Dr. Carl de WetAcademic Lead for Primary Health Care, Griffith University School of Medicine

GPLO Liaison officer, Gold Coast

CLINICAL COMPETENCE

Summative and formative clinical assessment tools used in Australian and New Zealand medical schools

We are already doing it…

The real question is

…how can we do it better or at least be more objective?

PERSPECTIVES

Clinical Competence

Practiceand theory

Medical studentsand junior doctors

GP trainers

CLINICAL COMPETENCE

Medical Dictionary for the Health Professions and Nursing © Farlex 2012

Performing within the legal scope of defined practice, following standards or principles that

satisfy the demands of the given situation

Sufficient ‘…knowledge, skills, and attitudes…’ **

** Rice, C. A., & Sinclair, M. (1995). Competency‐based objectives for clinical training. Canadian journal of medical technology, 57(3), 136‐140.

The quality of having sufficient knowledge, judgement, skill or experience for some purpose *

* Webster Dictionary

BLOOM’S TAXONOMYCognitive

Knowledge

1. Recall data

2. Understand

3. Apply (use)

4. Analyse (structure / elements)

5. Synthesise (create / build)

6. Evaluate (assess, judge in relational terms)

Affective

Attitude

1. Receive (awareness)

2. Respond (react)

3. Value (understand and act)

4. Organise personal value system

5. Internalise value system (adopt behaviour)

Psychomotor

Skills

1. Imitation (copy)

2. Manipulation (follow instructions)

3. Develop precision

4. Articulation (combine, integrate related skills)

5. Naturalisation (automate, become expert)

direct observation, 

simulations, 

case presentations,

MCQs

essays,MCQs

OSCEs

workplace based assessment

MILLER’S PYRAMID

ACTION

PERFORMANCE

COMPETENCE

KNOWLEDGE

cogn

ition

beha

viou

r

THE AMAC ASSESSMENT FRAMEWORK

Burg, F. D., Lloyd, J. S., & Templeton, B. (1982). Competence in Medicine. Medical Teacher, 4(2), 60‐64

‘… A clinically competent doctor would be someone who has the knowledge, judgment, skill and

experience to diagnose correctly and, in addition, who is capable of

providing appropriate treatment interventions’

UNCONSCIOUS

COMPETENCE

CONSCIOUS COMPETENCE

CONSCIOUS INCOMPETENCE

UNCONSCIOUS INCOMPETENCE

THE ‘CONSCIOUS COMPETENCE LEARNING MODEL’

Wrong Analysis

Wrong Intuition

Right Analysis

Right Intuition

EXPERT

NOVICE

COMPETENT

ADVANCED BEGINNER

PROFICIENT

THE BENNER MODEL

Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park: Addison‐Wesley.

CLINICALCONTEXT

A FRAMEWORK OF CLINICAL COMPETENCEAND ITS APPLICATION*

Cognitive Abilities• Biomedical and clinical knowledge and the ability to apply it to concrete situations

Diagnostic Problem Solving and Clinical Judgmenta. Obtaining sufficient information from clinical history and patient notesb. Performing a focused physical examinationc. Utilizing and applying laboratory tests methods correctlyd. Utilizing and applying medical procedures correctlye. Arriving via a reasonable differential diagnoses at a final diagnosis

Interpersonal Skills• Effective communication with patients and colleagues

Professional Qualities• Respectful and professional relationships with patients and in the provision of health care

* Wimmers, PF. Developing Clinical Competence. Printpartners Ipskamp B.V. The Netherlands, 2006

Competence is not the same as knowing – on the contrary, it may well be about recognizing one’s own limits

**** From: Wojtczak, A. (2002), Glossary of Medical Education Terms: Part 1, Medical Teacher, 24(2). 216‐219.

Available online: http://esmeprogramme.org/amee2006/pdffiles/Occasional_03.pdf.

Competence is what a doctor is capable of doing… performance is

what she / he actually does*

* Senior, J. R. (1976). Toward the measurement of competence in medicine. Philadelphia: National Board of Medical Examiners.

… competence does not come from the self, but rather from the people around us — our

patients, our colleagues, and our supervisors... a physician cannot claim

competence for himself or herself, but must instead be given…

…In the arena of medical education, competence is earned by consistently

excelling in patient care and earning the notice, praise or promotion from

supervising physicians.

Shah, J. ME, How Does a Doctor Become Competent? (Part 2 of 3). Published August 2016.Available online at: http://in‐housestaff.org/doctor‐become‐competent‐part‐2‐3‐266.

Minimum standards

‘Bestow’ vs ‘achieve’

‘Stages’ vs ‘journeys’

±6% vs ±40%

WHY IS SELF‐ASSESSMENT UNRELIABLE?

• Illusory superiority • The Dunning‐Kruger effect

EMPATHY

Competence• Behavioural expression of empathy• Personality

‐ Self‐esteem‐ Sociability‐ Loneliness

Take‐home pointEnhancing the ‘genuine’ behavioural expression of empathy, or at least ‘retarding its decay’, make medical students appear to be more clinically competent to both examiners and patient

THE KIDDY RING INTERVIEW

From a course devised by Kiddy and Company (Bristol) on “Advanced Interviewing and Assessment”

What am I a part of?

Who am I?

How could I deal with this?

Why am I doing this?

When and where does this behaviour occur?

What am I doing?

Opportunities / Constraints

Action / Reaction

Emotion / Intellect

Motivation / Permission

Mission / Role

Vision / AmbitionPURPOSE

IDENTITY

BELIEFS

CAPABILITY

BEHAVIOUR

ENVIRONMENT

DILT’S LOGICAL LEVELS FRAMEWORK

I can’t do that here

identitybeliefs and values

capability

behaviour

environment

‘Sum up’

Ask:  ‘Is there a problem?’

Environment; Behaviour; Capability; Beliefs and values; Identity; Spirituality

Define the problem

Diagnoses

MAKING AN EDUCATIONAL DIAGNOSIS

‘…The path to competence is not a linear one; it is full of trials and

tribulations, mistakes and errors, frustration and self-doubt. However, it

is only through these difficulties that the physician emerges fully competent.

Without the struggle, competence will never be attained...’

Shah, J.  How Does a Doctor Become Competent? (Part 2 of 3). Published August 2016.Available online at: http://in‐housestaff.org/doctor‐become‐competent‐part‐2‐3‐266.

Shared understanding

Clinical competence assessed

Educational diagnoses

Next step….. providing feedback

EXPERT

PROFICIENT

COMPETENT

ADVANCED BEGINNER

NOVICE

THE DREYFUS MODEL

Rules

Intuition

Considerseverything

Relevantfocus

Doesn’t knowwhat doesn’t

know

Metacognitiveability

THE INNER CURRICULUM*• Survival: time

• Safety: access help

• Confidence: blind‐spots

• Recognition

• Self‐esteem: strengths and limitations

• Autonomy: purpose, worth, direction, job satisfaction

* Roger Neighbour. The Inner Consultation, Second edition. Radcliffe, UK, 2004.* Roger Neighbour. The Inner Apprentice: An Awareness‐Centred Approach to Vocational Training for General Practice, Second Edition. CRC Press, UK, 2004.