Development of generic skillsBMJ 1998; 317 doi: http://dx.doi.org/10.1136/bmj.317.7160.2 (Published 12 September 1998) Cite this as: BMJ 1998;317:S2-7160
There are competencies every doctor must have that are not taught at medical school. David Pencheon sets out on the path of lifelong learning
- David Pencheon, consultant in public health medicine
As doctors, we learn four sets of skills: firstly, the basic medical sciences that medical schools purport to teach us; secondly, the specialist skills that we learn (despite our professional examinations); thirdly, the special interest skills that most of us develop in our substantive posts; and fourthly, least acknowledged, but equally important, are the many generic skills (see box) that we pick up by that well trusted, educational technique of subconscious osmosis. By muddling through, many doctors become reasonably competent at these generic skills. We should, however, be more explicit about the most important of these skills and how they might be acquired.
Curriculums are becoming increasing explicit in what competencies are expected. A competency (defined as the ability to perform an activity within an occupation to a set standard) is a natural unit of curriculum and professional development. Unfortunately, it is not clear how to develop these competencies systematically or how to measure them objectively. This is more true of generic competencies (for example, managing a meeting) than of technical competencies (for example, performing a lumbar puncture). There is rarely a systematic approach to learning generic skills. How many of us, needing to write a business plan and project manage a research bid, suddenly appreciate the concept of a learning need?
Generic skills are those that we all need to manage the world around us so that we can use our technical skills more effectively.
Some essential generic skills
Managing yourself (time management)
Managing resources (usually money)
Managing other people
Being part of and leading a team
Appointing and interviewing
Giving and taking feedback
Life long learning (learning skills)
Writing and publishing
Knowledge skills, libraries, and information technology
Managing yourself is usually called “time management,” as though it is something external that is being managed. When you manage time, you are effectively managing yourself and your priorities. Ultimately, this is up to you, but good guidance can help you start.(1)
The most important resource we all have to manage at some time (other than people) is a budget. When we are awarded research grants we think our troubles are beginning, not ending. Find someone who knows the basics of accountancy and who can communicate them clearly.
Managing other people
This is the ultimate generic skill. The central feature of good management is to get other people to do what you would like them to do. These sorts of skill - for example, to be the medical director of a trust - are well described in previous Career Focus articles.(2)(3) I discuss here some of the most important skills.
Leading is about creating and communicating a plausible vision and empowering colleagues so they can help achieve it. Plenty of people have visions, and many other people are able to empower. When you have the ability, motivation, and resources to combine these, you are a leader.(4)
The most important formal opportunity to get things done with other people is some sort of meeting. Meetings can happen anywhere, from a corridor to a boardroom. To get the best outcome from a meeting, be clear about what you would like to achieve and what you think is possible before the meeting starts. If you have a game plan with a colleague, brief and debrief carefully. It is said that the minutes of the most carefully planned meetings are written beforehand.
In general, the people who achieve most in meetings are clear about what their ideal (and realistic) outcome is; know who the key players (allies and blockers) are and what motivates them; have a good sense of timing; sit where everyone's eye (especially the chairperson's) can be caught easily.
The selection process (interviewing and appointing) risks being a minefield of political correctness and legal pitfalls, but there are many good courses available locally to help make the process as easy, fair, and productive as possible. The quality of our professional lives (to say nothing of the care that our patients receive) depends largely on our colleagues. To improve your competence (for example, to interview is good practice for being interviewed and vice versa) and confidence, consult the postgraduate dean's office, your college's continuing medical education coordinator or any of the Career Focus trilogy on selection.(5–7)
One of the most common grievances of registrars is the poor quantity and quality of feedback about their professional progress from so-called mentors and tutors. The annual assessment process introduced by Calman has gone only some way to address this. Giving good feedback improves the quality of professional development, quality of care, and morale of staff. It is a vital skill to acquire. Learning how to do it well needs good facilitation with techniques such as role play and well devised exercises. While you are learning how to give it, make sure you learn how to receive it too. Every course for trainers should address this regularly.
So much information is available and is being generated that we stand no chance of keeping up to date with all the information we might need, no matter how specialised we are.(8) The only sustainable method of keeping up to date is to adopt a “just in time” approach, rather than a “just in case” approach. In essence, we need to be skilled at turning clinical problems into answerable questions, finding the relevant research information in minutes and hours - appraising it, using it, and storing it for subsequent use in similar clinical situations.
An example of this transition is the tradition of running a journal club. A common mistake at such events is to start with papers that are unrelated to everyday practice. It is better to start with actual clinical problems.(8)
The importance of being able to reflect on one's knowledge and ability cannot be overstated. The figure shows the classic progress over time of competence and insight.(9) The paradox is identifying where one is “unconsciously incompetent.”
The first steps in developing a lifelong approach to learning entail attitudes not skills. Much of what we think we know may be untrue and much of what we need to know, we don't. This should not paralyse us with fear, anxiety, and lack of credibility. It should motivate us to be honest about our contribution and limitations and energise us to learn the skills needed to keep as up to date as possible.
Writing and publishing
The only way to learn to write is to do it.(10) Spend as much time as your family can bear with pen, paper, or computer. Tell editors why you have submitted to their journal. Read Richard Asher's advice on writing (for example, discard the first four drafts and always discard the first paragraph - permanently).(11) Ask for and listen to feedback. Learn to use a word processor to shape thoughts and order ideas, and to turn a good idea into a good read (preferably via a good piece of research). Learn to write concisely, making every word count. Anyone can communicate a message in 10 pages. Do it in one. Supplement your dictionary with a good style guide. At least if you are wrong you can be consistent.
Libraries and IT
In such a knowledge-rich profession as medicine, effective use of a library service is vital to the quality of patient care. If you have access to a good library and you need to relearn your skills every time you use it, you are probably not using it enough. If you don't have near 24 hour access to library services ask your local clinical or GP tutor or postgraduate dean how this issue is being addressed, and offer to help.
One of the most important skills that doctors find useful to develop is searching for answers to questions from computerised databases such as Medline. In particular, understand Medical Subject Headings and their tree structure. Ask your local library or the BMA about courses.
Good teachers are good learners. Learn what good learning is all about, and the process of good teaching will become obvious. The connection between teaching and learning is so profound, it is surprising that teaching hospitals are not called learning hospitals. The most effective way to increase your teaching skills is to set meaningful objectives at the beginning of any session or programme in consultation with the learners and refer to them as the teaching proceeds.(12)
How to develop the skills
The most important step in developing skills is to identify skill gaps. This is best done with a trusted colleague who can encourage constructive reflection. For specialist registrars, a formal process exists to address learning needs at the annual assessment. Being reflective about skill gaps and planning how to fill them should be part of everyday behaviour, not an annual ritual.
You should reflect on your own ability by seeking and listening to feedback; identify your learning needs and plan how you will meet them; and carefully observe the generic skills of other people and consider if you can learn from them. You should also identify at least one good course. These may be provided by the postgraduate dean's office, the continuing medical education/professional development activities of your college or faculty, organisations such as the King's Fund, or by you and your colleagues, possibly with outside help, facilitation or funding.
Specialist registrars should make full use of the individual and group time allocated to them for professional development. Find out how much your training programme allocates, how you all use it, and compare this with other specialties. Analyse attendance and, with the college tutor, clarify what the needs of your group of registrars are. Start with the journal club (although you may want to change its name to a learning set).
Many bodies are responsible for helping develop your professional skills (royal colleges, postgraduate deans, etc) - inquire about what is available. If there is no local directory of courses, offer to help by demonstrating the need, the possible action, and the potential benefit and cost.
To sum up: generic skills are all vitally important in helping us do our jobs in an effective and fulfilling way. Bodies and individuals responsible for funding, arranging, and delivering postgraduate and continuing education have a profound responsibility for ensuring that we are all able to develop these skills. As individuals we have a duty to start that process.