The Question of Competence Reconsidering Medical

Education in the Twenty First Century, 1st Edition

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 Copyright © 2012 by Cornell University

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First published 2012 by Cornell University Press

Printed in the United States of America

Library of Congress Cataloging-in-Publication Data

The question of competence : reconsidering medical education in the twenty-first century /
edited by Brian D. Hodges and Lorelei Lingard.
p. cm. — (The culture and politics of health care work)
Includes bibliographical references and index.
ISBN 978-0-8014-5049-5 (cloth : alk. paper)
Copyright © 2012. Cornell University Press. All rights reserved.

1. Medical education. 2. Competency-based education. 3. Clinical competence. I. Hodges,

Brian David, 1964– II. Lingard, Lorelei. III. Series: Culture and politics of health care work.
R735.Q47 2013
610.7—dc23 2012013769

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The Question of Competence : Reconsidering Medical Education in the Twenty-First Century, Cornell University Press, 2012.
 For the Wilson Centre: A place that has inspired so
many of us to think and to see in ways not
imagined before we walked through its doors
Copyright © 2012. Cornell University Press. All rights reserved.

The Question of Competence : Reconsidering Medical Education in the Twenty-First Century, Cornell University Press, 2012.
Copyright © 2012. Cornell University Press. All rights reserved.

The Question of Competence : Reconsidering Medical Education in the Twenty-First Century, Cornell University Press, 2012.
 Contents

Foreword
M. Brownell Anderson ix
Acknowledgments xiii
List of Abbreviations xv

Introduction 1
Brian D. Hodges and Lorelei Lingard
Copyright © 2012. Cornell University Press. All rights reserved.

1. The Shifting Discourses of Competence

Brian D. Hodges 14
2. Rethinking Competence in the Context of Teamwork
Lorelei Lingard 42
3. Perturbations: The Central Role of Emotional Competence in
Medical Training
Nancy McNaughton and Vicki LeBlanc 70

The Question of Competence : Reconsidering Medical Education in the Twenty-First Century, Cornell University Press, 2012.
 viii Co ntents

4. Competence as Expertise: Exploring Constructions of

Knowledge in Expert Practice
Maria Mylopoulos 97
5. Assessing Competence: Extending the Approaches to Reliability
Lambert W. T. Schuwirth and Cees P. M. van der Vleuten 113
6. Blinded by “Insight”: Self-Assessment and Its Role in
Performance Improvement
Kevin W. Eva, Glenn Regehr, and Larry D. Gruppen 131
7. The Competent Mind: Beyond Cognition
Annie S. O. Leung, Ronald M. Epstein, and Carol-Anne E. Moulton 155

References 177
Contributors 205
Index 209
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The Question of Competence : Reconsidering Medical Education in the Twenty-First Century, Cornell University Press, 2012.
 Foreword

Medical education has been the subject of repeated examinations and

in-depth reports about changes that are needed to improve the education
of physicians. In 1910, Abraham Flexner wrote a report, funded by the
Carnegie Foundation for the Advancement of Teaching, that advocated
for changes and promoted standards for medical schools and is credited
with changing the way doctors are educated. Perhaps most important,
Copyright © 2012. Cornell University Press. All rights reserved.

Flexner made medical education a social cause, demonstrating its impor-

tance in everyone’s life. Flexner’s work exposed poor educational con-
tent and processes in the preparation of physicians and began what has
been a century-long concern with the quality of physician education and
practice.
Today, at the beginning of the twenty-first century, the concern with the
preparation of physicians continues unabated with significant changes un-
derway in the content, pedagogy, and assessment of physicians and other
health care professionals. Two U.S.-based organizations, the American
Board of Medical Specialties (ABMS) and the Accreditation Council for

The Question of Competence : Reconsidering Medical Education in the Twenty-First Century, Cornell University Press, 2012.
 x Fore word

Graduate Medical Education (ACGME), have taken the lead in promot-

ing competency-based training for all physicians.
In addition to the work of the ABMS and the ACGME in the United
States, the importance of competence and the attention being paid to it in
medical education is reflected in a group of reports that have been published
in the past twenty years. Each report defines the qualities and outcomes
desired in the “competent” physician. The reports include: Tomorrow’s
Doctors from the General Medical Council in the United Kingdom; the
Medical School Objectives Project (MSOP) reports from the Association
of American Medical Colleges (AAMC); Good Medical Practice-USA; The
Future of Medical Education in Canada from the Association of Faculties
of Medicine of Canada; Scientific Foundations for Future Physicians from
the AAMC and the Howard Hughes Medical Institute; and its companion
report, Behavioral and Social Science Foundations for Future Physicians from
the AAMC.
As we see from the focus and titles of these efforts and reports, account-
ability and responsibility to the public have led to yet another shift in the
paradigm of medical education. The key concept in this new paradigm is
competence. But just what constitutes competence?
We use many words to define competence—capability, know-how, ex-
perience, expertise, aptitude, fitness, skill, and proficiency—but as the title
of this book suggests, questions remain about competence. This is why an
exploration that provides critical insights into the idea of competence could
not be more needed and more timely.
Medical education is now moving from a structured, process-based sys-
tem that specifies time spent in a classroom or clinical experience (such as
a ten-week clerkship in internal medicine) and defines this as the amount
Copyright © 2012. Cornell University Press. All rights reserved.

of time needed to “learn” the content, to a competency-based system that

defines the desired outcome of training, the outcome driving the edu-
cational process (such as competence in the ability to take a history and
physical examination). The paradigm shift from the structure- and pro-
cess-based curriculum to a competency-based curriculum and evaluation
of outcomes is among the most profound changes in medical education.
The outcomes we want from medical education now are physicians who
bring a humanistic approach to medicine; who have a patient-centered
approach to medical care; an appreciation of the value of fundamental

The Question of Competence : Reconsidering Medical Education in the Twenty-First Century, Cornell University Press, 2012.
 Foreword xi

research for the advancement of medical science; a global perspective on

contemporary health issues; and an appreciation of the importance of the
biological and population sciences for the advancement of medicine. We
want practitioners who are able to participate effectively in multidisci-
plinary and team approaches to patient care; to contribute to eliminating
medical errors and improving the quality of health care; and who know
how to balance individual and population health needs when making deci-
sions about patient care.
The real challenge for those involved in designing competency-based
educational programs is to recognize the complexity of competence as a
concept. Only then can they effectively delineate the knowledge, skills,
and attitudes that learners must acquire to be able to perform within each
domain at a predetermined level and to recognize that the expected level
of performance within each domain will vary depending on the learner’s
stage of education and the specialty he or she is learning. The authors of
this book help us do just that. They examine the challenges facing medical
education and introduce the concept of “discourse” as a mechanism both
for examining the idea of competence and considering how to implement
competency-based education. In so doing, they provide us with a new way
to ask the questions that are at the heart of every report advocating change,
every criticism of medical education, and every conversation that questions
why health care is the way it is today.
The chapters in this book range from an exploration of the discourse
on cognition and teamwork to the role of emotion in becoming a com-
petent health care professional. The concepts presented in each chapter
are rich, even complex, and they are presented articulately and elegantly.
Compelling and thought provoking, the essays invite the reader to engage
Copyright © 2012. Cornell University Press. All rights reserved.

in a range of conversations about competence. The book also provides a

comprehensive literature review of the most important work on defining,
articulating, and measuring competence. Having all of these references in
one place makes for a powerful resource.
This book is rich with new ideas and invites ongoing debate, discussion,
and further research (as suggested in several chapters). I hope that the ideas
presented in the book will help regulatory organizations and those devoted
to assuring the health of the public assess the language and ideas needed to
advance the concept of the competent physician/healthcare worker.

The Question of Competence : Reconsidering Medical Education in the Twenty-First Century, Cornell University Press, 2012.
 xii Fore word

Read this book. Share it with colleagues, family, and anyone concerned
about the education of future physicians. From the thoughtful reflections
of each author, you will learn something new, you will find ideas with
which you do not necessarily agree, and you will be thinking about the
ideas presented for a long time to come.
M. Brownell Anderson
Copyright © 2012. Cornell University Press. All rights reserved.

The Question of Competence : Reconsidering Medical Education in the Twenty-First Century, Cornell University Press, 2012.
 Acknowledgments

This book would not have been possible without the dedication and
thoughtful input of a number of individuals. All of the chapter authors
tolerated a punishing schedule of editing with good humor and grace, re-
sulting in the marvelous essays in this volume. The series editors, Sioban
Nelson and Suzanne Gordon, skillfully shepherded the book, generously
providing advice and guidance throughout. Carla Taines brought careful
Copyright © 2012. Cornell University Press. All rights reserved.

attention to every aspect of the book’s format and was a wonderful col-
laborator. Alan Bleakley very kindly reviewed the whole manuscript and
provided incisive and helpful commentary. Holly Ellinor assisted cheer-
fully with formatting at multiple stages. Finally, each of us was fortunate
to have formal support that made this project possible. Brian Hodges was
supported by the University of Toronto Faculty of Medicine, the University
Health Network, and the Richard and Elizabeth Currie Chair in Health
Professions Education Research at the Wilson Centre for Research in Ed-
ucation. Lorelei Lingard was supported by the Department of Medicine
and the Centre for Education Research & Innovation, both at the Schulich
School of Medicine and Dentistry, University of Western Ontario.

The Question of Competence : Reconsidering Medical Education in the Twenty-First Century, Cornell University Press, 2012.
Copyright © 2012. Cornell University Press. All rights reserved.

The Question of Competence : Reconsidering Medical Education in the Twenty-First Century, Cornell University Press, 2012.
 Abbreviations

AAMC Association of American Medical Colleges

ABIM American Board of Internal Medicine
ABMS American Board of Medical Specialties
ACGME Accreditation Council for Graduate Medical Education
CBME competency-based medical education
CEX clinical evaluation exercise
Copyright © 2012. Cornell University Press. All rights reserved.

CIHR Canadian Institution of Healthcare Research

CME continuing medical education
CVP central venous pressure
EI emotional intelligence
EPR electronic patient record
ESR electron spin resonance
IPC interprofessional collaboration
IPE interprofessional education
KBE knowledge-building environment
MOC maintenance of competence

The Question of Competence : Reconsidering Medical Education in the Twenty-First Century, Cornell University Press, 2012.
 xvi Abbreviations

MSOP Medical School Objectives Project

OSATS objective structured assessment of technical skills
OSCE objective structured clinical examination
PBLI problem-based learning and improvement
PFL preparation for future learning
SBP systems-based practice
SPS sequestered problem solving
SSHRC Social Sciences and Humanities Council of Canada
Copyright © 2012. Cornell University Press. All rights reserved.

The Question of Competence : Reconsidering Medical Education in the Twenty-First Century, Cornell University Press, 2012.