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Exploring Integration in Action: Competencies as Building Blocks of Expertise

Mylopoulos, Maria PhD; Borschel, Debaroti (Tina) MD; O’Brien, Tara MD; Martimianakis, Sofia MA; Woods, Nicole N. PhD

doi: 10.1097/ACM.0000000000001772
Research Reports

Purpose Competency frameworks such as the CanMEDS roles and the ACGME core competencies may lead to the implicit assumption that physicians can learn and practice individual competencies in isolation. In contrast, models of adaptive expertise suggest that the integration of competencies reflects the capabilities of an expert physician. Thus, educational programming aimed at teaching discrete roles or competencies might overlook expert physician capabilities that are central to patient care. To develop expertise, learning opportunities must reflect expert capabilities. To better understand the relationship between competency-based medical education and expert development, the authors sought to explore how integrated competencies are enacted during patient care by postgraduate medical trainees.

Method Using a cognitive ethnographic approach, in 2014–2015 the authors conducted observations and—to refine and elaborate these observations—ad hoc informal interviews with 13 postgraduate trainee participants. Data collection resulted in 92 hours of observation, 26 patient case portraits, and a total of 220 pages of field notes for analysis. Through analysis, the authors identified and examined moments when postgraduate trainees appeared to be simultaneously enacting multiple competencies.

Results The authors identified two key expert capabilities in moments of integrated competence: finding complexity and being patient-centered. They described two mechanisms for these forms of integration: valuing the patient’s narrative of their illness, and integrated understanding.

Conclusions Understanding integrated competencies as the building blocks of expert capabilities, along with recognizing the importance of mechanisms that support integration, offers an opportunity to use existing competency-based frameworks to understand and teach adaptive expertise.

M. Mylopoulos is assistant professor and scientist, Wilson Centre and Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada.

D.(T.) Borschel is associate professor, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.

T. O’Brien is assistant professor, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.

S. Martimianakis is research assistant, Wilson Centre, University of Toronto, Toronto, Ontario, Canada.

N.N. Woods is assistant professor and scientist, Wilson Centre and Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.

Funding/Support: This study was funded by the Royal College of Physicians and Surgeons of Canada, Royal College/AMS CanMEDS Research and Development Grant, 13/AMS-01. This work is supported by the Medical Psychiatry Alliance, a collaborative health partnership of the Centre for Addiction and Mental Health, the Hospital for Sick Children, Trillium Health Partners, and the University of Toronto, as well as the Ontario Ministry of Health and Long-Term Care and an anonymous donor.

Other disclosures: None reported.

Ethical approval: This study was approved by the Research Ethics Board at Women’s College Hospital in Toronto, Ontario, Canada, on November 11, 2013.

Correspondence should be sent to Maria Mylopoulos, Wilson Centre, 200 Elizabeth St., ES 1-565, Toronto, ON M5G 2C4; telephone: (416) 340-3615; e-mail:; Twitter: @mmylopoulos.

© 2017 by the Association of American Medical Colleges