When competent isn’tgood enough

Many clinical teachers viewcompetency-based train-ing with suspicion. From a

cautious distance, it looks a lotlike a series of low hurdles overwhich a candidate must stepbefore being declared fit forpractice by assessors who havechecked off their satisfactoryprogress. This sort of ‘clipboardtraining’ is an anathema to thosewho believe that it takes time anddeep immersion in the clinicalworkplace for novices to be prop-erly inducted to the science, artand craft of health care. There isalso suspicion that the compe-tency-based training agenda isbeing pushed by governmentalbureaucrats keen to see the newhealth workforce produced asquickly and cheaply as possible inthe face of diminished workinghours and patient contacts:‘Competent is good enough, nowget to work’. And if you define thecore competencies of one healthprofession, then others canincorporate bits of them into theirown training programmes tofacilitate role substitution. A lit-tle like finding out the secretherbs and spices in order to copya fried-chicken recipe.

This is a minimalist and neg-ative view of competency-basedtraining for the health profes-sions, which is surely a huge stepahead of the old time-servedmodel. It has never been shownhow much time must be spentparticipating in health care with-out training objectives, activesupervision or clearly defined endpoints before a novice is ready topractice independently, and sovocational training programmesvary wildly internationally interms of duration, style andcontent.

A more positive way of viewingcompetency-based training is notas the minimum standard thatmust be reached before certifica-tion, but as a good way of lettingtrainees know what they don’tneed to do more of. Specialistmedical registrars, for example,often sweat over their learningplans in anticipation of tomor-row’s meeting with their supervi-sor, desperately trying to figureout their learning needs. Surelyit’s easier to know what you doknow than what you don’t know(to partially paraphrase DonaldRumsfeld).1 Having already

achieved a series of clearlydefined competencies, the learnercan then seek help from theirsupervisor to focus on the gapsthat remain.

I was introduced to this con-cept several years ago by a pair ofNorth American medical studentswho were undertaking a new lon-gitudinal clinical placement pro-gramme. When quizzed on whythey had volunteered for this 12-month, community-based andintegrated programme rather thanstaying in the relative safety of abig general hospital, they simplysaid that they wanted to be thebest they could possibly be. It wastoo easy to hide amongst thethrong of students in the generalhospital, bumping along fromrotation to rotation, and justgetting by. In their longitudinalprogramme, the students had aclose relationship with their year-long tutor who knew them wellenough to challenge them todevelop their skills across thewhole curriculum, not just onwhat was likely to be examined.The competencies expressed inthe curriculum in this case do notrepresent low hurdles to be

Editorial

� Blackwell Publishing Ltd 2012. THE CLINICAL TEACHER 2012; 9: 135–136 135

stepped over, but instead providea baseline from which the stu-dents attempt to jump as high asthey can.

As 2012 is an Olympic year,sporting analogies are largelyunavoidable. In this case, how-ever, the image of the clinicalteacher as a sporting coach isirresistible and appropriate. Theclinical teacher in a coaching roleis able to help their learner toidentify their goals, developstrategies to achieve them, and tosupport their efforts to do so. Nocoach is satisfied with his or hercharge being competent: coachesare all about striving forexcellence.

Being a coach is very differentto being a tutor. The clinical tutorplays an important role in helpingstudents to contextualise andunderstand material presented in

the clinic or the classroom. Tutorshelp students learn what theyneed to know to pass the course.Clinicians who coach have a muchmore emotionally connected rolewith their learners: there’s pas-sion involved. When a clearunderstanding of the parametersof the relationship has beennegotiated, the clinical coach isempowered to challenge theirstudent to focus on areas of need,raising himself or herself to thestandard of which both know theyare capable. Central to this rela-tionship, of course, is the sense oftrust that comes from knowingthat the coach is absolutely com-mitted to the student and theachievement of their goals.

If a training programme is setfor a particular duration, thenusing a competency-based ap-proach to shorten it may well beshort-sighted. Efficiency is not

just about saving time or money:it is also about doing the mostwith what is available. A coachingapproach means that learners canbe helped to build on thosecompetencies they have alreadyachieved and to add others,becoming not just competenthealth professionals but trulyexcellent ones. That is whatpatients really want: clinicianswho are the best they can possiblybe.

Steve TrumbleEditor in Chief

REFERENCE

1. Rumsfeld D. http://www.defense.

gov/Transcripts/Transcript.aspx?

TranscriptID=2636. Accessed on 4

March 2012.

doi: 10.1111/j.1743-498X.2012.00580.x

136 � Blackwell Publishing Ltd 2012. THE CLINICAL TEACHER 2012; 9: 135–136