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Toward Authentic Clinical Evaluation: Pitfalls in the Pursuit of Competency

Ginsburg, Shiphra MD, MEd; McIlroy, Jodi PhD; Oulanova, Olga MA; Eva, Kevin PhD; Regehr, Glenn PhD

doi: 10.1097/ACM.0b013e3181d73fb6
Physician Competencies

Purpose The drive toward competency-based education frameworks has created a tension between competing desires—for quantified, standardized measures on one hand, and for an authentic representation of what it means to be a good doctor on the other. The purpose of this study was to better understand the tensions that exist between competency frameworks and faculty's real-life experiences in evaluating residents.

Method Interviews were conducted with 19 experienced internal medicine attendings at two Canadian universities in 2007. Attendings each discussed a specific outstanding, average, and problematic resident they had supervised. Interviews were analyzed using grounded theory.

Results Eight major themes emerged reflecting how faculty conceptualize residents' performance: knowledge, professionalism, patient interactions, team interactions, systems, disposition, trust, and impact on staff. Attendings' impressions of residents did not seem to result from a linear sum of dimensions; rather, domains idiosyncratically took on variable degrees of importance depending on the resident. Relative deficiencies in outstanding residents could be overlooked, whereas strengths in problematic residents could be discounted. Some constructs (e.g., impact on staff) were not competencies at all; rather, they seem to act as explanations or evidence of attendings' opinions. Standardized evaluation forms might constrain authentic depictions of residents' performance.

Conclusions Despite concerted efforts to create standardized, objective, competency-based evaluations, the assessment of residents' clinical performance still has a strong subjective influence. Attendings' holistic impressions should not be considered invalid simply because they are subjective. Instead, assessment methods should consider novel ways of accommodating these impressions to improve evaluation.

Dr. Ginsburg is associate professor of respirology and internal medicine, and clinician educator/researcher, Wilson Centre for Research in Education, University Health Network, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.

Dr. McIlroy is assistant professor, Department of Medicine, University of Toronto, and affiliated scholar, Wilson Centre for Research in Education, University Health Network, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.

Ms. Oulanova is a PhD candidate, Department of Adult Education and Counseling Psychology, Ontario Institute for Studies in Education, University of Toronto, Toronto, Ontario, Canada.

Dr. Eva is associate professor, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.

Dr. Regehr is professor, Department of Surgery, and associate director, Centre for Health Education Scholarship, University of British Columbia Faculty of Medicine, Vancouver, BC, Canada.

Correspondence should be addressed to Dr. Ginsburg, Mount Sinai Hospital, 433-600 University Avenue, Toronto, Ontario, Canada, M5G 1X5; e-mail:

© 2010 Association of American Medical Colleges