{ "abstract": "Introduction: Graduate medical education (GME) selection processes may pose significant barriers to implementing competency-based health professions education (CBHPE). Current selection metrics are largely nonpredictive of future success, and the removal of clerkship grades has given rise to a shadow economy of effort focused on publications, research hours, and other activities that detract from clinical training. This misalignment between selection practices and CBHPE principles constitutes a wicked problem that requires innovative approaches to develop new solutions. Methods: We conducted a TRIZ (Theory of Inventive Problem Solving) exercise, a Liberating Structure that challenges assumptions by asking what would make a process fail spectacularly. Eight participants representing three countries, two continents, and four medical specialties convened via video conference in October 2025. Participants served as proxies for key stakeholder groups (students, program directors, medical school leadership, and patients/society), identified elements of the worst-possible selection system, compared them to current practices, and proposed solutions. Results: Participants identified numerous elements characterizing suboptimal selection systems, including inequitable and biased processes, arbitrary decision-making, gaming of metrics, resource-intensive processes that fail to differentiate candidates, misinformation from training sites, and prioritization of self-interest over patient needs. Many of these elements were recognized as present in current GME selection systems worldwide. Discussion: Recommendations to align selection with CBHPE included embedding social accountability throughout selection, leveraging coproduced competency frameworks, prioritizing workforce diversity, ensuring equity in assessment and selection, incentivizing a growth mindset through a transparent learner handover, and implementing structural innovations, including preference signaling or potentially lottery systems, to better align CBHPE and selection.", "abstract_shown": true, "affiliations": [ "Professor of Emergency Medicine and Associate Dean of Admissions and Assessment, Stanford University School of Medicine, Palo Alto, California", "Professor of Pediatrics and Clinician Educator, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba", "Assistant Professor of Medicine, Harvard Medical School, Director of Faculty Continuing Medical Education, Division of General Internal Medicine, Massachusetts General Hospital, Director of Evaluation, Harvard Kidney Urology Hematology Training Institute, Boston, Massachusetts", "Michael Reese Endowed Professor of Medical Education, Departments of Medical Education and Pediatrics, University of Illinois Chicago, Chicago, Illinois", "Dean of Medicine, Vice-President Medical Affairs, Toronto Metropolitan University, Brampton, ON; Clinical Professor (part-time), Department of Medicine, Division of Emergency Medicine/Division of Education and Innovation, McMaster University centre for Education Research, Innovation, and Theory (MERIT), Faculty of Health Sciences, McMaster University, Hamilton, ON", "Professor, Vice Chair of Education, Oregon Health and Science University, Portland, Oregon", "Conjoint Professor, Faculty of Health and Medicine, University of Newcastle; Subject Coordinator, Graduate Programs in Surgical Education, University of Melbourne", "Associate Professor, Head of Randwick Clinical Campus, School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney", "Professor of Health Systems Science, Associate Dean of Medical Education Research and Scholarship, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California" ], "article_type": null, "arxiv": null, "author_total": 10, "authors": [ { "affs": [ 0 ], "name": "Holly A. Caretta-Weyer", "orcid": "0000-0002-9783-5797" }, { "affs": [ 1 ], "name": "Ming-Ka Chan", "orcid": "0000-0003-2989-7766" }, { "affs": [ 2 ], "name": "Mary Ellen J. Goldhamer", "orcid": "0000-0002-2648-8791" }, { "affs": [ 3 ], "name": "Alan Schwartz", "orcid": "0000-0003-3809-6637" }, { "affs": [ 4 ], "name": "Teresa M. Chan", "orcid": "0000-0001-6104-462X" }, { "affs": [ 5 ], "name": "Lalena M. Yarris", "orcid": "0000-0003-1277-2852" }, { "affs": [ 6 ], "name": "Ian W. Incoll", "orcid": "0000-0001-8082-2976" }, { "affs": [ 7 ], "name": "Arvin Damodaran", "orcid": "0000-0002-5067-9483" }, { "affs": [ 8 ], "name": "H. Carrie Chen", "orcid": "0000-0003-1663-1598" }, { "name": "As members of the International Competency-Based Health Professions Educators Collaborative" } ], "bibtex": "https://research.draconitic.com/paper/f09g2krc5zq25.bib", "cited_by": 0, "doi": "10.5334/pme.2596", "fulltext_url": "https://account.pmejournal.org/index.php/up-j-pme/article/view/2596", "id": "f09g2krc5zq25", "issns": [ "2212-277X" ], "landing_url": "https://doi.org/10.5334/pme.2596", "language": "en", "licence": "CC-BY", "licence_label": "CC BY", "licence_source": "journal", "licence_url": "https://creativecommons.org/licenses/by/4.0/", "metadata_licence": null, "native_subjects": [ [ "lcc", "LC8-6691" ], [ "lcc", "R5-920" ], [ "openalex", "2739|Medical Education and Admissions" ] ], "openalex": "W7214786909", "pdf_url": "https://pmejournal.org/articles/2596/files/6abba432e3a5f.pdf", "pmcid": null, "pmid": null, "published": "2026-09-01", "publisher": "Ubiquity Press", "ris": "https://research.draconitic.com/paper/f09g2krc5zq25.ris", "sources": [ { "first_seen": "2026-10-31T14:22:05Z", "native_id": "01fbc63d97ce4fd4b541dae89007d34f", "source": "doaj", "url": "https://doi.org/10.5334/pme.2596" } ], "subjects": [ { "field": "medicine", "origin": "openalex:2739|Medical Education and Admissions", "subfield": "epidemiology-public-health" } ], "title": "The Wicked Problem of Selection and Competency-Based Education: Applying TRIZ Inversion to the Graduate Medical Education Selection Process", "title_text": "The Wicked Problem of Selection and Competency-Based Education: Applying TRIZ Inversion to the Graduate Medical Education Selection Process", "type": "peer-reviewed", "updated_at": "2026-10-31T14:22:05Z", "url": "https://research.draconitic.com/paper/f09g2krc5zq25", "venue": "Perspectives on Medical Education", "versions": [] }