Medical competence as a multilayered construct

Abstract

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. © 2023 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.

Keywords

Author Keywords

Not provided

Index Keywords

Skill adult clinical competence female human male medical education Humans Article psychometry human experiment professional competence attitude cognitive load personality Medicine health care delivery standardization Delivery of Health Care habit Psychometrics information source self actualization tension

Author Affiliations

University Medical Center Utrecht, Utrecht, Netherlands

University of Limerick, Limerick, Munster, Ireland

Institute of Health Sciences Education, School of Medicine, Montreal, QC, Canada

Institute of Health Sciences Education, Université McGill, Montreal, QC, Canada

University of Toronto Faculty of Medicine, Toronto, ON, Canada, Holland Bone and Joint Program, Sunnybrook Research Institute, Toronto, ON, Canada

Funding & Acknowledgements

Universiteit Utrecht, UU

The first author wishes to acknowledge Dr Anastasia Kurysheva, who studied at Moscow State University and Utrecht University, for valuable conversations about the concept of perezhivanie, and Dr Tavis Apramian and Stephen Billett for helpful correspondences about the manuscript. Both Dr Kurysheva and Dr Billett have given valuable comments on an earlier version of the manuscript.

Lomonosov Moscow State University, MSU

The first author wishes to acknowledge Dr Anastasia Kurysheva, who studied at Moscow State University and Utrecht University, for valuable conversations about the concept of perezhivanie, and Dr Tavis Apramian and Stephen Billett for helpful correspondences about the manuscript. Both Dr Kurysheva and Dr Billett have given valuable comments on an earlier version of the manuscript.

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Medical competence as a multilayered construct

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