Balancing Cohesion and Diversity in Competence Committees: Insights from Internal Medicine and Rheumatology

Objectives In 2019, Rheumatology in Canada transitioned to competency-based medical education (CBME), mandating the development of competence committees (CCs). CCs interpret aggregated assessment data about residents to inform decisions about learner progress and achievement. In the psychology literature, groups are generally thought to make better decisions than individuals by generating more ideas, drawing on broader perspectives, and reducing errors. Evidence suggests that heterogeneous groups—when supported by robust rules and procedures—are more likely than homogeneous groups to consider a broader range of options leading to higher-quality decisions.[1] While equity, diversity, and inclusion (EDI) are increasingly emphasized, little is known about how CCs in internal medicine and its subspecialties consider and enact diversity in their membership and deliberations.

Methods We conducted a qualitative study using semi-structured interviews with 18 CC members and chairs from 6 Canadian universities. All participants were drawn from internal medicine or its subspecialties, including 2 from Rheumatology. Interviews explored perspectives on diversity, committee composition, decision-making rules, and fairness. Data were transcribed, coded in NVivo™, and analyzed thematically, with reflexive dialogue across a multidisciplinary research team informing interpretation.

Results Five themes emerged. (1) Diversity beyond demographics: Ethnicity was rarely considered; instead, committees emphasized variation in academic rank, practice site, life stage, or assessment philosophy. (2) High agreement and collegiality limited structured decision-making: Consensus was easily reached, though participants acknowledged risks of groupthink. (3) Integrating context and diversity considerations: Committees valued contextual and anecdotal data, particularly regarding international medical graduates and equity-deserving residents. (4) Awareness sparked by reflection, but training absent: Few had received CC-specific EDI training; interviews prompted recognition of this gap. (5) CBME as aspirational but burdensome: CC responsibilities were widely viewed as resource intensive.

Conclusion Cultural diversity was rarely prioritized, reflecting both structural limitations and resource constraints. CCs valued multiple forms of diversity and recognized the risks of excessive cohesion. Decision-making was typically consensus-driven and collegial but concerns about groupthink and lack of formal decision rules persisted. Efforts to incorporate contextual information aimed to promote fairness but lacked consistent safeguards against bias. As CBME continues to evolve, CCs must balance cohesion with diversity, efficiency with deliberation, and objectivity with contextual fairness. Achieving this will require local innovations—such as bias training, deliberate diversification, and explicit decision rules—alongside broader systemic reform to ensure fair, defensible, and developmentally oriented assessment for all learners.

References [1.] Stahl G. J Int Bus Stud 2010;41:690-709.