No Free Lunch in Competency-Based Health Professions Education: Exploring Trade-Offs, Value, and Shared Investment in Health Professions Education.

Background/Problem: Competency-Based Health Professions Education (CBHPE) aims to improve workforce readiness, patient safety, and equity, but achieving these outcomes requires sustained investment. The "No Free Lunch" (NFL) rule underscores that value cannot be realized without visible costs, which can be financial, cultural, temporal, and structural. Although costs are ideally shared across the health professions education and health care ecosystem, interest holders often invest unevenly despite broad benefits. As a result, many programs and institutions struggle to implement and sustain CBHPE, even as adoption grows globally. Purpose/Approach: This paper examines how "value" and return on investment (ROI) in CBHPE are conceptualized across learners, faculty, institutional leaders, governments/funders, clinical systems, accreditors/regulators, professional organizations, and patients/communities. The authors describe tensions regarding who invests and who benefits, identify practical trade-offs, and highlight opportunities for alignment across settings, including low-resource contexts. We propose an interest-holder-informed framework that links typical investments to forms of value/ROI to support explicit, context-sensitive cost-sharing. Key Insight: Value in CBHPE is contextual, shaped by the mission of the interest holder, the time horizon for returns, and available resources. Because benefits are often diffuse or delayed, ROI may be difficult to demonstrate, reinforcing underinvestment. Value must ultimately be judged by benefit to patients and communities. Conclusion: CBHPE cannot rely on the goodwill of those closest to implementation. Sustainability requires clear articulation of value, shared responsibility for costs that are proportional to benefits, and alignment between goals and resources among interest holders. CBHPE should be treated as long-term infrastructure for better care, not a temporary reform.