The term competence appears in many forms and guises in the research literature on the professions. Nevertheless, a clear definition is needed to guide a review of this kind. Eraut's (1998) review of definitions and meanings of competence distinguishes between those authors who treat competence as a socially situated concept -- the ability to perform tasks and roles to the standard people expect -- and those who define it as individually situated, a set of personal capabilities or characteristics (Neufeld and Norman, 1985). Eraut argues in favour of a socially situated definition, because the notion of competence is central to the relationship between professionals and their clients; and recommends using the word capability to describe the individually situated concept of ``what a person can think or do''. Whether or not a person's capability makes them competent in a particular job depends on them being able to meet the requirements of that job. Hence competence in a job is defined as the ability to perform the tasks and roles required to the expected standard.
The advantage of this definition is that it can be applied to a professional at any stage in their career, not only to the newly qualified. The standard expected will no doubt vary with experience and responsibility and take into account the need to keep up to date with changes in practice. It also leaves open the question of who will decide what is to count as competence when different people have different expectations. This is an essentially political issue. While the GMC has the legal authority, many cases are `resolved' at local level or between doctor and patient without referring the matter any further. The position of postgraduate trainees is more complicated as they are still under supervision; nevertheless it would clearly be inappropriate for those towards the end of their training to be closely supervised all the time. Training results in a steadily increasing range of competence, accompanied by gradually decreasing levels of supervision; and the process of expanding one's range of competence continues after completion of training. Throughout this period the principle holds good of not undertaking work for which one is not competent without appropriate supervision, whatever one's status.
The GMC's publication Good Medical Practice states in a preface entitled ``Duties and Responsibilities of Doctors'' that:
``The principles of good medical practice and the standards of competence, care and conduct expected of you in all aspects of your professional work are described in this booklet. They apply to all doctors involved in healthcare.'' (page 1)
This confirms the importance of meeting expectations and emphasises that this applies to all aspects of professional work, not just those that might be described as purely medical. The GMC does not refer only to competence but also to care and conduct, because there can be a gap between competence -- what a doctor can do - and performance -- what a doctor does do. This gap can be caused by personal factors such as dispositions or attitudes, environmental factors such as workload, workplace climate and working conditions, or situational factors such as multiple emergencies and lack of support. While membership examinations for the Royal Colleges assess medical knowledge and clinical competence, assessments during specialist training and for CCST are based on performance on the job over a considerable period of time.
Rethans et al. (1990) point out that many researchers have failed to appreciate this distinction between competence and performance, also noting that only one of the eight studies reviewed was able to show that competence was a significant predictor of performance. They argue that this was not due to measurement deficiencies, as claimed, because it was a behavioural problem rather than a psychometric problem. More research should focus on the conditions which influence doctors' performance. Their own study (Rethans et al., 1991) of 36 General Practitioners in the Netherlands used standardised patients both for an initial assessment of competence under relaxed conditions and for blind visits to their practices 12 months later to assess performance under normal working conditions. When considering assessment results alone, the doctors did better on the competence than the performance assessment. When using efficiency-time scores, the doctors did better in actual practice. Only when both assessment results and efficiency-time scores were used did competence predict performance. In a different context, Rhoton et al.'s (1991) analysis of 45 anaesthesiology residents handling of critical incidents showed that two thirds of the variability was predicted by two non-cognitive variables, ``conscientiousness'' and ``composure''. Thus below standard performance may not signify lack of competence.
Precisely what constitutes the expected standard which defines competence can also be a problem. The most basic specification of competence is that used by the General Medical Council, whose new assessment arrangements have now been tested in the courts. Then for General Practitioners there are two further specifications to be considered. The Summative Assessment of GP Registrars is set at a higher standard than the GMC basic; and at a higher standard still are the requirements for becoming a Member of the Royal College of General Practitioners. This is also intended to be achieved towards, or soon after, the end of the training period. The confusion this causes the public can be traced to two separate uses of the term competence in everyday discourse. One usage treats the attribution of competence to a person as a binary decision: either one is competent or one is not competent. The decision might not be easy but only two answers are possible. For example, for any given situation one is either insured or uninsured. The other usage treats competence as a position on a continuum of expertise, probably somewhere in the middle, i.e. rather less than excellent. One might be very content with a competent lawyer when buying a house, but look for an expert when seeking advice on a piece of complex litigation. Thus, being referred to as ``competent'' could in some circumstances be perceived as a rather negative comment.
Pietroni (1993b) explores the practical implications of multiple levels of competence, both confirming the need for a minimum level of performance, below which behaviour is defined as negligent (i.e. the GMC level for keeping on the register) and arguing for targeting postgraduate education and training on a level well above that minimum. He also points out that setting the standard below the current average would be complacent, setting it at the average would be conservative and setting it above the average would be very challenging. Whatever the standard of performance at the end of training, the expectation must be for continuing improvement thereafter; and this depends on the doctor's attitude towards quality improvement and lifelong learning. Many of those we consulted commented on the gap between the standard associated with the Certificate of Completion of Specialist Training (CCST) and that expected of an established consultant, and this must be at least as significant for GPs who receive much less training for a job of similar complexity. Thus the chapter on Continuing Medical Education is an important part of this report.
Specifications of competence are essential for setting standards, and the Certificate of Completion of Specialist Training (CCST) is competence-based. So also are the clinical components of membership examinations of the Royal Colleges. Nevertheless, the transition from implicit judgements of a doctor's competence to explicit descriptions which can guide both training and assessment has not been easy. Many would argue that it still has a long way to go. Difficulties include:
These problems are not confined to the field of medicine. Nevertheless, the importance for educational policies and programmes, which aim to develop the attributes of competence and judgement, of specifying both the attributes and the nature of competence itself cannot be underestimated. Apart from the publications of the Royal Colleges themselves, there are a number of journal articles discussing various aspects of competence and a range of publications from the Royal College counterparts in North America and Australia.
One document which we found particularly valuable, both in its description of aspects of competence and its discussion of the design of appropriate postgraduate programmes to develop competence is the recent report of the Federated Council for Internal Medicine Task Force on the Internal Medicine Residency Curriculum (Sox et al., 1997) which is available from the American College of Physicians and also on the Internet www.asim.org/fcim.
In order to overcome some of the difficulties listed above, this Task Force asked experts in the field of Internal Medicine ``to identify those difficult-to-measure properties of the expert internist that might be overlooked after biomedical knowledge and skills are presented in organ-specific competency lists.'' They called this construct ``physicianship'' and saw it as ``the difference between the expert internist and the journeyman practitioner''. They grouped the suggestions received into 20 categories, which they call Integrative Disciplines; and these are accompanied by 24 categories of clinical competency.
The term ``discipline'' may not seem quite appropriate in the British context, but the categories themselves make good sense. These are listed in the Panel below, according to the three FCIM tiers of category. First, are the core values of internal medicine which, they anticipate, will be learned largely through discussion, problem-solving exercises, workshops and practical experience. Next, are the characteristics, or salient expressions, of these values, which are likely to require at least some formal instruction in addition to opportunities for practice and formal feedback. The final tier comprises integrative skills, or applications, of the values and characteristics, for which theory may be less important and the main approach to learning is acquiring experience in realistic settings.
|
Integrative Disciplines and Categories
Comprising Physicianship
Sox et al. (1997) |
For each of these headings 6-12 competencies are listed and possible learning venues suggested. The examples listed below indicate the general approach. In essence this document takes a set of duties similar to those listed in the GMC's Good Medical Practice and provides a set of competencies to indicate what a doctor would need to understand and do in order to fulfil those duties with a high level of professionalism.
|
Examples of General Competencies Associated with Physicianship
Humanistic Practice of Medicine (page 25)
Understand the concepts of the health belief model; know how to elicit it and how to work constructively in a patient-centred way with persons from different cultural groups.
Professionalism (page 27)
Medical Ethics (page 29)
The Medical Interview (page 39)
|
Another approach to mapping the range of competence is to focus on areas of activity and responsibility, and relationships with the other people involved.
For example, six areas of responsibility can be usefully distinguished:
The main groups with whom doctors have to develop and sustain appropriate working relationships are
These responsibilities and relationships determine the expectations of doctors and hence the range of their competence. Then individual doctors also have overall responsibility for controlling their own behaviour, for self-management and self-evaluation. We do not propose to describe in detail the full range of clinical skill required for each specialism, though some are much more clearly described than others. That would go beyond our capability and involve too much specialist discussion for a report whose prime focus is learning. Instead we shall elaborate further the range of competence associated with what Calman et al. (1999) recently described as ``the next and potentially more challenging stage'' in the development of Higher Specialist Training:
``Ensuring that, in addition to developing effective clinical skills, trainees are also able to respond to service changes and to develop a wider range of competencies, including team working, communication skills, and the ability to identify health needs and understand the opportunities for health promotion.'' (page 30)
Often the least well defined area in the doctor-patient interaction zone is that of communication. The GMC booklet Good Medical Practice sets out the doctor's responsibilities very clearly in paragraph 12. A general disposition to be polite, considerate and respectful is important; but there are also quite complex skills to be learned. Patient rights to know and to choose are of central concern; but the general principle of informed consent begs the questions of `how well informed' and `whose consent'. Malloy et al. (1992) investigated the influence of treatment descriptions on elderly patients completing `advance directives'. 77% changed their minds at least once when given the same scenario but a different description of the intervention, of whom two thirds changed their mind four or more times. The FCIM Task Force suggests that a doctor should:
The issue of patients whose decision-making capacity may be in doubt is only a small part of a much wider problem of patient understanding. The GMC's duty ``to give information to patients in a way they can understand'' must be one of the most difficult to fulfil; and ``inadequate explanation'' is one of the most frequent forms of patient complaint. Moreover, the consequences for the quality of care tend to be underestimated. Sanson-Fisher and Maguire's (1980) research review suggested that the way doctors interact with their patients affects the adequacy of clinical interviews, patient compliance and satisfaction and responses to potentially distressing medical and surgical procedures, all of which may in turn affect long term outcomes for patients. They also presented evidence of the consequences for patients of ineffective communication skills in junior doctors. A later study by Tuckett et al. (1985) of doctor-patient communication in general practice found that in ``as many as one in every two consultations patients could not recall all the key points..., could not make correct sense of them, or were not committed to them'' (pp 167-178)
``Because doctors did not know the details of what patients were thinking, the information they did give could not relate, in any precise or considered way, to the ideas patients themselves possessed. In short, there was little dialogue and little sharing of ideas. In consequence, doctors could have no way of knowing whether the information they offered was being understood `correctly' or not. Equally, patients could have no way knowing whether their understanding of what doctors said was `correct'.'' (p 205)
At a more general level, and particularly in community settings and clinics, it is important for the doctor to find out what is worrying the patient and why they have come for a consultation in order to frame the health problem in an appropriate way for progressing the situation. The doctor's problem may not be the same as that of the patient (McWhinney, 1985).
Another aspect is communication with relatives and/or friends, when there is patient consent to informing them. Patients benefit from the opportunity to talk things through with family and/or friends, who also need to be well informed. Moreover drug compliance, reporting of side-effects, and changes to diet and/or lifestyle are more likely to be sustained when there is family understanding and support. In many cases continuing communication with both patients and families will need to be part of the care plan. Nurses and therapists will often have good opportunities for this; so the whole care group need to be well briefed and to know who is responsible for talking to whom, and for checking up later on how much has been understood. In some cases, especially where there are psychological aspects to be investigated, the problem may not be confined to the person who first sees the doctor. Both the framing of the problem and the response to it may involve skilful communication with several people.
Health promotion and preventive medicine also require good communication skills with patients, relatives and the wider community, as well as the disposition to seek and take opportunities to talk about the relevant issues. The administration and management of communication is also an important area of competence, and this does not mean doing everything oneself. The GMC publishes guidance on serious communicable diseases and fitness to drive a vehicle; but there is little reference to the detection of risk-bearing psychological problems by doctors outside general practice and psychiatry. Given the increasing emphasis on preventive medicine policies, it would seem reasonable to suppose that some of the competencies required for membership of the Faculty of Public Health Medicine (Kisely and Donnan, 1997) might also be needed by other doctors, e.g. good understanding of local variations in health problems, epidemiological approaches to the assessment of health care needs, evaluation of health care policies.
Teamwork, management and leadership skills are needed in a wide range of contexts: within the relevant care groups and the medical practice or firm; and in order to perform duties needed for the effective and efficient functioning of the health care organisation in the interests of its patients, employees and other stakeholders. Interprofessional communication, team working skills, record-keeping are frequently cited examples. So are teaching and training; but not appraising, mentoring and giving feedback. Practice evaluation and quality improvement skills cannot be taken for granted but require systematic development (Eliastam and Mizrahi, 1996). The FCIM Task Force listed 13 competencies for the Management of the Quality of Health Care, mostly methodological (e.g. measuring patient satisfaction, measures of severity of illness and comorbidity, knowing methods for evaluating the effectiveness and efficiency of one's practice patterns) but also including.
``Know how to lead a health care team that is trying to improve the quality of its services (understand team behaviour, working with a team, and reshaping a team).'' (page 59)
The research on changing primary health care points to the need for multiple interventions, which combine the development of competence through CME with interventions aimed at changing aspects of practice management (see Chapter 6). Often noted gaps between individual or team competence and performance may also be attributable to lack of management competence within the team or at higher levels. This may be highlighted by the development of clinical governance for which the link between quality and improvement and management responsibility will be critical.
Finally, we come to the competence to manage one's job as a whole. This includes determining priorities, implementing professional values, improving the quality of one's personal practice, self-evaluation for all one's roles and duties, monitoring one's own health and stress-level and taking appropriate action. The importance of competence at a whole job level is seen by many as necessary for ensuring that competence in different aspects of the job is translated into performance. An emerging issue in this area arises from a greater wish by doctors to protect their personal lives and avoid high stress and burn-out by limiting their hours of work (Yedidia et al., 1993): doctors too have rights. However, this can be interpreted as unprofessional by ``the older generation''. Apart from the problem of overall staffing levels, the central issue is often continuity of care. This is turn depends on the ability of the whole health care team to organise itself in a way that ensures such continuity. The notion of team competence and organisational competence are being increasingly used in the private sector. While this goes beyond the brief of this report, it indicates the extent to which interprofessional work is likely to be expected of doctors in the future and hence the attributes of competence required for it.
The term judgement is less controversial than competence for most doctors, because it conveys a sense of expertise. However, some gynaecologists now avoid the term `clinical judgement' because it has acquired a connotation of paternalistic devaluing of women's choice. One meaning of the term is legalistic: a court or a disciplinary hearing makes a judgement; and this meaning is often extended to cover the process of assessment, where examiners also are described as making judgements. More frequently, `judgement' is a term used to describe the highest level(s) of expertise. According to whether they use a broad or narrow definition of competence, they will define judgement either as an advanced level of competence or as that area of expertise which goes beyond competence. The most salient attributes of judgement reported in our consultative interviews concerned making holistic and balanced decisions in situations of uncertainty and complexity. More specifically, descriptions of bad judgement included:
Good judgement, by implication, is the opposite of bad judgement, but is not always described in the same terms. For example, good judgement could mean:
Situations where judgement (hopefully good) was called for included:
Other aspects of judgement described in the literature concern:
Our consultations revealed the expectation that, given sufficient time, all postgraduate trainees would become at least minimally competent doctors. If they failed, this would normally be due to dispositional factors -- a profound disregard for patients and/or an unwillingness to evaluate their own practice and acknowledge where improvement is needed. The self-evaluation problem might concern not just a doctor's personal practice but also his or her role in the health care team and the practitioner community. Difficulties in moving from completion of training to the role of consultant were often attributed to overconfidence, failure to recognise what further learning was needed and a failure to fit into the new context and grow into the new role. This also was sometimes described as bad professional judgement. Whether clinical or more broadly professional, judgement takes time to acquire and its development cannot be guaranteed by good training.
2.6 SummaryCompetence is defined as ``the ability to perform the roles and tasks required by one's job to the expected standard''. This definition does not apply only to the intended outcomes of basic and specialist training. Throughout postgraduate education doctors have direct responsibilities for providing patient care and their current competence has to meet this service expectation as it changes with increasing experience and seniority. They are also seeking to expand that competence to meet anticipated future responsibilities; and this dual obligation presents a considerable challenge. Their success in meeting this challenge is significantly affected by the balance between the demands of their job and the opportunities presented by their learning programme. Further insight into the nature of this challenge is provided by recognising the distinction between competence, what a doctor can do, and performance, what a doctor does do. There are many reasons why a doctor's performance may not reach the level of their competence. Some of these are associated with personal factors such as disposition, attitude and life-events outside the job. Some are associated with contextual factors such as workload, working conditions, levels of support and unexpected bursts of emergency work. The difficult task of specifying competence is discussed with reference to finding the appropriate level of detail, capturing the essence of expertise, recognising the integrated nature of performance, and covering the full breadth of the doctor's job today. The evidence feeding into this process tends to come from committees of experienced physicians who also have a record of contribution to postgraduate education. Contributions from research are rare but might be useful if based on studying doctors' responsibilities and relationships as well as their clinical experience. These have been clearly addressed by recent publications of the General Medical Council; and an excellent example of a complete analysis of the competency goals of residency programmes and planning appropriate ways to achieve them is provided by the US Federated Council for Internal Medicine Task Force. The significance of communicative competence and management competence in particular is discussed in separate sections. The chapter concludes with a brief summary of interviewee responses to questions concerning salient attributes of judgement and situations where judgement is required. Though not providing an agreed definition of judgement, the analysis highlights aspects of a doctor's work where feedback on performance, case discussion and possibly even coaching are especially important during postgraduate medical education. |