GENERIC COMPETENCIES IN POSTGRADUATE MEDICAL TRAINING:THEIR IMPORTANCE ILLUSTRATED BY A DOCTOR'S NARRATIVE ON COMPETENCY-BASED PRACTICE
GENERIČNE KOMPETENCE V PODIPLOMSKEM IZOBRAŽEVANJU ZDRAVNIKOV: NJIHOVA POMEMBNOST, ILUSTRIRANA Z IZKUSTVENO PRIPOVEDJO ZDRAVNIKA
Nadine van der Lee1, Joanne P. I. Fokkema1, Fedde Scheele2 Prispelo: 15. 1. 2012 - Sprejeto: 5. 9. 2012
Review article UDC 61:371.13/.16
Abstract
Medical education pr^ogr^ammes worldwide ar^e becoming competency^-based, aiming to provide tr^aining in all aspects r^elevant to the future practice of physicians. These involve competencies that exceed the sole domain of medical e^xp^rtise and sk^ills, beholding i.e. communication, collaboration, ethics, and ma^na^g^m^nt. A^lthough the necessity of these so called 'generic' competencies has become cle^r in investigations into workp^lace and societal needs, i^ecognition of the importance of these competencies by the medical profession is sometimes challenging. In this article, the r^el^vance of gener^ic competencies to daily pr^^ctice is illustr^at^d by t^o nar^ratives fr^om obstetr^ics-gynaecology. Subsequent r^eflection on these nar^ratives illustr^ates the importance of the incorporation of generic competencies in medical training.
Key words: medical education, postgraduate education, generic competency, narrative, teamwork, management
Pregledni znanstveni članek UDK 61:371.13/.16
Izvleček
Izobraževa^nje zdr^avnikovpo svetu postaja vse bolj usmerjeno v kompetence, saj je cilj r^elevantno izobr^až^v^nje za bodoče pr^ak^ično zdr^avnikovo delo. Te kompetence presegajo strokovnost in veščine in obsegajo tudi komunikacijo, sodelovanje, etiko in upr^a^ljanje. Čepr^av so r^azis^a^e dokazale, da so te tako imenova^ne 'gener-ične' kompetence na delovnem mestu in pr^i dr^užb^nih zahtevah potr^ebne, p^r^iznanje s str^ani medicinske str^oke p^r^edsta^lja izziv. V tem prispevku z dvema pripovedma iz porodništva in ginekologije ilustriramo pomembnost generičnih kompetenc v vsakodnevnem delu. Posledični razmislek o teh pripovedih ilustr^ir^a pomen v^k^ljučit^e gener^ičnih kompetenc v izobraževanje zdravnikov.
Ključne besede: izobraževanje zdravnikov, podiplomsko izobraževanje, generične kompetence, pripovedi, timsko delo, upravljanje
1 INTRODUCTION	doctors need to possess nowadays, research into
workplace requirements and societal needs has The purpose of medical training is to adequately prepare been conducted in the past decade (1). This has students for their work as a doctor. As society and brought to light that, apart from medical knowledge the medical world changes, the regular adjustment of and skills, competencies such as communication, medical training programs is necessary to keep in pace teamwork and ethics are important for physicians to with those changes. To identify which competencies function adequately (2-4). Therefore, beyond medical
1St Lucas Andreas Hospital, Department of Health Care Education, Jan Tooropstraat 164, 1061 AE Amsterdam, The Netherlands
2VU University Medical Center, Department of Medical Education, Amsterdam, The Netherlands Correspondence to: e-mail: nadinevanderlee@gmail.com
knowledge and skills, increasing attention is now being paid in medical training to these so-called "generic competencies" (5) that exceed the domain of clinical expertise. Instead of specific situations, they should be applied in addition to medical knowledge whenever needed in practice, like communication with patients and collaboration in a health care team (1). Now that these generic competencies have been acknowledged as important for medical practice, the so-called "competency frameworks" have been composed to guide medical training in addressing all competencies (6, 7).
Examples of these competency frameworks are the Canadian Medical Educational Directives for Specialists (CanMEDS), the United Kingdom's Tomorrow's Doctors, and the North American Accreditation Council for Graduate Medical Education (ACGME) (6-8). The CanMEDS framework defines seven roles a doctor must take on: Medical Expert, Communicator, Collaborator, Health Advocate, Manager, Scholar and Professional. The Tomorrow's Doctors framework includes three domains of a doctor's performance: the doctor as a Scholar and Scientist, as a Practitioner, and as a Professional. Finally the ACGME defines six competencies for a doctor: Patient Care, Medical knowledge, Practice-based Learning and Improvement, Interpersonal and Communication skills, Professionalism, and System-based practice. Worldwide, undergraduate and postgraduate medical education programmes that have been reformed, now provide so-called "competency-based education" (CBE) based on such a competency framework. The value of generic competencies and competency-based programs could easily be underestimated by medical personnel with a strong focus on biomedical knowledge and research. This manuscript aims to illustrate the value of generic competencies in the training of doctors and medical specialists by the narrative description and reflection on two real life workplace experiences of a gynaecologist.
2 METHOD 2.1 Design
Since the end of the previous century, the narrative has become increasingly recognized as a way to remember and communicate important ideas and values (9). Narratives provide meaning, context and perspective for the situation at hand. Furthermore, narratives that are true to people are their building bricks for common behaviour. They support people in connecting with
others who cherish the same beliefs as captured in the narratives. While collecting important narratives, people develop as a person and as a professional (10, 11). In this manuscript, two experiences of the narrator are described, after which reflection is provided on the generic competencies that come up in the narratives.
2.2	Team
The senior author of this manuscript (FS) is the narrator. He is a professor in medical education, a practicing obstetrician-gynaecologist in an urban hospital where he is also the lead consultant in charge of postgraduate training in obstetrics-gynaecology. With regard to competency-based education, he is constantly concerned with pointing out competency learning opportunities in his practice to trainees and guiding them in their development towards being a competency-based professional. The two junior authors (NL and JF) both have one year of clinical experience as house officers in obstetrics-gynaecology and surgery respectively. They currently conduct PhD research into postgraduate medical education, after which they will start their specialty training.
2.3	Procedure
Two narratives from real life workplace experiences of the senior author formed the basis of this project. In the subsequent reflection on the narratives, the narrator and his two junior colleagues jointly pinpointed the core problem of those experiences. Next, they discussed which generic competencies in medical practice from these experiences should be explicated as important.
3 NARRATIVES
Narrative 1: Crew Resource Management
'This story is about obstetrics. I had been trained extensively in obstetrics and after more than ten years of experience as a house officer and trainee, I became a consultant. For consultancy, we had been trained to be the final responsible person, which meant I had to make sure I had all the knowledge and skills for complex obstetric cases. I also needed to adequately organise and utilise labour ward personnel, although my training had not emphasized how to do this. During my work, I noticed that obstetric care consisted of two worlds: the world of the doctors and the world of the others. To get a better understanding of why those two worlds existed, we started auditing recurrent
obstetric disasters. Through these audits, we were able to detect where these two worlds failed recurrently. Interestingly, we found both worlds had enough medical knowledge, technical skills and infrastructure. However, it was the ineffective communication and unstructured collaboration between both worlds that led to underachievement in the provision of optimal care by the team as a whole. Lacking the expertise to solve these problems, we decided to fly in experts in crew resource management from aviation science. With their help, ideas about structured attention for collaboration training were introduced and new vocabulary like 'briefing- debriefing' and 'speak-up' came into use. Following this, our obstetric lead consultant and an enthusiastic nurse introduced weekly obstetric drills in our hospital. In these drills, a team composed of various professionals (mimicking actual practice) treats a simulated patient (a hired actor) while being observed by one of the consultants and a nurse. The observed teamwork and communication is discussed afterwards in the debriefing. This weekly drill has been in use for several years now and the ward has changed. The worlds of doctors and of the others seem to have merged, members of the healthcare team report increased self-fulfilment and pleasure from their work, and patient satisfaction on the care provided by the team has improved.
Narrative 2: Talking to Managers
'Starting as a young consultant in obstetrics-gynaecology, I was appointed to reorganise the care for infertility treatment within our department. In the Netherlands, gynaecologists work in groups of five to twenty concentrated within one hospital and they have a relatively strong influence on hospital governance, both in policy and in financial matters. Working in my group of eight consultants, I was appointed to develop a plan for patient care in the infertility ward, which I had to discuss with the hospital board. My focus was clearly on good patient care. I wanted to make sure that medical treatment was evidence- and protocol-based, and of a high standard, with continuous monitoring of the quality of care by measuring medical outcomes and patient satisfaction. In writing the plan, I estimated the number of personnel I would need and I described the infrastructure needed. Although I had not been trained for management tasks, and nor had any of my role models in my professional life, I just took this task for granted and did what I thought was best in this situation. After spending nine months in my new working environment, I had developed a business plan for the fertility clinic and I was ready for a meeting with the
hospital board. The day I went to discuss the needs for our fertility clinic with the hospital board, I was excited about the beautiful ideas I had come up with. I was convinced I would succeed in persuading the hospital board to provide us with the personnel and infrastructure needed. You can imagine how disappointed I was when the hospital board started to yawn during the board meeting. From their comments and questions, the board did not seem to understand the importance of my ideas. I left feeling confused, without results and even a bit insulted. These people didn't know anything about my profession and seemed not to care about my patients! One of my senior colleagues noticed my disappointment and decided to help me. He offered to join me in the next meeting with the hospital board. He would do the talking. During the board meeting, I couldn't understand what he was talking about at all and I had the impression that my subject had been forgotten. After we left the board room, I asked him what he had been talking about. I was quite surprised when he answered that my wishes for the fertility clinic had been discussed and that all of them had been granted. Now I knew that I was the ignorant person here. What kind of language had he been using? Why had no one ever taught me how to speak to hospital boards as successfully as this colleague apparently could? Sometimes you have to think and talk like a manager, my colleague taught me. In the following years, I sadly learned that I was not alone in failing managerial tasks. In the period when I was active as an appraiser in the assessment and appraisal of consultants of various specialties, I encountered quite few frustrated colleagues who once had great ideas for better health care, but felt that no one had ever listened to them. They hadn't had the colleague that finally saved me from a failure to set up our fertility clinic.
4 REFLECTION
The above narratives illustrate the importance of several competencies for the work of medical specialists nowadays that exceed the domain of medical expertise: communication and collaboration within a team, team management, and communication and collaboration with managers.
In the following section, these three competencies will be highlighted, illustrated by current knowledge about these competencies and their relevance from medical education literature.
In the experiences described in the first narrative, the competencies of communication and collaboration within a team, and team management were needed.
4.1	Communication and Collaboration Within a Team
In the process of making the "two worlds" on the labour ward work together, they had to be merged in some way. This aim is in line with the extensive literature on teamwork, since good teamwork is associated with positive effects on clinical outcomes and patient safety, and work atmosphere and culture for doctors (12, 13). Therefore, it doesn't seem justifiable to withhold training from young doctors in working in a team with various professionals and in the skills of communicating with these colleagues. This is an essential, generic competency for all of them (14). The literature regarding healthcare teams describes how purposeful, unambiguous, respectful and effective conversations help gain consensus and increase collaboration (15). Fortunately, these 'team' competencies are included in the currently existing competency frameworks. For example, in the development of the CanMEDS framework, communication and collaboration within a team were acknowledged as important in for the performance of a doctor, as is reflected by the incorporation of the roles of Communicator and Collaborator (6).
4.2	Team Management
Also arising in the first narrative is the fact that the final responsible consultant is not only accountable for his own performance, but also for the performance of the interprofessional labour ward team. Being held accountable implies that the consultant has to control the team's performance and should intervene when the quality of care is jeopardized (as did the consultant in the narrative). Crucial competencies in this situation are the ability to monitor the quality of care and to register the way the team is functioning, as well as having knowledge of teamwork strategies; what strategy is appropriate for what situation, and how to successfully apply this strategy and monitor the effect of the intervention. The preparation of trainees for these competencies is known to be flawed, as illustrated by Westerman at all. They found that new consultants feel prepared for only half of their work, namely the medical part. The other half, consisting of managerial and entrepreneurial tasks, they feel unprepared for by their postgraduate medical training (16). The role of Manager has been included in the CanMEDS framework, to ensure attention to the development of managerial skills for doctors.
4.3 Communication and Collaboration with Managers
In the second narrative, our narrator was clearly lacking competence in communication and collaboration with managers, and experienced the contribution of his senior colleague's competency in that area. In the course of his career, our narrator noted that many more colleagues lack this general competency of bridging the gap with the management. This is unfortunate, since instead of getting motivated to explore the feasibility of great ideas, doctors get frustrated by not achieving what they want because of their inability to cooperate with hospital management, while our changing society and medical practice are in need of fruitful collaborations to adapt to changing needs. In literature, knowledge on the organizational aspects of care is considered an important competency for a doctor by general practitioners(17) and medical leadership competencies, such as effective communication, time-management, meetings skills, systems thinking, and knowledge about information systems, are predicted to become more important for a doctor's practice (4, 18). Moreover, it has been shown within the health sciences that generic competencies, such as communication, leadership and teamwork, are important for success on the job market after postgraduate training (19). Furthermore, a doctor trained in generic competencies, like skills in negotiation with other professionals (e.g. about financial and administrative issues), is less likely to get burned out when transitioning from trainee to certified medical specialist (16).
5 CONCLUSIONS
By describing and reflecting on two narratives about healthcare practice, this article illustrates the importance of generic competencies in medical practice. This is supported by research into medical practice and societal demands, which has clarified the attitudes, skills and knowledge required by doctors to work in current and future practice. Although cultural and contextual nuances should not be neglected, it is clear that generic competencies, such as communication, management skills and collaboration, are pivotal for all doctors. Therefore, generic competencies have rightly been incorporated into medical training programmes. Both trainers and trainees should take these parts of the training programme as seriously as the medical content. By doing so, medical students and postgraduate trainees are more likely to become adequately prepared for their future careers.
References
1	Bowden JA. Competency-based education: neither a panacea nor a pariah. 1995, 1-3-2006.
2	Teutsch C. Patient-doctor communication. Med Clin North Am 2003; 87: 1115-45.
3	Neufeld VR, Maudsley RF, Pickering RJ, Turnbull JM, Weston WW, Brown MG, et al. Educating future physicians for Ontario. Acad Med 1998; 73: 1133-48.
4	van der Lee N, Westerman M, Fokkema JP, Van der Vleuten CPM, Scherpbier AJ, Scheele F. The curriculum for the doctor of the future: messages from the clinician's perspective. Med Teach 2011; 33: 555-61.
5	Scheele F, Teunissen P, Van Luijk S., Heineman E, Fluit L, Mulder H, et al. Introducing competency-based postgraduate medical education in the Netherlands. Med Teach 2008; 30: 248-53.
6	Frank JR, Danoff D. The CanMEDS initiative. Med Teach 2007; 29: 642-7.
7	Swing SR. The ACGME outcome project: retrospective and prospective. Med Teach 2007; 29: 648-54.
8	GMC - General Medical Council: Tomorrow's doctors. Available from: http://www gmc-uk org/Educating_Tomorrows_Doctors_ working_group_report_ 20080620_v1 pdf_30375087 pdf. Accessed: September, 2009.
9	Fisher WR. Human communication as narration: toward a philosophy of reason, value, and action. Columbia, S.C.: University of South Carolina Press, 1987.
10	Greenhalgh T. Narrative based medicine: narrative based medicine in an evidence based world. BMJ 1999; 318: 323-5.
11	Greenhalgh T, Hurwitz B. Narrative based medicine: why study narrative? BMJ 1999; 318: 48-50.
12	Andreatta PB. A typology for health care teams. Health Care Manage Rev 2010; 35: 345-54.
13	Manser T. Teamwork and patient safety in dynamic domains of healthcare: a review of the literature. Acta Anaesthesiol Scand 2009; 53: 143-51.
14	Scheele F. The story of health care's Achilles' heel. Med Teach 2011; 33: 578-9.
15	Veltman L, Larison K. P.U.R.E. (purposeful, unambiguous, respectful, and effective) Conversations and electronic fetal monitoring: gaining consensus and collaboration. Am J Obstet Gynecol 2010; 203: 440-4.
16	Westerman M, Teunissen PW, van d, V, Scherpbier AJ, Siegert CE, van der LN, et al. Understanding the transition from resident to attending physician: a transdisciplinary, qualitative study. Acad Med 2010; 85: 1914-9.
17	Jung HP, Wensing M, Grol R. What makes a good general practitioner: do patients and doctors have different views? Br J Gen Pract 1997; 47: 805-9.
18	Williams SJ. What skills do physician leaders need now and in the future? Physician Exec 2001; 27: 46-8.
19	Semeijn JH, Velden van der R, Heijke H, Vleuten van der C, Boshuizen HPA. Competence indicators in academic education and early labour market success of graduates in health sciences. J Educ Work 2006; 19: 383-413.