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\begin{document}

\title{When were clinicians ever not competent?}



\author[1]{Mathew Mercuri  }%
\affil[1]{Mcmaster University}%


\vspace{-1em}



  
  \date{June 13, 2024}


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Competence based education (CBE) has become increasingly popular as of
late among health professions training programs. Models of CBE have been
developed and implemented by major licensing bodies and professional
Colleges (and affiliated education programs), such as the Royal College
of Physicians and Surgeons of Canada (RCPSC) and the Association of
American Medical Colleges (AAMC). In this month's issue of
the\emph{Journal of Evaluation in Clinical Practice} , several studies
describe an experience with designing and implementing a CBE model
{[}1-6{]}. On the surface, the desire to ensure that health professions
trainees are competent is commendable -- just as it is likely few would
argue that the care they receive should not be evidence based, I suspect
that few (if any) would be comfortable with the clinician prescribing or
managing said care being less than competent. However, the notion of a
need for a CBE model might suggest that there was some issue with
competence in the training of past clinicians that needed remedy, i.e.
there is a lack of competence among some clinicians entering their
profession that is in part a product of their training.

When considering public perception of clinician competence, that of
physicians in particular, history is not kind. Over the past two
millennia, medicine got it wrong more often than right -- humoral
theory, bloodletting, miasma and contagion were all highly subscribed
among the healthcare community but are now relics of a bygone era. In
fact, the poor track record of medicine was the basis for a need for
evidence based medicine (EBM). Practitioners of healthcare were often
portrayed as ineffective, as providing little more than palliative
support while nature took its course for better or worse, or even
crueler, as charlatans peddling nostrums {[}7{]}. Artists were no kinder
to clinicians. For example, Shaw's \emph{The Doctors Dilemma} portrays a
group of physicians as self-absorbed, greedy, overly confident in their
unproven (and presumably, ineffective) pet ``cures'', with only the
poorest among them as having any sense of humility and patient centred
focus in his practice {[}8{]}. It seems that only within the last
century did clinicians develop a good public reputation, much of which
might be more appropriately attributed to improvements in hygiene
practices/standards of living at a societal level (e.g. the McKeown
Thesis{[}9{]}) or likewise to medical science and the discovery of
``silver bullet'' cures (e.g. antibiotics, insulin, etc.) rather than to
a change in how clinicians approached the learning of their craft and
care of their patients. However, a historical lack of curative success
and a poor reputation does not entail a lack of competence. A clinician
working in Europe during the first millennium of the Common Era would
have been considered competent provided he (or much rarer, she) mastered
humoralism according to the teachings of Galen. Is it possible that
future generations will look at the clinicians of today -- even those
who train under CBE -- in the same light as we do clinicians of the
past? Should a failure of today's medicine in the eyes of future
generations invalidate the competence of contemporary clinicians? I
suppose the impact of the answer to such questions on the issue of
competence hinges on how we define (and measure) competence.

What then makes a clinician competent? The obvious answer is technical
knowledge in the clinician's given area. By that, I assume that for a
clinician to be considered competent, she requires a minimum
understanding of the content and technique of her given profession
contemporaneous with the period of practice.11A minimum understanding of
content and technique is required to be accepted into the profession,
but it is not the desirable end. Clinicians are expected to participate
in a model of lifelong learning with a goal of mastery over that content
and technique. However, knowledge might be considered the minimum
requirement. Several frameworks of competence outline additional
requirements. For example, the ``CanMEDS'' framework, issued by the
RCPSC, identifies ``the abilities physicians require to effectively meet
the health care needs of the people they
serve''22http://www.royalcollege.ca/rcsite/canmeds/canmeds-framework-e,
accessed on June 8, 2020., which includes the roles of the physician as
medical expert, communicator, collaborator, leader, health advocate,
scholar, and professional. The criteria by which these ``roles'' were
selected (and other ``roles'' excluded), including the theoretical
and/or empirical justification for their inclusion as part of
``competence'' is not clear to me, nor is it entirely clear if available
metrics are sufficient in demonstrating that the roles have in fact been
achieved by the trainee or how one operationalizes those roles in
practice. Are clinicians who lack ability in any of these ``roles''
incompetent? Does meeting all of them according to some threshold ensure
competence? As health professions are typically self-regulating, it is
up to the governing bodies of each profession to decide, which might
suggest that competence is a product of the times rather than akin to a
``natural kind''33If it is the case that ``competence'' in medical
practice, for example, is in fact a standard set by the profession
(which I think most people would agree is the case), then judging the
competence of past or future physicians by the current standard might be
inappropriate. That raises issues about differing standards of
competency for currently practicing physicians who trained at different
times. In Canada, we are currently going through a transition whereby
our training programs have two cohorts -- one that is training under the
previous ``time based'' model and the other under the current
``competence by design'' model. Is it the case that there is a
relatively less (or no) guarantee that those training under the previous
model are competent? The answer to that question might impact the extent
to which we should have confidence in currently practicing clinicians,
or at least relative to the next generation. Regardless, all practicing
clinicians are accountable to a standard set by their respective
professional Colleges, which likely makes the issue moot once trainees
enter independent practice..

It would be silly to suggest that clinicians who trained under a pre-CBE
model are not competent any more than it is to suggest that clinical
decisions prior to the adoption of the EBM movement were not based on
evidence. Certainly, we have no shortage of competent clinicians
practicing today. Those clinicians were accepted into the profession
(and maintain standing) on some assessment of competence. However,
institutions may have good reason for implementing CBE beyond simple
competence concerns. For example, CBE programs can facilitate the
development of an infrastructure of accountability that extends beyond
activities of remediation or accelerating advancement to independent
practice. That infrastructure can be leveraged to ensure transparency in
assessment and advancement, identify individualized training needs, etc.
that can be important components of ensuring and achieving equitable
access to health professions, particularly for traditionally
underrepresented populations.44It is important to note that while CBE
might drive the development of such an infrastructure, a CBE training
model is not necessary to do so. Certainly, institutions can and should
be striving to improve on accountability, equitable access, etc.,
irrespective of a CBE model.

On the other hand, we have no shortage of experience with poor
decisions, suboptimal patient outcomes, iatrogenic effects, etc., that
often raise concern about clinician ability (or competence). Poor
outcomes, or at least those not aligned with the expectations of the
public (irrespective of if those expectations are realistic) could be
construed by some as a result of incompetence. Likewise, inequitable
access (within or between communities) to appropriate expertise might
raise concern of a lack of professional competence (i.e. the profession
is not meeting the needs of the population inclusively). One way such
perceptions by the public can be problematic for healthcare professions
is that may erode the powerful position of institutionalized healthcare
(and its providers) that exists in many societies. One could argue that
EBM had a powerful effect on securing the public's trust in healthcare
by leveraging public perception of science as apolitical, objective,
etc. Does CBE play a similar role by highlighting high professional
standards only achievable by those ``worthy'' of the profession, who
were rigorously assessed using quantifiable (often presented as
``objective'') metrics, irrespective of whether that results in better
care for patients? If so, then CBE may constitute a political move to
retain or grow power rather than a remedial exercise to ensure no one
joins the profession without having the skills necessary to provide
appropriate care (by some defined public standard) for those seeking
service. In other words, one might argue that CBE is not a response to a
concern about competence -- it is a response to a potential loss of
standing relative to alternative modes of care or other social services.
I am not suggesting that is necessarily the case, as I know several
health professions educators who are honest in their pursuit to train
clinicians who will excel in serving and providing care for the
community. That seems to be the rule rather than the exception. However,
the goals of the educators may not always tightly align with the goals
of the institution, which may also be responsible for securing funding,
maintaining status, public accountability, etc.

Models of health professions training that focus on assessing and
achieving defined competencies rather than hoping that important
abilities are acquired over a defined time period (that also relies on
the reliability and validity of licensing exams) are admirable. It is
difficult to argue that achieving competence should not be the explicit
focus of training. Perhaps one of the greatest benefits of CBE is that
it puts competence to the forefront, just as EBM did for evidence.
However, we must be vigilant to ensure that ``competence'' stays more
than a buzzword or a tool of branding. Terms lacking substance can have
a negative effect on patient care -- too often the terms ``patient
centred'' and ``evidence based'', for example, are invoked as
placeholders for quality patient care without any evidence to support
that whatever intervention or program those terms are describing has any
positive impact beyond rhetorical. We have not entered into an era of
clinician competence simply because CBE has been implemented. Rather,
what I see as the greatest benefit of CBE is the opportunity for
improving and ensuring accountability.

References

\begin{enumerate}
\tightlist
\item
  Rich J, Young SF, Donnelly C, et al. Competency-based education calls
  for programmatic assessment: But what does this look like in practice?
  Journal of Evaluation in Clinical Practice 2020;26(4):
\item
  Hamza DM, Ross S, Oandasan I. Process and outcome evaluation of a CBME
  intervention guided by program theory. Journal of Evaluation in
  Clinical Practice 2020;26(4):
\item
  Egan R, Chaplin T, Szulewski A, et al. A case for feedback and
  monitoring assessment in competency-based medical education. Journal
  of Evaluation in Clinical Practice 2020;26(4):
\item
  Katoue MG, Schwinghammer TL. Competency-based education in pharmacy: A
  review of its development, applications, and challenges. Journal of
  Evaluation in Clinical Practice 2020;26(4):
\item
  Crawford L, Cofie N, McEwen L, Dagnone D, Taylor SW. Perceptions and
  barriers to competency-based education in Canadian postgraduate
  medical education. Journal of Evaluation in Clinical Practice
  2020;26(4):
\item
  Railer J, Stockley D, Flynn L, Hastings-Truelove A, Hussain A. Using
  outcome harvesting: Assessing the efficacy of CBME Implementation.
  Journal of Evaluation in Clinical Practice 2020;26(4):
\item
  Porter R. The Greatest Benefit to Mankind: A Medical History of
  Humanity. New York: W.W. Norton \& Company; 1997.
\item
  Shaw, B. The Doctor's Dilemma: A Tragedy. London: Constable and Co.;
  1922.
\item
  McKeown T. The role of medicine: Dream, mirage or nemesis? Nuffield
  Trust; 1976. Available at:
  https://www.nuffieldtrust.org.uk/files/2017-01/1485273106\_the-role-of-medicine-web-final.pdf.
  Accessed on June 8, 2020.
\end{enumerate}

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