A Call for Clarity

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Beyond competencies – What should every Canadian medical graduate be able to do?

Consider this: When you find yourself a passenger on an aircraft coming in for a tricky landing on a stormy night, would you be more comforted by the knowledge that your pilot is an expert in aeronautics and aircraft design, or that he/she has demonstrated the ability to successfully land similar aircraft, in similar conditions, many times previously?

I think most folks would hope, and reasonably expect, that somebody at pilot school is ensuring that their graduates are able to land airplanes safely before pinning those wings on his or her chest.

Let’s switch to a medical equivalent. If you or your loved one is brought to an emergency department with severe abdominal pain, you should certainly expect that the physician providing care has all of the attitudes and personal qualities that have been articulated by our professional bodies and engaged by our medical schools. But, at that moment, I suspect that what you’re looking for is someone who can deal efficiently and effectively with the vessel, viscus or infectious process that’s causing the grief. There are, after all, priorities, and there are things that we expect doctors, and only doctors, to do.

Undergraduate medical education programs have become increasingly competency-based. A “competency”, in the educational sense, can be defined as an attribute, knowledge or skill that an individual learns and eventually possesses. Being an effective communicator, professional, scholar are examples of such competencies that all would agree should be part of any physician’s toolbox. In such frameworks, being a “Medical Expert” (knowing about clinical conditions and how to manage them) is another independently described competency. Many organizations have developed very well thought out and comprehensive descriptions of the competency set they feel describes the ideal, fully formed and practice-ready physician. For example:

  • The College of Family Medicine describes a “Triple C” curriculum–comprehensive care, continuity of care, centred on Family Medicine. The CFM has also provided an examination of CanMEDS from a Family Medicine perspective, interpreting the seven roles as 63 more tailored competencies, many of which are further described with bulleted sub-competencies. http://www.cfpc.ca/uploadedFiles/Education/CanMEDS-FMU_Feb2010_Final_Formatted.pdf
  • South of the border, our American colleagues at the Association of American Medical Colleges (AAMC) has recently released a vision which articulates 8 “Domains” informed by 58 “competencies”, which are roughly equivalent to the CanMEDS “enabling competencies”.
  • The Medical Council of Canada, the body responsible for developing the examinations that qualify medical school graduates to practice, has largely embraced the CanMEDS framework in describing objectives for their examinations. It describes the “Medical Expert” in terms of “clinical presentations”, which are patient issues that graduates are expected to handle effectively. http://apps.mcc.ca/Objectives_Online/objectives.pl?loc=home&lang=english

In this increasingly cluttered landscape, our seventeen Canadian medical schools are independently working to produce graduates ready to engage residency programs. (Read this “on the way to, but not yet quite there” with respect to full qualification). To do so, they develop frameworks based on competencies, usually leaning heavily on CanMEDS. As they go about this, they face a number of challenges:

  • These competency frameworks were developed with the intention of describing attributes and skills of practicing physicians, not novice learners. They therefore require upstream translation, which can lead to inconsistent interpretation.
  • Competencies are notoriously difficult to objectively and fairly assess. (How would you design a final examination for the “professionalism” competency?).
  • The evaluative standard used to measure success of medical school graduates is established by the Medical Council of Canada and is based primarily on clinical presentations (ie. do-ing, not be-ing). Purely competency-based curricula are therefore at risk of being out of step with the testing their graduates will be expected to undertake.
  • Dedicating increasing curricular time and attention to teaching and assessment of individual competencies threatens to further stress already packed curricula and displace core teaching of the basic and clinical sciences.

And there’s an even more fundamental problem. Any profession, indeed any occupation, is best understood in terms of the services provided. We understand lawyers, for example, as people who defend us in court, ensure our legal documents are in order etc, not as expert communicators, translators of legislation, advocates for social justice, or any of what I am sure are many important competencies that enable lawyers to be lawyers.

The competencies, whether considered individually or in aggregate, fall short in providing a clear and universally understood image of the “complete” medical school graduate.

Doctors, I think anyone would agree, are people trained to care for other people in the context of clinical illness.

If we extend that understanding a little further, we could pragmatically define the mission of undergraduate medical education to produce graduates capable of assessing, diagnosing, stabilizing and initiating both preventive and therapeutic management for the patients they will serve. If we accept that definition, then it would appear we have a “gap” between our mission and our competency frameworks.

Out of all this, the concept of “Entrustable Professional Acts” (EPAs) is beginning to emerge. This concept, attributed to and well articulated by by Dr. Olle ten Cate (ten Cate,2013: Nuts and Bolts of Entrustable Professional Activities. Journal of Graduate Medical Education: March 2013, Vol. 5, No. 1, pp. 157-158).

and has recently been promoted by the AAMC who have developed an approach that is being trialed at ten US medical schools. https://members.aamc.org/eweb/upload/Core%20EPA%20Curriculum%20Dev%20Guide.pdf

EPAs can be regarded as the specific set of skill and knowledge- based responsibilities that graduates can be expected to achieve. Competencies become the component attributes, knowledge and skills students must achieve in order to adequately carry out the EPAs.

Examples of EPAs would include the following:

  • the ability to carry out an efficient and effective history and physical examination
  • developing a useful differential diagnosis for patients presenting with common clinical problems
  • the recognition of critically ill patients, and how to stabilize their condition
  • accurate documentation of clinical encounters
  • the ability to obtain informed consent for medical procedures

The performance of EPAs must be informed by and incorporate appropriate competencies, such as communication, scholarship, professionalism and collaboration with other providers. EPAs cluster competencies into meaningful activities that can be observed in the workplace and therefore much more amenable to assessment.

Each competency may relate to multiple EPAs. The scholar competency, for example, would be critical to the ability to diagnose, develop management plans, and provide informed consent.

A set of EPAs in aggregate, provide an intuitively appealing and holistic impression of physician expectations that can be consistently understood by students, UG teaching faculty, postgraduate training programs, medical regulatory agencies and the public. As such, they provide a point of common understanding that may provide clarity as to developmental milestones, including the UG-PG interface (ie. Post-graduate programs can more easily understand and provide input as to the expectations at entry).

The AAMC document describes 13 EPAs and how they relate to their competency framework. The “Scottish Doctor” is another EPA-based framework. Beyond the particular items these two groups have identified, I think their value is in the demonstration that a clear, performance-based, objectively assessable and intuitively understandable articulation of the Canadian medical graduate is within our reach.

The Canadian undergraduate medical education community, at recent meetings, has been engaging these issues with increasing interest and commitment. The vision that’s emerging is for a pan-Canadian definition of the medical school graduate, based on EPAs, and informed by the excellent work carried out by organizations such as the Royal College, CFP and MCC. Such a consensus would benefit our medical schools, students, faculty, postgraduate program leaders and, importantly, the Canadian public.

I, for one, am looking forward those discussions.

Anthony J. Sanfilippo, MD, FRCP(C)
Associate Dean,
Undergraduate Medical Education

6 Responses to A Call for Clarity

  1. Adrian Baranchuk says:

    I have enjoyed reading your comments, Dr Sanfilippo. They helped us to understand a more holistic view of medical education. I read your posts with interest. Thanks for this continuous communication with the medical community.

  2. Karen Schultz says:

    Interesting times thinking about competency assessment and how to go about doing that in a rigourous way that is acceptable for both our learners as well as our preceptors. The competency frameworks (like Can MEDS/Can MEDS FM) are very important but are too large and yet simultaneously not integrative enough to assess learners in their day to day encounters with patients (you never do just one role with a patient but integrate a number in a complex way, e.g. communicator, manager, advocate etc). As you may know we have embraced EPAs in Family Medicine too and are finding them very useful…by being thoughtful about the activities we call EPAs (to ensure that as a collection they cover off our objectives and competencies) we now have a way to observe residents doing those activities and can therefore assess their performance/competency. Of course, there are lots more questions to answer about competency assessment but the EPAs feel like a great start and maybe we can learn from each other as we go down this path:)
    Karen Schultz
    Queen’s FM Program Director

  3. Tony: Thanks for this thoughtful summary of the evolving landscape of medical education. I would suggest (harkening back to your “pilot in a storm scenario”) that we have drifted too far away from the primacy of the “Medical Expert” in UGME education.

    I believe that most patients want their surgery done by technically excellent surgeons, their A fib abated by a master of the procedure and their colonoscopies performed by an adept gastroenterologist. If they can also be good team members and are sensitive to diverse social needs …even better (but they better know how to cut, sew, ablate and insert).

    We intuitively understand that take off and landing an airplane (while only one of the competencies required of a commercial airline pilot) is an irreducible minimum requirement. Its a must have-not a nice to have. Mandating 97 “enabling competencies” for pilots would be of little interest to most passengers.

    Likewise, by piling on huge numbers of desirable (but “non mission critical”) competencies on trainees and medical schools tends to conflate the essential with the merely desirable. Let’s not equate landing the plane with the ability to thank departing passengers for choosing Air Canada!

    Perhaps this is the voice of dinosaur..but I suggest that we have strayed too far from the focus on training physicians to be medical experts. Some correction is in order.

    • Thank you Steve. I think the key is going to be to accept that the intrinsic competencies are just that – intrinsic qualities that should guide how physicians deliver medical care, not constitute separate and distinct learning goals. The EPA approach makes this possible, and appears to be gaining momentum. Stay tuned.

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