Competency based training is a framework for incompetence
BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2909 (Published 25 April 2014) Cite this as: BMJ 2014;348:g2909
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I would like to thank the authors of the rapid response articles posted to date for their support for the views I expressed in my Personal View.
I was stimulated to write this article (and my previously published BMJ blog -
http://blogs.bmj.com/bmj/2014/02/26/jonathan-m-glass-blood-taking-is-so-...) after attending meetings discussing the future of Foundation Year and registrar training. At a number of these meetings it was evident that change was to be be imposed despite a groundswell of opinion from the majority of those at the meeting that the impending changes were detrimental to the future of training.
I don't in any way think the current crop of students and junior doctors are to be blamed for the need to comply with the system being imposed upon them. I recognise we have many excellent trainees who are victims of a system not designed for excellence or the pursuance of excellence.
Bernard Shaw wrote in his introduction to The Doctor's Dilemma 'There is a fashion in operations as there is in sleeves and skirts'. Whilst I believe this is true of surgery, I'm sure it is also true of education. Whilst being seen wearing trendy clothing may do no harm even if it goes rapidly out of fashion, passing through a training scheme whilst being exposed to an educational system that goes out of favour or that is subsequently recognised as not giving the desired outcome, can be detrimental to the individual and to their future in whatever field they are pursuing.
I felt it was no longer right to be silent and further felt there were likely to be other practitioners with similar views. This is evident from these 5 responses and from emails I have received since this article has been published.
I note the view that I should aim to educate the student who is only there to complete another page of their book and not send them away. I would do so I hope by persuading them of the real purpose of attending a clinic - the joy of learning and the desire to be better.
I am a super subspecialist but strongly believe that the art of doctoring is at the heart of how medicine should be practised and whilst recognising the need for subspecialisation, it should not be at the cost of losing the core values of the profession.
Jonathan Glass
1. The craze for operations. The Doctor's Dilemma. Preface on Doctors. George Bernard Shaw. Penguin Books 1946. P18.
Competing interests: No competing interests
I agree wholeheartedly with Jonathan Glass’s astute and timely critique of competency-based training. This educational fashion, which has sadly achieved dominance in contemporary postgraduate medical training, is part of the wider ‘industrialisation’ of medical practice, a phenomenon that seeks to reduce the highly complex psychosocial roles of the doctor to discrete production-line components (1). The selective focus on the measurable that is inherent in this world view inevitably devalues and marginalises the higher order skills essential to becoming a wise, humane, empathic practitioner (2). If assessment drives learning, then competency-based training risks deprofessionalising our trainees, shaping their emerging identities into box-ticking technicians. If we want a profession able to engage with the richness and complexity of our patients’ lives (3), then this approach to training is simply not fit for purpose.
Fortunately there are signs of the pendulum swinging back. On the Postgraduate Certificate for Teachers in Primary Care (the ‘Teaching the Teachers’ qualification undertaken by London GPs wanting to become trainers), we encourage a critical stance in relation to dominant educational paradigms, as well as a long historical view that sees competency-based training as one possible approach among many. Our students, who will become the GP educators of the future, often develop trenchant critiques of competency-based models, arguing for an awareness of the value of process over outcome, and finding an antidote in theories of learning that favour reflection, intuition and the co-construction of professional knowledge through participation in communities of practice (4). Perhaps in the next generation a model of training will emerge that is less readily measured and monitored by our political and managerial masters, but more aligned to what it means to become a doctor.
Regrettably our own Royal College has jumped enthusiastically on the competency bandwagon, cramming the nMRCGP trainee eportfolio with a bewildering array of boxes to tick, which often bear little relation in real-life training to the challenges and complexities of becoming a GP. It is enormously heartening to read in Glass’s Personal View that the competency hegemony is not going unchallenged in specialist surgical training. Perhaps the time has come to launch a concerted rearguard action against the competency wonks across our profession, in the interest of protecting and nurturing what really matters as we strive to educate our future professional colleagues.
Jim Boddington
GP Partner and Trainer, Shoreditch Park Surgery, 10 Rushton St, London N1 5DR
Course Tutor, Postgraduate Certificate for Teachers in Primary Care
jim.boddington@nhs.net
1. Iliffe, S. From general practice to primary care: the industrialisation of family medicine. OUP 2008.
2. Fish, D. and de Cossart, L. Developing the wise doctor: a resource for trainers and trainees in MMC. RSM Press 2007
3. Sweeney, K. Complexity In primary care: understanding its value. Radcliffe 2006.
4. Ileris, K. Contemporary theories of learning: learning theorists… in their own words. Routledge 2009.
Competing interests: Course tutor on the Postgraduate Certificate for Teachers in Primary Care
I think Dr Glass identifies some important issues in terms of the way in which the appearance of learning is being reduced to ticking a box and how this serves to undermine the achievement of mastery. My only reservation is that he says he would turn away the box-ticker, rather than role model his professionalism, enthusiasm and commitment. Extrinsic motivators can be converted into intrinsic ones and the experience of observing an expert's practice (both clinically and in the way in which he communicates with his patient) would be of benefit.
Competing interests: No competing interests
Bravo. Finally, we hear someone speak the words burning through so many of our hearts & minds. The desperate need to mow the field even, clear of tall poppies, eliminating any natural tussock or bluebells or daisies is stupid.
Average, mediocre, Standards, fill the log book, these competency matters rule the pea brains who currently design our governance and education systems. With such an emphasis on mediocrity we will never have that little slip of leeway that generates minds like Einstein or Marie Curie.
Thank goodness this author finally bit the bullet and wrote an article damning the dumb down syndrome besetting medical education.
Competing interests: No competing interests
I feel compelled to congratulate Mr Glass on an excellent article that exemplifies eloquently the problems with a 'tick-box' mentality that has come to dominate both under- and post-graduate medical education.
The system myself and other juniors are negotiating our way through is not without its antecedents. As a reasonably recent graduate I am assured by my seniors that we have a much fairer and perhaps less arbitrary deal than our pre-MMC counterparts. This sense of fair-play is manifest in curricula for the various specialty training programmes with corresponding e-portfolios, assessment tools and goalposts. Seen constructively these serve to guide and assess the trainee objectively, overall giving reassurance of adequate competency progression to specialty boards and the general public.
While at face value positive, as the opportunistic medical student of Mr Glass's piece serves to represent, such reductionism into lowest common denominator snapshots of the just-adequate has the potential to normalise a desire to achieve nothing beyond this. As Mr Glass suggests, we are in danger of engendering a culture with which our predecessors would most probably have been unfamiliar and uncomfortable.
Such a stark caricature is perhaps unfair to most trainees and having jumped multiple hurdles we generally want to achieve the highest standards possible. However, in reality in order to be confident of progression, subscribing, at least partially, to the philosophy of e-portfolio is necessary. Peri-ARCP I am acutely aware of the potential perils that await the trainee with a missed 'Mini-CEX' here or delayed 'CBD' there. While workplace-based assessments and excellent training experiences are of course not mutually irreconcilable, and indeed are designed to overlap, I feel that occasionally the knowledge of unyielding numerical assessment checklists forces the trainee to prioritise the assessment over the experience e.g. hours spent reflecting into a computer screen.
I believe that while there is lot to be thankful for with the current system, it fails fundamentally in that it indirectly propounds an environment in which excellent, dedicated colleagues can fall foul of overtly rigid e-portfolio-based assessments, while simultaneously less-giving subscribers to the 'just-adequate' school can sail through unscathed.
I suppose we need a system that not only assures competency, but registers and rewards excellence. While this is easier said than done, if we expect the minimum then the health service is in danger of getting the minimum; the Sistine Chapel vs. the garden shed - the choice is ours.
Competing interests: No competing interests
I would like to thank Mr Glass for making the excellent points about the significant harms associated with an excessive focus on 'competency based methods' in medical training. The powers that be in medical training (formerly with PMETB and now resting with the GMC) have moved from an apprenticeship model towards a fundamentalist approach that relies excessively on 'competency based methods'. Rather than addressing the fundamental issues such as inadequate exposure to specific clinical tasks, it has been easier to use competency based box ticking as a sticky plaster to pretend that training has been unaffected by the EWTD.
The harms from such an approach have included the demotivation of trainees, who now focus on minimum standards and not excellence, and a massive amount of time wasted polishing shiny online ‘e-portfolios’ rather than gaining valuable clinical experience1 2. This approach has also allowed a worrying proportion of first year doctors to completely bypass any emergency experience3. The solution to this problem is simple and it has not been adequately addressed by the Shape of Training review which bizarrely advised shortening training even further despite plummeting experience levels. We need those with expertise in training back in charge of regulation, the Royal Colleges, and we need to shift the balance back towards experience and the apprenticeship.
1. Leung WC. Competency based medical training: review. BMJ (Clinical research ed.) 2002;325(7366):693-6.
2. Pereira EA, Dean BJ. British surgeons' experiences of mandatory online workplace-based assessment. Journal of the Royal Society of Medicine 2009;102(7):287-93.
3. Dean BJ, Duggleby PM. Foundation doctors' experience of their training: a questionnaire study. JRSM short reports 2013;4(1):5.
Competing interests: No competing interests
Competency based training framework is helpful for curriculum design of courses aimed at performance of specific tasks and for maintaining quality standards, especially in areas with weak accreditation systems.
Sir,
A competency based training framework is helpful for designing curricula of courses, especially for courses that are skill based and require the candidate to be proficient in performing specific tasks. The process helps in keeping the focus of the course, ensuring that the candidate attains the core competencies and can perform the tasks the course intends to equip him/her with. Especially when new courses are being designed, for capacity building of large work forces, for being administered by several organizations / institutions (say diploma/masters courses in Public Health) throughout the country, the process helps in maintaining uniformity in standards and quality assurance. The process of deriving instructional objectives, learning objectives, learning experiences and evaluation to achieve specific core competencies ensures that the curriculum remains focused on the intended outcomes. This is especially important if the system of accreditation of training institutes / courses is weak in a country and several players are involved in offering courses.
Competency based training also helps in aligning the course to the national priorities. While listing the core competencies, during curriculum development, one can simultaneously review whether the competencies address the National Priorities and align the course accordingly.
While keeping the curriculum principally structured on its core competencies, there should be adequate opportunity and space in the curriculum to let the student ” wander off “and explore areas of interest and learn by intuition and trial and error. This will make the course interesting and give the student a break from structured learning. Competencies in the domains of Evaluating and Creating need to be included to encourage students to think individually and synthesize from what they have learnt.
Competing interests: No competing interests