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;333:748All rapid responses
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We wonder Olle ten Cate is referring to some of the qualities of
traditional postgraduate training hidden in his ‘Trust, competence, and
the supervisor’s role in postgraduate training’ [1]. We believe that
trustworthiness has always been a fundamental attribute in postgraduate
training and trainees develop this attribute with clinical knowledge base,
experience and professional development. In fact traditional postgraduate
medical training has been efficient and has produced competent and
trustworthy clinicians without formal assessment of trustworthiness.
Author has mentioned about the potential in using trainers gut
feelings in assessment of trainee’s trustworthiness. This can be
subjective and may depend on trainer’s personality and their relationship
with trainees. Although means of measuring trustworthiness have been
exploited outside clinical training [2], it is a personal attribute and is
difficult to assess.
Over a period of time trainers make an opinion about their trainee’s
competence and trustworthiness. This is based on trainee’s overall
performance. In clinical practice trustworthiness is not solely based on
person’s honesty; it also depends upon how much confidence a trainer has
his or her trainee’s clinical skills, decision making and sense of
responsibility. Trainees in the old fashioned training system will agree
that they were relied upon more than trainees in the new system. If this
is true, it may be a reflection of their level of competence and
confidence in patient management.
In our opinion if training structure is sound and overall higher
standards of competence are achieved, there may not be a need to assess
trustworthiness. On the other hand, there may be some room for improvement
in the training structure. European Time Working Directive it is clearly
having an impact on training. Instead of assessment the emphasis should be
on safeguarding quality of training so that trainees achieve an adequate
level of competence and trustworthiness will follow automatically.
References
[1] Olle ten Cate Trust, competence, and the supervisor's role in
postgraduate training
BMJ 2006 333: 748-751.
[2] John J. Kelly, Fred Njuki, Peter L. Lane, and Robert K. McKinley
Design of a Questionnaire to Measure Trust in an Emergency Department
Acad. Emerg. Med. 2005 12: 147-151.
Competing interests:
None declared
Competing interests: No competing interests
After reading the article “Trust, competence and the supervisor’s
role in postgraduate training” published by BMJ1, we would like to share
our experiences on this field with you.
Located to the southern central region of the island (Cuba), Cienfuegos
province has 2000 physicians working in its health system.
In 2002, doctor
performance assessment was carried out throughout the province. The
process had been successfully introduced in 1999 at the Gustavo Aldereguía
Lima University Hospital2.
Performance assessment is not a new procedure in the enterprise world. It
has been defined as a process which systematically provides an exact and
reliable description of the worker’s individual efficiency, what he is
able to do out of what he must do3. It is known that from the moment the
first man was hired his performance turned to be assessed.
We entirely agree with the author’s opinion because we regard performance
assessment a wider and a more integrating process than competence
assessment since the former evaluates not only the worker’s knowledge but
also takes into account their motivational and behavioral elements. Based
on this definition, it could be explained the classical equation: results
equal knowledge (competence) by (never plus) motivation: thus, if any of
them is zero, the result will be zero too.
Taking into account the above concept, 751 physicians working in either
primary or secondary medical assistance were evaluated, representing 37.6%
of this occupation category of the province. A 0-10 point quantitative
scale with punctuation ranking determined by experts’ criteria was used to
score the following elements: work quantity, quality and results;
knowledge show up (competence); cooperation; human relationship ethics,
behavioral attitude towards post-graduate training; personal image,
creativity, attendance, punctuality and working hours efficiency;
fulfillment of the established regulations and degree of patient’s
satisfaction.
Lowest scores (weaknesses) were mainly found in the items related to post-
graduate training and amount of work with 8.04 points and 9.02 points,
respectively.
To know our doctors’ performance weaknesses allows us to determine the
establishment of the corresponding individual development program which
will contribute to save the gap between the doctors and staff we have and
the ones we need to have.
References.
1.Ten Cate O. Trust, competence, and the supervisor’s role in postgraduate
training. BMJ 2006;333: 748-51.
2.Alvarez-Li FC, Ordúñez-García PO, Espinosa-Brito AD. Introducción de la
evaluación del desempeño individual en un hospital cubano. Metodología y
resultados. Rev Calidad Asistencial. 2006:21(2):102-10.
3.Chiavenato I. ED humano. En su: Administración de Recursos Humanos.
Santafé de Bogotá:McGraw-Hill. 1998:259-291.
Competing interests:
None declared
Competing interests: No competing interests
problem trainees
Olle ten Carte is to be congratulated on his recent clear eyed view
of trust and judgement in performance analysis/ assessment of trainees by
consultants[1]. The article cites that educators need to exploit gut
feelings about trustworthiness for assessment purposes. This questions
the presumption that completing competencies creates a competent
individual capable of high quality professional performance. Ticking the
boxes provides an inflexible view of an individual’s development
diminishing the role of professional judgment[2]. The process may be
applicable to the Novice Learner as described by Dreyfus’ Model of Skills
Acquisition but what of the Proficient Senior Trainee or the Expert that
has to sub-consciously multi-task and deal with so-called “crowdedness?”
Although the vast majority of trainees easily attain competencies and
professional behaviours, there are a small number of trainees who provide
us with the greatest difficulties in appraisal and assessment. This group
is typically competent but cannot perform (in local parlance, they have
the ingredients, but just can’t bake a cake). Typically, trainees in this
group lack insight into their position, and challenge the assessments and
decisions made by experts about their competence, citing personality
clashes and prejudice on the part of individuals. Clearly such conflict
does occur but multiple similar opinions across several departments is
suggestive of a difficulty with an individual trainee rather than
individual trainer. Nevertheless it remains difficult to justify the
complex, intangible expert opinion based assessment against simplistic
tick box objective competencies successfully completed. The situation can
be further compounded by the external forces of a society obsessed with
quantitative measures of performance, whether it is conviction quotas for
police constables, GCSE league tables for schools or reductions in
orthopaedic waiting lists. By placing all our faith in tick box
competencies as a measure of competence the profession is in danger of
“throwing the baby out with the bathwater”.
Thus in conclusion documentation and regular review are essential and
whilst aforementioned prejudice can masquerade as learned opinion,
evidence exists to confirm the usefulness of professional opinion in
assessment. Greaves and Grant have described how Consultant Anaesthetists
use observation of work in the operating theatre to accurately assess
performance[3]. Similarly Coles describes how professionals can exercise
appropriate judgements[4] without resorting to protocols in situations
where there is no right answer. Our departmental experience is that the
introduction of both shift work for Trainees and Consultant job plans
provides fewer opportunities to assess professionalism and competence
beyond the level of a Novice or Advanced Beginner. We must therefore
continue to engage in the assessment process while emphasising the
limitations of the “tick-box” competency, otherwise we risk trivialising
professionalism[5] and handing further control of our development to those
outside the Medical Profession.
References
1. ten Cate O. Trust, competence, and the supervisors role in
postgraduate training. BMJ 2006; 333: 748-51
2. Goodman N. The tick boxing travesty. BMJ 2006; 333: 155.
3. Greaves JD, Grant J. Watching anaesthetists work: using
professional judgement of consultants to assess the developing clinical
competence of trainees. BJA 2000; 84: 525-33.
4. Coles C. Theoretical findings. Developing professional
judgement. J Cont Ed in Health Professions 2002; 22: 3-10.
5. Coles C. The development of professional judgement. Society for
Education in Anaesthesia (SEA.) Royal College of Anaesthetists, London,
March 2005
Competing interests:
None declared
Competing interests: No competing interests