Anthony Sanfilippo

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