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Competency based training is a framework for incompetence

BMJ 2014; 348 doi: (Published 25 April 2014) Cite this as: BMJ 2014;348:g2909
  1. Jonathan M Glass, Department of Urology, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 9RT

Excellent care for patients cannot be learnt by ticking off arbitrary numbers of activities, writes Jonathan M Glass. We should want to produce masters of our art, not technicians

At the beginning of one of my urology clinics, there came a knock on the door. A medical student holding a yellow notebook asked to attend so that she could do a scrotal examination, to sign off “scrotal examination” in her record book. It wasn’t because she particularly wanted to know the various pathological conditions that she may encounter in the scrotum; neither was it because she wished to be reminded of the beautiful anatomy of the inguinal canal. No; just as long as the book got signed, that was sufficient.

As well as the record book so loved by medical schools, a competency based training system is now entering all levels of British medical training. Our registrars must have their ability to perform a particular procedure assessed on a four point scale from level 1 (beginner) to level 4 (where they can deal with any complication). A competency based system is part of the assessment of progress for foundation year and core training. Furthermore, increasing rigidity is applied to the number of cases that our registrars are supposed to have performed to achieve their certificate of completion of training.

When novice artists joined the studios of the great Renaissance painters, I suspect they didn’t just want to be assessed on how they used a paintbrush. They wanted to learn about depth, perspective, and form. They wanted to discover how to source and mix colours to produce the perfect result for the scene being depicted. They wanted to be guided by the experienced and talented master who knew how to use all of the elements available to create the perfect result and who, most remarkably, could see the glorious whole that they were working on, while the assistants could focus only on the small section on which they had been asked to work.

It’s not clear how many of each procedure a higher surgical trainee should do to ensure that they are competent. And, just like the trainee artists, some will possess natural flair in their chosen field and will quickly become adept operators; others will be grafters who reach surgical safety only once their confidence allows them to express themselves freely. Being rigid about absolute numbers is a flawed idea.

But the tick box exercise of competency based training is far more flawed. The process suppresses quality in medical students and discourages their personal development when the student is encouraged not to seek the wider experience, but simply to fill a book with signatures.

And there is so much more that we need to instil into these fledgling doctors than we can measure by this system. I don’t really care that my treating surgeons have done x or y number of cases—but I do care that they wish to strive continuously for excellence, that they are obsessed with personal improvement and the desire to offer the best care. I want to know that throughout their training they have believed that medicine is not about clocking in and out; it’s about considering the vulnerabilities of the patient, the concerns of the family, the finality of responsibility, the greater picture. It’s about the art of doctoring, not simply the mechanics of procedures. Like Caravaggio or Michelangelo, it’s about seeing the whole picture in its complete form and coordinating the work of others whose focus is on a small area.

So, what do I say to medical students who knock on my clinic door? I explain that if getting their book signed is their only motivation, then no, they can’t attend. But if they are there because they wish to see as many patients as possible, because they recognise that by doing so they will learn as much as possible, and because they are fascinated by humanity and are desperate to see how senior consultants can put patients at ease when discussing potentially embarrassing symptoms; if their thirst for knowledge is unquenchable and their desire to be the best is unstoppable; and if their drive for excellence and their recognition of their privileged future role are permanent—then yes, they can attend.

A tick box form or booklet, together with an incorrect focus on the hours a doctor has worked rather than a system encouraging a true focus on the care of the patient, will never develop the best quality doctors for the future of our nation. We should want to produce masters of our art, not technicians; to produce masterpieces, not sketches. Is it not time for a medical educational renaissance?


Cite this as: BMJ 2014;348:g2909


  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Not commissioned; not externally peer reviewed.

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