settings where specialty-specific competencies can be most readily observed and documented, and off-service rotations, where such observations are harder to coordinate, become structurally vulnerable.

The technical heart of the argument lies in what the authors reviewed. They examined the Competence by Design EPAs for pediatrics, emergency medicine, and internal medicine and found that many could be achieved through specialty-specific clinical experiences alone. From an assessment standpoint, observing a trainee within her primary specialty environment is simply more straightforward than coordinating EPA observations across services. The result is a quiet restructuring of educational time: programs ask whether experiences once obtained through off-service rotations could instead be delivered within home services, simulation environments, longitudinal experiences, or academic curricula. In some cases, the authors acknowledge, such redesign genuinely improves efficiency and removes experiences no longer essential to contemporary practice. The problem is what falls through the cracks.

What falls through the cracks, the perspective contends, is a form of learning that extends well beyond discipline-specific competence. Off-service rotations were never designed only to expose trainees to additional medical content. They served as opportunities to develop broader clinical judgment, encounter uncommon clinical presentations, understand the operational realities of adjacent specialties, and build the relationships that support future collaborative practice. Evidence supports this broader view. A study by Diffley and colleagues demonstrated measurable gains in clinical understanding following a one-month off-service plastic surgery rotation, framing the allocation of resident time as a cost-benefit decision in which educational breadth must be weighed against opportunity costs. Their findings suggest that clinical exposure itself, rather than curricular content alone, drives meaningful learning and may enable knowledge transfer across specialties.

The social infrastructure of care may be the most underappreciated casualty. Research by Chan and colleagues identified familiarity as a central mechanism influencing referral and consultation interactions among residents. Familiarity emerged through repeated exposure over time: rotating through other services, shared educational experiences, collaborative patient care, and even informal interactions outside clinical work. Residents reported that knowing colleagues personally increased receptivity, empathy, and willingness to engage in discussion and debriefing after consultations. Familiarity was closely tied to trust, as repeated interactions allowed physicians to develop an understanding of one another’s practice styles and clinical reasoning. Shared experiences also created alignment of interests and improved communication efficiency during patient transfers. Off-service rotations, in this light, function not merely as educational exchanges but as mechanisms for developing the interpersonal relationships that allow healthcare systems to coordinate care effectively.

To make sense of what may be changing, the authors deploy a conceptual lens borrowed from human factors engineering: the Systems Engineering Initiative for Patient Safety, or SEIPS 3.0 framework. SEIPS conceptualizes healthcare as a system of interacting people, tasks, technologies, environments, and organizational structures that shape care processes and outcomes. Crucially, it recognizes that healthcare work occurs through interconnected physical, cognitive, and social or behavioral processes. From the physical process perspective, cross-disciplinary experiences expose residents to diverse environments, workflows, operational structures, technologies, and patterns of patient movement across the system. A resident on an off-service rotation encounters different approaches to triage, consultation, discharge planning, escalation of care, documentation, and referral, developing a broader awareness of how healthcare systems function across boundaries.

The cognitive dimension is equally consequential. Different specialties prioritize different information, operate with different thresholds for intervention, and conceptualize patient problems in distinct ways. Participating in these environments helps residents develop more flexible mental models and appreciate that similar clinical presentations can lead to different but equally appropriate approaches to care, depending on context. The social and behavioral dimension completes the picture: healthcare depends on communication, coordination, role negotiation, and shared understanding across individuals and teams. Working alongside other residents and faculty allowed trainees to become familiar with professional cultures, consultation practices, service expectations, and the day-to-day realities of adjacent specialties, shaping future interactions in subtle but important ways. The educational question, reframed through SEIPS, is whether redesign unintentionally narrows the physical, cognitive, and social processes through which residents learn to participate in complex healthcare systems.

The concern is not hypothetical. Residents within EPA-based systems have reported that predefined assessment structures may not fully capture the complexity, breadth, and contextual nature of clinical work, and have expressed worries that emphasizing specialty-specific EPAs could diminish learning opportunities occurring outside directly assessed activities. The authors also point to systems-level evidence: a study by Saffo and colleagues showed that placing an internal medicine triaging resident in the emergency department reduced preventable admissions while significantly improving trainee experiences related to patient flow and initial management. Off-service clinical roles, that work suggests, can simultaneously enhance medical training and healthcare system efficiency by fostering interdisciplinary collaboration and expanding competencies in triage and care transitions. Patients, after all, rarely experience healthcare through the boundaries of specialties; they move across services, teams, and settings throughout their care journey.

The perspective is careful to avoid arguing against competency-based training, EPAs, or educational redesign. Its constructive proposal is that programs should identify and preserve forms of learning that become less visible within outcome-based models, not because they lack value but because their outcomes are harder to document directly. The authors outline concrete opportunities: longitudinal cross-disciplinary experiences, integrated clinics, structured patient-following activities across services, joint academic half-days, cross-specialty simulation, collaborative case reviews, intentional consultation experiences, and assessment activities that explicitly recognize systems-oriented and collaborative skills. They cite a promising example from Clark and colleagues, who described recurring combined educational sessions between emergency medicine and internal medicine residents built around shared clinical problems and transitions of care. Residents valued the shared experience itself as much as the educational content, reporting increased understanding of colleagues’ working conditions, recognition of shared goals, and appreciation for opportunities to discuss common frustrations and collaboratively identify solutions.

The deeper implication reaches beyond residency offices into the architecture of medical training itself. Little empirical work has examined how off-service and cross-disciplinary experiences have actually changed following implementation of outcomes-based training models, how curricular restructuring decisions are made, or which educational outcomes may be affected by these changes. The authors, whose work was supported in part by the Social Sciences and Humanities Research Council of Canada, invite clinicians and educators to consider not whether to preserve prior rotation models, but how to preserve the elements of cross-disciplinary exposure that remain essential for preparing clinical learners for practice. As training systems evolve, educational leaders may benefit from asking not only whether competencies are achieved, but also what forms of learning become more or less available through curricular redesign. In a healthcare system where collaboration across specialties determines patient outcomes, the perspective suggests, the invisible curriculum of familiarity, trust, and systems awareness may be worth more than any single assessed task.

Subject of Research: Medical Education

Article Title: Preserving the Educational Value of Off-Service and Cross-Disciplinary Experiences in Competency-Based Residency Training

Article References: Bilgic, E., Zarandi, A., Athina (Tina) Martimianakis, M., Ngo, Q. N., Fleming, A., & Martin, L. (2026). Preserving the Educational Value of Off-Service and Cross-Disciplinary Experiences in Competency-Based Residency Training. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10808-6

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10808-6

Keywords: residency training, competency-based medical education, off-service rotations, cross-disciplinary learning, SEIPS framework, postgraduate medical education, Preserving, Educational, Value, Off-Service, Cross-Disciplinary, Experiences