Medical competence as a multilayered construct.

BACKGROUND: The conceptualisation of medical competence is central to its use in competency-based medical education. Calls for 'fixed standards' with 'flexible pathways', recommended in recent reports, require competence to be well defined. Making competence explicit and measurable has, however, been difficult, in part due to a tension between the need for standardisation and the acknowledgment that medical professionals must also be valued as unique individuals. To address these conflicting demands, a multilayered conceptualisation of competence is proposed, with implications for the definition of standards and approaches to assessment. THE MODEL: Three layers are elaborated. This first is a core layer of canonical knowledge and skill, 'that, which every professional should possess', independent of the context of practice. The second layer is context-dependent knowledge, skill, and attitude, visible through practice in health care. The third layer of personalised competence includes personal skills, interests, habits and convictions, integrated with one's personality. This layer, discussed with reference to Vygotsky's concept of Perezhivanie, cognitive load theory, self-determination theory and Maslow's 'self-actualisation', may be regarded as the art of medicine. We propose that fully matured professional competence requires all three layers, but that the assessment of each layer is different. IMPLICATIONS: The assessment of canonical knowledge and skills (Layer 1) can be approached with classical psychometric conditions, that is, similar tests, circumstances and criteria for all. Context-dependent medical competence (Layer 2) must be assessed differently, because conditions of assessment across candidates cannot be standardised. Here, multiple sources of information must be merged and intersubjective expert agreement should ground decisions about progression and level of clinical autonomy of trainees. Competence as the art of medicine (Layer 3) cannot be standardised and should not be assessed with the purpose of permission to practice. The pursuit of personal excellence in this level, however, can be recognised and rewarded.

Contradictions and Opportunities: Reconciling Professional Identity Formation and Competency-Based Medical Education.

The widespread adoption of Competency-Based Medical Education (CBME) has resulted in a more explicit focus on learners' abilities to effectively demonstrate achievement of the competencies required for safe and unsupervised practice. While CBME implementation has yielded many benefits, by focusing explicitly on what learners are doing, curricula may be unintentionally overlooking who learners are becoming (i.e., the formation of their professional identities). Integrating professional identity formation (PIF) into curricula has the potential to positively influence professionalism, well-being, and inclusivity; however, issues related to the definition, assessment, and operationalization of PIF have made it difficult to embed this curricular imperative into CBME. This paper aims to outline a path towards the reconciliation of PIF and CBME to better support the development of physicians that are best suited to meet the needs of society. To begin to reconcile CBME and PIF, this paper defines three contradictions that must and can be resolved, namely: (1) CBME attends to behavioral outcomes whereas PIF attends to developmental processes; (2) CBME emphasizes standardization whereas PIF emphasizes individualization; (3) CBME organizes assessment around observed competence whereas the assessment of PIF is inherently more holistic. Subsequently, the authors identify curricular opportunities to address these contradictions, such as incorporating process-based outcomes into curricula, recognizing the individualized and contextualized nature of competence, and incorporating guided self-assessment into coaching and mentorship programs. In addition, the authors highlight future research directions related to each contradiction with the goal of reconciling 'doing' and 'being' in medical education.

A cross-sectional survey of doctors' views on flexible postgraduate physician training in Ireland.

Recruitment and retention of doctors is a priority for the Irish healthcare service, with many leaving to work in regions with more favourable conditions. Aligning flexible training options with other jurisdictions may be an effective means of improving working conditions. We sought to assess possible improvements to the existing system and to review barriers to flexible training. We carried out a survey using 'Survey Monkey' and disseminated it to 1557 basic specialist (BST) and higher specialist trainee (HST) doctors of the Institute of Medicine, 3500 members of the Irish Medical Organisation (IMO), and across social media. There were 854 respondents; 303 (35.5%) BST, 352 (41.2%) HST, 125 (14.6%) non-training doctors, unknown, n = 74. The response rate was approximately 15-23%. Non-consultant doctors identified a preference for access to flexible training (n = 849, 99.4%), with 82.2 of doctors reporting that they would consider applying (n = 702). Most (92.4%) considered the current provision of 16 whole-time equivalent positions as inadequate (n = 789). Of doctors who would not apply for flexible training, themes identified included a perceived negative impact on their career, not meeting eligibility criteria, prolonged training, and salary implications. Suggestions for improving the system included expanding the number of places available, removing eligibility criteria, job sharing options, and the provision of regional training schemes. Access to flexible training should be a priority for the healthcare service, which may enhance recruitment and retention. A majority of our sample of non-consultant doctors identified a preference for access to flexible training options.

Tutor Uncertainty in Dealing with Unprofessional Behaviours of Medical Students and Residents: a Mixed Methods Study.

BACKGROUND: Despite acknowledgement of medical students' expected professional behaviours and attitudes, there remains widespread reluctance to report students that behave inappropriately. Existing literature focuses on why faculty fail to fail, overlooking the tutors who deal with students day to day. We investigated how tutors address inappropriate behaviours and attitudes in students and residents. METHODS: A mixed methods study was carried out consisting of a survey and two focus groups with tutors. Seventeen tutors from the University of Limerick School of Medicine, Ireland, took part in the survey (n = 22%) and eight tutors participated in two focus groups during the 2018-2019 academic year. RESULTS: Findings suggested that 59% of tutors would take a different approach to addressing unprofessional behaviours witnessed in medical students and residents. A total of 88% of tutors said they intervened on a professionalism issue with 52% saying 'once in a while'. In contrast to the survey, tutors in the focus groups expressed a lack of confidence in addressing some behaviours due to a lack of time, not seeing the outcome of process/remediation etc. Tutors indicated a strong preference for case-based training on assessing professional identity formation (PIF). CONCLUSIONS: We found tutors typically work closely with students on a day-to-day basis managing unprofessionalism issues. Tutors valued regular communication about policies and procedures about appropriate conduct as well as support, advice, and/or oversight from independent members of university staff. This research highlights the need for training designed for busy tutors as a distinct type of medical teacher. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s40670-021-01429-1.