All About Competency: Part 1

Part 1: What Are Competencies and Their Challenges to Medical Education and Admissions?

 
Among the students I have known as a peer or a professor, the phrase “Book smart but common sense dumb” could be applied to many of them (trust me, I was one).  For quite a long time, pre-health students placed their faith on the maxim, “make the grades and test scores, and just about everything else would come easier for you.”  While I cannot see that advice holding any less weight, there are always a few people that have amazing credentials who are much less than what their profile suggested.
For a number of years, this issue of looking at the candidate as “more than just numbers” has permeated through industry and education.  Numbers did not predict performance in areas where performance cannot easily be quantified.  Patient satisfaction with their interactions with health care providers did not improve, and for those in under-resourced environments, some could politely describe the professional-patient relationship as “indifferent.”
Medical education finally realized that professionalism expectations for behavior and conduct had to be part of the equation.  In 2001, six core competencies were adopted by the Accreditation Council for Graduate Medical Education (ACGME) which began a domino effect of looking at medical education as an acquisition of competencies.  Resident directors must now show that their residents had acquired and further developed these competencies based on direct observation and feedback in addition to any board exams or other opportunities to present cases before faculty and peers.
The competency list shocked medical schools into thinking about the competencies they were developing in their students, and it even permeated to training postdoctoral researchers, where I had a role developing the professionalism domain.  Now competency expectations have finally emerged in undergraduate science education and pre-health admissions, and the challenge now falls on students, applicants, advisors, faculty, and admissions officers to develop curricula to address those competencies and tools to evaluate competency acquisition.

What is a competency?

“…competencies will be more meaningful if trainees understand specifically how they relate to important professional activities in their own specialty.”  (Acad Med 86(2):161-165, February 2011).

“Competency is the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and the community being served.”  (JAMA 287:226-235, 2002; cited by AAMC/HHMI Scientific Foundations for Future Physicians, 2009).

In short, a competency encompasses not just acquisition of knowledge but also a consistent application of that knowledge, especially in a relevant context, whose mastery can be assessed or measured.  To use the above example, my students could recite the central dogma back to me on exams, but a more competent individual can show how it is fundamental when discussing a current research topic or explaining how certain drugs in HIV treatment interfere with these processes.  To use another example, knowing all the words in a dictionary won’t help you if you don’t know how to put those words together in the right situations (“where is your bathroom?”).  The more competent an individual is with a language, the more complex one’s sentences can be to convey ideas or messages to others.

AAMC/HHMI Scientific Foundations for Future Physicians

To extend this analogy, the future of medicine requires health professionals to be fully conversant in a rapidly more complex scientific and technological world.  If one were to try to teach “everything” about medicine to a class of medical students, one can argue that it would clearly take more than four years without breaks.
In a world where a significantly updated smartphone or tablet is released every year, much of the information taught to students will likely be irrelevant or proven wrong within ten years after graduation.  Clearly, it is not so important for students to have biblical knowledge of medicine – as was expected of physicians in the early 20^th century – but to recognize how to manage the four or five new bibles of knowledge that will be created and re-edited during their professional lives.
In 2009, a blue ribbon panel of scientists, clinicians, and educators convened by the Association of American Medical Colleges and the Howard Hughes Medical Institute published a set of science competencies (foundations) for future physicians (SFFP).  In a way, these competencies update the decades-old discrete, didactic, course-based curriculum that was taught to all health professionals (gross anatomy, biochemistry, histology, etc.) which was less effective in helping physicians (and their patients) in clinical applications.  With the scientific competencies, it is now expected that students develop not only a general understanding of those scientific principles but also apply that knowledge in their clinical experiences (as often seen in systems-based curricula and case-based curricula).
Medical schools must be able to assess their students’ acquisition of these competencies in their curriculum when it comes to promoting and graduating students, and align them to competencies expected for residency training.  For individuals in medical education who had been previously restricted to find innovative ways to train new physicians, the SFFP serves as the gauntlet thrown down.
Individuals who aspire to enter professional school were not exempt from the SFFP.  The panel summarized expected competencies for entering students which included foundational competency in mathematics, research methodology, physics, chemistry, and four major areas of biology and biochemistry.  Many medical schools have since begun to adopt these competencies as admissions expectations for incoming students, which means that grades – while still very important – may need to be supplemented by scholarly activity (research) to demonstrate a higher-level of competency.
As a result, undergraduate institutions are challenged to adjust their “pre-health curricula” and consider creating innovative courses or interdisciplinary majors where students can further apply their knowledge and become more competent in these areas.  In the ideal world, this means that science professor letters of recommendation should be more explicit in discussing the competency development of each applicant according to their perspective, so mentoring relationships become even more critical to an applicant’s profile.  Finally, essay and interview questions can be crafted or evaluated that test the level of scientific competency development that go beyond “tell me about your research”.

The near future

The competency train is not stopping just with science.  Competencies can also be applied to an understanding of cultural or political issues that undergird the delivery of health care, not to mention the psychological or personal behaviors that correlate to a successful long-term career in the profession. The AAMC Behavioral and Social Sciences Expert Panel should release a report this year on this subject.  Indeed I am already measuring all these competencies among pre-health advisees and impending applicants for their institutional letter, which I will discuss in a future article.
Emil Chuck, Ph.D., is the Health Professions Advisor and Term Assistant Professor of Biology and Bioengineering at George Mason University.  He has worked with Kaplan Test Prep & Admissions as an admissions consultant, student advisor, and test prep instructor.  There are no conflicting relationships that are relevant or associated with the information in this article.