Analysis And Comment Medical education

Trust, competence, and the supervisor's role in postgraduate training

BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.38938.407569.94 (Published 05 October 2006) Cite this as: BMJ 2006;333:748
  1. Olle ten Cate, director (t.j.tencate@umcutrecht.nl)1
  1. 1 Centre for Research and Development of Education, University Medical Centre Utrecht, PO Box 85500, 3508 GA Utrecht, Netherlands
  • Accepted 17 July 2006

The decision to trust a trainee to manage a critically ill patient is based on much more than tests of competence. How can these judgments be incorporated into assessments?

Competency based postgraduate medical programmes are spreading fairly rapidly in response to the new demands of health care. In the past 10 years, Canada, the United States, the Netherlands, and the United Kingdom have introduced competency models and other countries are following.15 These frameworks are valuable, as they renew our thinking about the qualities of doctors that really matter.

Paramount in these developments is the view that quality of training should be reflected in the quality of the outcome—that is, the performance of its graduates. As postgraduate training almost fully focuses on learning in practice, training and assessment moves around the top two levels of Miller's hierarchical framework for clinical assessment (figure).6 Knowledge and applied knowledge of residents may be interesting, but performance in practice is the real thing. The question is: How can we assess it?

Miller's pyramid for clinical assessment

Competence does not necessarily predict performance

Competency based training suggests that competence and competencies are what we want trainees to attain. But is this the same as performance? If a doctor is competent, what happens if she does not perform according to her assessed competence? Most authors agree that performance involves more than competence.7 It clearly includes something that cannot easily be caught with traditional assessment methods. One component is willingness to apply your competence.8 But there is more.

Consider two residents, 1 and 2. Resident 1 scored A on the knowledge, applied knowledge, and objective skills examinations whereas resident 2 scored B. Both serve in a night shift in the hospital, and you are on call that week. Each of them faces a critical acute care problem. Resident …

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