This article is a sequel to one published in 2002 only a few years after the initiation of the shift to competency-based medical education (CBME). The authors reflect on the major forces that have influenced the movement and tipped the balance toward widespread adoption of CBME in the United States, primarily in graduate medical education. These forces include regulatory bodies, international counterparts, and the general public. The authors highlight the most important lessons learned over the decade. These include (1) the need for standardization of language to develop a shared vision of the path ahead, (2) the power of direct observation in assessment, (3) the challenge of developing meaningful measures of performance, (4) desired outcomes as the starting point for curriculum development, (5) dependence on reflection in the development of expertise, (6) the need for exploiting the role of learners in their learning, and (7) competent clinical systems as the required learning environment for producing competent physicians.The authors speculate on why this most recent attempt to shift to CBME differs from previous aborted attempts. They conclude by explaining how the recent lessons learned inform the vision of what successful implementation of CBME would look like, and discussing the importance of milestones, entrustable professional activities, and an integrated, rather than a reductionist, approach to assessment of competence. The fundamental question at each step along the way in implementing CBME should be "How do we improve medical education to provide better care for patients?"