The increasing codification and regulation of medical competence highlights the multi-faceted and complex nature of being a doctor. Not only are extensive skills and knowledge expected within the doctor's area of specialism, but also high levels of communicative ability, ethical understanding and responsibility, teamworking capability and organizational ability.
Although much is learned pre-registration, the greater part of a doctor's overall and effective competence and judgement is developed post-registration: through active involvement in a large number of cases; through teaching and supervision; through discussion and teamwork; through reflection on practice; and through formal study.
Two questions underpin this review. First, what is the nature of medical competence and judgement? Second, how can post-registration medical education be organized so as to develop it in an effective and efficient manner? However the first question is answered, it is clear that the pivotal learning experience is, and will remain, the doctor's exposure to, and involvement in, a wide range of real cases; cases where difficult judgements have to be made, often with uncertain and insufficient data and sometimes against severe time pressures.
The main method used was a review of the research literature in two fields:
Where appropriate, research literature from outside the field of medicine has been introduced which relates to professional expertise, the definition and specification of competence, decision-making, and learning in the workplace: these are fields with which either or both of the authors is conversant. Details of the search methodology for (1) and (2) above are provided in Appendix A. The bulk of this search was conducted by Ian Eiloart, the researcher on the project, whose assistance we gratefully acknowledge.
In addition to the search, we interviewed 12 experienced doctors with responsibilities in Postgraduate Medical Education, and studied Royal Colleges' documents on Basic Training, Higher Specialist Training and the Vocational Training of General Practitioners. The main purposes of the interviews were:
This helped us to contextualise our report, and confirmed that knowledge of the research under review was not widely distributed.
Given the substantial discussion of major papers in this report and the provision of abstracts for most entries in our database, we decided that the provision of an additional annotated bibliography would be redundant. The database itself will be available through the website of the University of Sussex School of Cognitive and Computing Sciences, as will the final (after review) text of this report.
Methodological approaches to research in medical education include a rather different balance of methods than those found in biomedical research. While this difference can be partly attributed to research funding on a much smaller scale, there are also many practical constraints on research into medical education. Numbers at postgraduate level are often too small for the use of inferential statistics, so a combination of qualitative methods and descriptive statistics is often used. Allocation to experimental or control groups is normally both random and explicit, but cannot often be blind. Since doctors in training are fairly sophisticated subjects, qualitative methods can allow some attribution of cause to desirable or undesirable outcomes, in the absence of such control studies.
Whenever control studies have been used we have noted this fact in the text, but we have not tried to make any judgements about whether they have been well used. Before and after studies are also reported as such. The absence of such annotations can be reliably interpreted as signifying the absence of such methods. There have been a small number of systematic reviews, mostly focussed on continuing medical education, where Davis et al.'s (1995) review is the most frequently cited. Irby's (1995) review on learning in ambulatory settings is another milestone, which includes a wider range of research methods reflecting the constraints and research feasibility in that area. On the theoretical side, research into clinical expertise tends to be based on written case descriptions and protocols, with decisions emphasising at the possible expense of natural validity.
Following this Introduction are two chapters on professional competence, judgement and expertise in medicine. Chapter 2 provides a definition of competence based on the expectations of employers, patients and the medical profession. This approach is implicit in the General Medical Council's publication Good Medical Practice; and is particularly well suited to postgraduate training, during which doctors' service contributions need to match their current competence, in addition to providing learning opportunities to extend that competence. This is followed by a brief discussion of the term judgement which we have not attempted to define. There are at least three meaning in use: some psychologists treat the term as synonymous with decision-making; our informants used it either with reference to its quasi-legal role in assessment or to refer to particularly complex decisions involving a high level of uncertainty. Instead of attempting to resolve these differences, we have focused on the term expertise, which has been the subject of considerable research. Chapter 3 reviews research into medical expertise, which seems to be almost universally defined in terms of the capability of those people deemed by their peers to be experts, or at least highly experienced and well respected. Thus the term ``expertise'' subsumes both competence and clinical judgement. Our understanding is that Postgraduate Medical Education is mandated to develop the competence expected of consultants of GP principals; and expected to make a significant start to the development of expertise which will continue to develop through lifelong learning long after postgraduate training has been completed.
Chapters 4 and 5 review the research on learning and the support of learning through guidance, coaching and supervision during postgraduate medical education. Chapter 4 covers learning in clinical settings and Chapter 5 learning in non-clinical settings. The majority of this research has been conducted in North America, where postgraduate medical education is based on residency programmes: these last for 3 to 6 years after graduation from Medical School, according to the specialism. Give the increasing emphasis on the maintenance of competence and further development of expertise after the completion of training, we have added a further chapter on Continuing Medical Education (CME) and Continuing Professional Development (CPD). Chapter 6 is particularly important because of the large volume of recent research on how doctors learn and the factors affecting changes in their practice; and preparation for this lifelong learning phase is an important goal for postgraduate training programmes.
Chapter 7 is a short specialist chapter on the use of Information Technology in training doctors, an increasingly important source of innovation in medical education. Chapter 8 reviews a second specialist area, Assessment and Revalidation, because these processes set the minimum standards for postgraduate medical education and continuing medical education, respectively. The ``backwash effect'' of assessment on learning is one of the most firmly established findings of educational research; so this has to be given constant attention as well as the normal expectations of valid and reliable assessment practices.
Finally, Chapter 9 discusses the implications of this research review for policy: the proper use of the construct of competence and the efficient and effective provision of post-registration medical education.
To aid the reader some synopses of key papers are ``boxed'' in the text. These boxed sections are a continuous part of the main text, though they can be read on their own.