Anthony Sanfilippo

Striving for a Culture of Competency

A few days ago walking through the hospital I ran into a very excited third year medical student who was anxious to tell me about a recent clinical experience.  Apparently she’d admitted a patient with a complex array of medical problems and, after considering the differential diagnosis, ordered a test that confirmed the presence of fairly rare condition that led to a very effective therapeutic approach.  The patient was much improved and our student, for the first time in her experience, felt that she had personally made a significant contribution to a patient’s care.  Importantly, she wasn’t telling me this to boast or claim personal credit.  She was simply very excited in the moment and wanted to share.

Our student experienced what could be referred to as the “magic moment”.  This is a term for that point in a physician’s development when they realize, for the first time, that they have acquired the ability to positively influence a patient’s life.  For some it comes in the form of a procedure well carried out, for others it’s a diagnostic success, for some the realization that they’ve brought resolution or comfort to a personal crisis in a patient’s life.  Whatever the form, the central element is the realization that their long and arduous learning process has borne fruit, and finally, rather unexpectedly, makes sense.  Their learning has transformed from an abstract, theoretical exercise to a pragmatic and practical application of knowledge and skills.  The “competency-based” construction of our curriculum suddenly seems sensible and, importantly, much less threatening.  I’ve also noted that when our students come to this point, the “stress” of medical school changes in a favourable way.  They realize that if they allow their learning to truly focus on their competency- based learning objectives, the rest will basically take care of itself.  With this realization comes confidence.  They come to regard exams as necessary inconveniences rather than fearsome high stakes threats.  They no longer require their teachers to validate their learning.  They have become, dare I say it, competent life-long learners.

Many medical schools have, over the past several years, adopted a competency-based framework to structure their curricula and assessment processes.  Here at Queen’s, we adopted this as the basis of our curricular reform which began 6 years ago.  It has provided a logical and comprehensive framework around which to establish objectives, courses, learning events, and all their associated assessment tools.  Unfortunately, I think we have to recognize that we have not yet adopted a competency culture.  Our students continue to have difficulty evolving from the consciousness that short-term knowledge assimilation and examination marks are the sole components of success.  Many continue to see medical school as a series of “hoops” through which they must pass, discarding now “unnecessary” information at each step in order to move on to the next challenge.  Experiences intended to build “softer” skills, such as reflective exercises and portfolio assignments, are often given short shrift, or at least secondary effort, because their relevance may be less apparent and “they’re hard to fail”.  To a novice mountain climber, the ability to effectively and efficiently tie knots seems a tedious and pedantic exercise, until one is perched on a ledge and relying on that skill to negotiate a climb.

This difficulty is, in many ways, completely understandable and we, as medical school faculty, are partially to blame.

  • Our admission processes are heavily reliant on academic success as a criterion.  Our students are therefore pre-selected and “hard-wired” to excel in relative terms (relative to other students), rather than against pre-determined competency goals.
  • We continue to use very traditional assessment processes to evaluate success.  While it’s true that our major purpose in setting assessments is to inform rather than select or stratify, our students can’t help but have a very fundamental and visceral response to the examination experience.  If you breed thoroughbreds to race, it seems, they will run when the gate opens.
  • We continue to award academic “standing” through a multitude of awards that our schools have administered for generations, the very purpose of which is becoming increasingly irrelevant in our current curricular structures, and may be unintentionally promoting many behaviours we now recognize as counter to our competency goals.
  • Perhaps most troubling of all, shortly after admission to medical school, we thrust our students into another increasingly competitive process to select and engage postgraduate training positions.

The environment, intentionally or not, is highly competitive.  Is this productive?  Does it drive desirable qualities?  Does it result in better (more competent) physicians?  Many would argue that competition for personal success is inevitable, drives learning and selects for qualities that will serve our students well in their careers and personal life.  The counter argument is that it drives the wrong (short term) approach to learning and requires students to make strategic decisions regarding their learning that are unaligned with the needs of their future patients.  The inconsistency between internal competition and the “collaborator” and interprofessional competencies we strive to achieve is obvious, as is the potential to disrupt peer-to-peer education that we recognize is so valuable.  Many schools, including our own, have taken baby steps to address this issue by moving to “pass-fail” assessments, but even this has been met with considerable internal controversy.

So, what’s to be done?  Can we do better?  I would respectfully offer a few suggestions for consideration and discussion.

1. Frank discussion early in medical school.  We need to engage the issue early on, clarifying for our student the reality that their learning objectives have fundamentally changed.  Essentially, their objective needs to shift from personal achievement to the needs of their future patients.
2. The concept of “relevance” is best learned through patient contact.  More contacts, in more “real life” venues, earlier in the medical school experience will be key.  Observerships, the First Patient Program and Week in the Country are great examples, but need to be contextualized in a way that allow the student to recognize the importance of competency acquisition.

3. More clarity regarding our learning objectives.  I think we have to acknowledge that the competency domains as defined by our professional colleges are insufficient unless buttressed by concrete applications.  Being a good Manager, for example, means very little.  However, when broken down into more practical applications, students not only see the purpose, but can navigate the learning much more efficiently.  For example:

  • Managing personal time
  • Managing a medical practice
  • Managing diagnostic testing for your patient
  • Managing your finances

This now become more than knot-tying for the sake of knot-tying.  Fortunately, there is considerable activity currently underway that will help.  The Royal College is in the process of revising and refreshing the CanMEDS framework.  A joint AAMC/AFMC committee is in the process of developing a set of competencies required of the medical student about to enter residency training, and documents such as “The Scottish Doctor” represent thoughtful and comprehensive attempts to catalogue practical physician competencies.

4. Testimonies from near peers and role models.  The experiences of senior colleagues who have recently and successfully navigated the challenges our students are facing can provide powerful motivation and validation.  It can also provide critical perspective to reduce unnecessary stress.

5. Assessment review.  There has been movement in recent years toward competency-based assessments, such as Objective Structured Clinical Examinations (OSCEs), both by the Medical Council of Canada and most medical schools.  However, these are very difficult to design, complicated to administer and very resource intensive.  We need to develop more practical approaches that will allow our students to demonstrate their achievement of the various competencies in an open, objective way.

6. Reconsideration of our awards.  Recognizing excellence and personal achievement is undeniably of value, but do our awards recognize the qualities and achievements we strive to develop?

7. Rethink and refine the process of transition to postgraduate training.  This has been identified as a concern by the Future of Medical Education in Canada initiative of the Association of Faculties of Medicine of Canada (AFMC), and is under active discussion at this time.  Models for more graduated transition are being considered, and will come under increasing discussion in coming months and years.

In summary, some degree of competitive tension will likely always be present within our medical training processes, and some degree of stress is not only inevitable, but may have a useful role in preparing students for the pressures of clinical practice.  However, are we doing our best to use both intentionally and intelligently?  Can we ensure they all experience their “magic moment” early in their training?  I think we could do better.  What do you think?