Medical competence as a multilayered construct

Abstract

BackgroundThe 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 modelThree 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.ImplicationsThe 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.

Transformations in medical education: A prudential perspective

“…It has become apparent that tensions exist between CBME and the obligation to attend to professional identity formation [5]. A recent commentary attempts to rescue the concept of “competencies” by distinguishing it from “competence” and foregrounding the latter; it argues that competence is multilayered and visualizes the continuum of medical education as existing on three separate levels [6]. The first layer, considered to develop primarily in undergraduate medical education (UGME) and labeled “canonical competence,” represents an amalgam of foundational declarative knowledge with a sprinkling of basic skills.…”