The Question of Competence: Reconsidering Medical Education in the Twenty-First Century

INTRODUCTION

Brian D. Hodges and Lorelei Lingard

Every way of seeing is also a way of not seeing.

Kenneth Burke

, Permanence and Change

In the past decade, competence has grown to the status of a god term in medicine and in many other health care disciplines (Burke 1935): an idea with such power that it readily trumps other, competing ideas to shape our educational values and decisions in innumerable—and often invisible—ways. It is, hands down, the governing notion underpinning our sense of what medical education should be striving for in the twenty-first century, overshadowing other popular notions including simulation, objective assessment, professionalism, and patient-centeredness.

The Origins of the Idea of Competence

Almost ten years ago, the shift from a traditional content-based curriculum to a competency-based curriculum was called the Flexnerian revolution of the 21st century (Carraccio et al. 2002). This in spite of the fact that competence broadly, and competency-based education specifically, are both old and evolving ideas, much debated in higher-education institutions and in the professions. Calls for competency-based education go back more than half a century (Grant 1979). Competence-based education has been defined as a form of education that derives a curriculum from an analysis of a prospective or actual role in modern society and attempts to certify student progress on the bases of demonstrated performance in some or all of the aspects of that role (Grant 1979). The movement has infused the educational mind-set of a wide range of disciplines, including management (Albanese 1989), psychology (Rubin et al. 2007), engineering (Dainty, Cheng, and Moore 2005), health care (Anema and McCoy 2010; Fullerton et al. 2001; Long 2000), teacher education (Houston 1973), and music (Madsen and Yarbrough 1980).

Predicated on the rise of behavioral objectives in the 1960s and 1970s, the competency-based education movement was originally driven by the need for greater accountability in training, the desire to support students to progress at their own pace, and the call to ensure that training programs were relevant to the goals of society (McAshan 1979). These drivers remain influential today. For instance, the Educating Future Physicians Project of Ontario, which resulted in the CanMEDS competencies for medical education, was driven by a perceived need for medicine to be more accountable to the needs of society (Whitehead, Austin, and Hodges 2011). Because of this, the development of competency frameworks, such as CanMEDS and the competency model for general practice in the UK, commonly involves a process of seeking public input (Patterson et al. 2000).

Within medical education, the argument for competency-based education has been under way for over fifty years (McGaghie et al. 1978). Recently, however, the wider social-accountability movement has breathed new life into the debate (Leung 2002). As Sullivan (2011) has argued, accreditation bodies now expect professionals to demonstrate that they are indeed achieving what they set out to do. Competencies and outcome-based education are measures that the profession has adopted to better regulate itself in the context of public concerns about patient safety, differential access to care, and the medical profession’s struggle with the increasing complexities of practice. What counts as competence is evident in the ways in which programs are structured and in the accountability processes that are implemented around them.

It is hard to find a single health care reform initiative that has not given significant attention to the process of health professional education, which is, in turn, linked to fostering the competencies thought necessary for practice in environments that are increasingly complex and stressful in the face of twenty-first-century political, economic, and technical demands. While there are ongoing concerns about competencies hype, their operationalization in a clinical apprenticeship model of education (ten Cate 2005), and the challenges they present for reliable and valid assessment (Jefferies et al. 2011; Lurie, Mooney, and Lyness 2009), there is no question that the idea of competence has effectively taken over the way we think about medical education goals and enact its curricular strategies. Within universities and other organizations that determine health professional curricula, hardly a discussion or meeting takes place in which competence is not central to the agenda.

The Ubiquity of the Idea of Competence

Competency frameworks now underpin (Simpson et al. 2002) all of medical training in the Western world. These include the Outcome Project of the U.S. Accreditation Council for Graduate Medical Education (ACGME 2011), the General Medical Council’s Tomorrow’s Doctor (General Medical Council 1993), the Scottish Doctor (Simpson et al. 2002), and the Canadian CanMEDS (Frank 2005) framework. The latter has enjoyed global uptake in countries such as the Netherlands and Australia (American Medical Association 2010a). Similar frameworks are beginning to proliferate globally (Stern, Wojtczak, and Schwarz 2006; Zaini et al. 2011), with implications for global human-health resource strategies and international medical education partnerships.

The idea of competence has proliferated conceptually as well as geographically. There is apparently no limit to the domains in which competence language is relevant. In addition to the usual suspects—clinical competencies such as medical expert and communicator—a range of candidate competencies have been promoted in recent years. In fact, as universities and their affiliated teaching hospitals recognize that attention to patient safety, team-based practice, lifelong learning, and the ability to understand and navigate systems are crucial to the delivery of safe and effective care, new competencies have become the lingua franca. Recent entries include science competency (Association of American Medical Colleges-Howard Hughes Medical Institute Committee 2009), patient-safety competencies (Walton and Elliot 2006), cultural competence (Taylor 2003), and humanitarian response, interestingly advocated as the competency of competencies (Hein 2010).

Not only geographically and conceptually pervasive, the idea of competence participates in some of the most critical debates in medical education. It has entered the medical school admissions discussion, offered as an improved candidate-selection strategy (American Medical Association 2010b) to ensure that the right individuals get through the gate into the medical profession. It also features prominently in accreditation; for instance, it governs the Liaison Committee on Education’s (LCME) standards for accrediting North American medical schools, particularly in relation to standard ED1, which outlines a medical school’s responsibilities to define objectives that guide curriculum content and evaluation strategies (LCME 2011). Competence is also arguably the backbone of the past decade’s wildly popular global medical education movement, whose agendas not only reflect national concerns but also respond to global forces. Reflecting the rise of a global economy in human resources generally and health human resources specifically, medical schools are embracing a global orientation and marketing their programs to students from around the world. Driven by a need to generate revenue, many medical schools have established contracts to sell services, curricula, or offshore, co-branded campuses to other countries.

Competence is also at the epicenter of the burgeoning field of medical education research and policy development. Competence rhetoric underpins investments in centers for research and development in health professional education around the world. More than twenty peer-reviewed journals publish a swath of literature dedicated to the pursuit of competence in the health professions. When health professional educators and researchers gather together nationally and internationally, competence is always an invited guest at the head table. For example, at the 2011 meeting of the Association of American Medical Colleges (AAMC) in Denver, Colorado, which attracted over four thousand participants, presenters sought to engage the audience by employing titles such as Competency-Based Medical Education: The Time-Dependent ‘Gestational’ Approach vs. Milestone-Dependent ‘Developmental’ Approach, Do New Models for Early Clinical Experience Produce More Competent Students? and Toward Achieving Competence across the Continuum of Medical Education. A session on Core Competencies for Collaborative Practice aimed to "define foundational competencies for interprofessional collaborative practice," tying this imperative to patient-centered care and quality outcomes (AAMC 2011).

Similarly, the nearly three thousand participants from more than seventy different countries who attended the 2011 Association for Medical Education in Europe Conference (AMEE) in Vienna, Austria, could attend more than twenty different sessions with competence in the title and many more oriented around the topic (AMEE 2011). The same pattern can be found in programs of the Asia-Pacific Medical Education Conference, held annually for over five hundred medical educators in Singapore, and the International Ottawa conferences, held every two years on a different continent, and attended by more than two thousand health professional educators from around the world. Both feature numerous sessions that focus on competence and its many offspring, including competency frameworks, competence-based curricula, competence assessment, and the like. Not only are academic seminars, keynotes, and workshops devoting large amounts of time to discussing variations on the theme of competence, but entire regulatory, licensure, and certification organizations around the world owe their existence to it.

The Debate about Competency-Based Medical Education

As the revolutionary rhetoric surrounding it suggests, the competence turn in medical education promises—and threatens—to change both the work medical educators do and the physicians we graduate. Which is why this book could not appear at a more timely moment. Any idea with the kind of power that competence currently wields in medical education deserves careful, critical attention. In the field of health professions education, there are many books and articles on how to do competency-based education. Many educators and researchers are also debating the wisdom of competency-based medical education, with some supporting and others challenging it. Supporters emphasize the transformative potential of competency-based education. One critical transformative point regards the tradition of time-based training, which medical educators have been chafing against in recent years in the face of the problems of physician shortages, physician education debt, and patient wait lists.

Competency-based training is promoted as a solution to this complex problem and, perhaps not surprisingly, surgeons are taking the lead in educational experiments to test this theory. The Royal Australasian College of Surgeons’ new Surgical Education and Training program, which commenced training in 2008, is competency based and shorter than any designed previously (Collins et al. 2007). Innovators at the University of Toronto are trialing a competency-based pathway as a solution to the problem of homogeneous postgraduate training regimens that can be prohibitively long and constraining to high performers Their competency-based pathway experiment is promoted as facilitating the fast-tracking of individuals who can show steep learning curves with all aspects of surgical competency (Grantcharov and Reznick 2009).

Critics point to the history of competency-based education in other professional fields and caution against the application of an approach based in technical and vocational fields to the complex, judgment-based profession of medicine. Arguing that the whole is more than the sum of the parts, detractors warn against the atomism, emphasis on routine skills, teaching-to-the-test, and checkbox-driven assessment that are common to competency-based approaches (Huddle and Heudebert 2007; Malone and Supri 2010). Competency-based education has been likened to tyranny (Brooks 2009) and to striving for mediocrity (Brawer 2009). Educators have worried that it promotes monkey see, monkey do education (Talbot 2004), and that it may have incapacitating effects on learners (Grant and Murray 1999) and focus our attention on minimum requirements (Bleakley, Browne, and Bligh 2010). Regarding the last point, some argue that preparation in the professions attends almost exclusively to the knowledge and skills required, paying minimal attention to the profession’s social ends and civic foundations (Colby and Sullivan 2008). Furthermore, while the drive to turn things into competencies may suit operational and instrumental skills, it is not only insufficient when it comes to more complex and relational aspects of medicine, but may in fact be a dangerous wrong turn motivated by a lust for assessment (Wear 2008).

In 2009, an international theory-to-practice consensus conference on competency-based medical education (CBME) was convened by the Royal College of Physicians and Surgeons of Canada (Frank et al. 2010). This group reviewed the broad educational literature to comprehensively lay out both the promise and the potential perils of this approach for the future of medical education. They characterized the promise of CBME in terms of its commitment to outcomes, potential for learner-centeredness, de-emphasis of time-based training, and promotion of portability in health human resources. Perils include CBME’s threat of reductionism, emphasis on lowest common denominator, tendency toward utilitarianism, and the potential logistical chaos of a progress-at-your-own-pace model. Offering redefinitions of key terms, the group recognized the transformative potential of CBME and called for ongoing debate about its utility and impact.

Another peril not as explicit in this report is the way in which competency definitions, lists, roles, and frameworks may, inadvertently or purposefully, transport purposes and values from their original setting to other settings (in time or in place) where those purposes and values may have invisible or unintended consequences. That is, the language of competence is not only descriptive but also constructive. Eraut (1994, 159) explains that definitions of competence…may be designed for one purpose, and in practice serve quite a different purpose…. The definition of what in practice was meant by ‘competence’ reflected the political purpose it was intended to serve. A 2011 analysis of the origins of the CanMEDS roles framework provides an illustration of the political purposes that may underpin definitions of competence; similarly, the energetic commentary this analysis prompted reveals that much is at stake in both the definitions themselves and the assertion of political purposes underpinning them (Sherbino et al. 2011; Whitehead, Austin, and Hodges 2011).

Debates about competence also have arisen in the globalizing world of medical education (Hodges et al. 2009). A case in point is the flurry of activity aimed at developing global standards for medical competence (Institute for International Medical Education 2002; Karle 2006). This push to identify a shared, global definition of competence or to operationalize global competence in one set of standards or roles is a logical extension of a global medical education market, but it raises the critical question of who decides what these elements of global competence are. Writing about medical education, Bleakley, Brice, and Bligh (2008) have raised a concern articulated by social scientists more generally (Navarro 1999) that the dominance (economically, culturally, linguistically) of particular countries or regions is almost certain to lead to the marginalization of priorities, values, content knowledge, and exposure to learning contexts of less dominant countries or regions. The dominance of language requires particular attention. If one is to take seriously writing since the mid-twentieth century about the linguistic turn—the shift in many scholarly disciplines that foregrounded the constructive function of language—how does one think about universal standards expressed in only one language? Ho and colleagues at the University of Taipei have conducted research showing that the construct of professionalism, a construct operationalized almost entirely in English-language medical education journals, is a subtly but crucially different notion when seen through the language and cultural filters of Taiwan. A greater emphasis on competence as an individual trait in North America as opposed to competence as a collective trait in Asia is just one of the nuances that renders a universal definition of a competence like professionalism" difficult (Ho et al. 2011).

The Unique Contribution of This Book

While some debate the pros and cons of competence-based medical education and others explain how to achieve various competencies, the authors of the seven chapters in this book offer something very different. Together, the essays in this volume offer something new to the scholarly discussion of competency-based medical education. They do not mount philosophical arguments for or against embracing the idea of competence in medical education. They do not join instrumental debates about how to do competency-based medical education. Instead, they critique the very notion of competence itself and attend to how it has shaped what we pay attention to—and what we ignore—in the education and assessment of medical trainees.

In differing ways, the leading medical education researchers who have contributed to this book all argue that we have only just scratched the surface of developing a sophisticated concept of competence with our various frameworks, taxonomies, checklists, and the like. Indeed, the risk is that as these lists get longer and longer, incorporating ever more diffuse elements, the word competence will actually stand in for so many things that it will come to represent nothing at all. While much attention has been paid to the operationalization of competence (and in particular the development of assessment tools), not enough has been paid to the fact that there are some dramatically different paradigms or discourses about what competence actually is. The goal of this book is to look critically and thoughtfully at several of these different conceptions, or discourses, of competence and to analyze the educational, moral, political, and scientific implications of adopting certain of these over others. To that end, the seven chapters in this book explore concepts of competence from a range of disciplinary perspectives.

The first chapter, The Shifting Discourses of Competence, by Brian Hodges, begins with the observation that if one reads the history of medicine, or any of the health professions, it is obvious that the elements used to define competence have changed considerably over time. Competencies move on and off lists of sanctioned and appropriate professional activities for various reasons that include advances in the science, but also include economic, political, and sociological factors. Analyzing the five key discourses that are used to conceptualize medical competence in North America today—knowledge, performance, psychometrics, reflection, and production—Hodges explores each in terms of the implications for learning, assessment, relationships, and the nature of educational institutions. Inspired by a Foucauldian genealogical approach, Hodges dissects the interrelations and power dynamics making each discourse possible. Finally, Hodges reflects on the practical and ethical dilemmas that students and teachers face if they are prepared to accept the notion that competence is a constantly shifting construction.

In chapter 2, Rethinking Competence in the Context of Teamwork, Lorelei Lingard considers the health professions’ traditional approach to competence as something that individual practitioners acquire, perform for assessment, and seek to maintain over their practice life. This individualist discourse of competence does not equip us well to address team situations, particularly those in which individually competent health professionals combine to form an incompetent team. She reviews the conventional, individualist discourse on competence that underpins much health professional education specifically—and Western culture in general—considering its theoretical origins and the ways in which it inclines medical educators to attend to some things and ignore others. After introducing a more emergent discourse that characterizes competence as a shared and distributed construct, she weighs the implications of viewing competence through both lenses. What kinds of education and assessment might be possible if our conventional discourse of competence were extended? How would such an extension challenge our traditional approaches to measuring and maintaining competence?

In the third chapter, Perturbations: The Central Role of Emotional Competence in Medical Training, Nancy McNaughton and Vicki LeBlanc explore the role of emotion as an integral, and often underappreciated, component of competency in the health professions. The authors bring two different scientific perspectives to the discussion. One perspective views emotion as a social construction, influenced by sociocultural processes. Viewed from this perspective, we would discover a better understanding of the nature of emotion and its relationship to competence through studying social processes, including the way that certain emotions come to be acceptable or unacceptable and, therefore, come to be associated with competence or incompetence. The second perspective views emotion as a neurobiological phenomenon that is related to other cognitive functions such as attention, memory, and decision making. Using this lens to understand how emotion affects competence means measuring cognitive and neurophysiologic variables such as performance, emotion, and salivary cortisol levels. The authors compare and contrast the implications of using each of these different approaches to understanding emotion and its relation to education and practice.

In chapter 4, Competence as Expertise: Exploring Constructions of Knowledge in Expert Practice, Maria Mylopoulos problematizes a commonly held view—that excellence in the education and training of future experts is crucial to the success of all professions—by exploring developments and debates in the conceptualization of expertise. She reviews the extensive literature on expertise over the last half century, pointing out that the understanding of expertise has recently expanded to include previously unexplored facets of expert performance. In particular, scholars and researchers are increasingly revisiting the role of knowledge in expert development and practice. Mylopoulos thus analyzes various cognitive constructions of expertise, with a particular focus on the differing ways in which the role of accrued knowledge has been conceptualized in models of expert development and practice. Her chapter discusses key implications of the various treatments of knowledge in theories of expertise for those seeking to understand competence through the lens of expert performance.

In the fifth chapter, Assessing Competence: Extending the Approaches to Reliability, Lambert Schuwirth and Cees van der Vleuten ask the question, what makes an assessment of competence a good assessment? Traditionally, assessment of competence has been viewed as a sort of psychological test, by which student characteristics that are not directly visible can be captured through the indirect measure of proxy behaviors. Quality criteria for assessment methods, therefore, are based on those used for psychological tests, the most well-known being reliability and construct validity. Reliability is expressed as reproducibility of the outcomes of the assessment tool—for example, had a group of students been given another test of equal difficulty on the same topic, would they then have obtained similar scores? Validity is understood to be a marker of whether the test actually measures the characteristic it purports to. Both criteria are currently determined using psychometric formulas applied to numerical data. Yet there are major limitations to the assumption that all elements of competence must be inferred from the numerical scores on reliable and valid tests. The authors argue that many current competence assessment instruments do not fit well into this paradigm. They contend that, to properly assess competence, subjective human judgment and qualitative language-based data are required. With the understanding that important decisions made about students must be fair and defensible, they consider the challenge associated with finding subjective assessments that meet high quality standards. These challenges notwithstanding, however, the authors address the urgency of exploring new directions in the assessment of competence.

In chapter 6, Blinded by ‘Insight’: Self-Assessment and Its Role in Performance Improvement, Kevin Eva, Glenn Regehr, and Larry Gruppen examine the foundations on which many modern theories of self-improvement are built. From athletic coaches to business leaders, there is a general belief that the path to better performance involves looking in the mirror to openly and honestly identify one’s weaknesses and take steps to improve on them. With the health professions as perhaps the most extreme example, the industry’s current models of maintenance of competence and self-regulation seem to be formalizations of the instruction Physician, know thyself. The authors caution against reliance on self-assessment of competence.

While each of us has more information with which to judge our own abilities than is available to external observers, Eva, Regehr, and Gruppen argue that it is this very wealth of information that may prevent us from generating accurate impressions of our own abilities. The authors review research that raises questions about the adequacy