To the Editor:
In their article earlier this year, Jones and colleagues1 reviewed arguments that core competencies may not deal with the reality of medical students' and residents' learning environment, stating that “unless the general competencies are clearly linked to clinical care, they are difficult to grasp.” They propose to address the student's reality by not focusing on deconstructing behaviors related to competency but on a more holistic model, proposed by others,2 of assessing entrustable professional activities (EPAs). However, to assess EPAs, a new set of deconstructed behaviors becomes essential. I am concerned that over time the EPAs in operation could become as reified as today's core competencies are.
I acknowledge that developing a process for assessing trainees' growth in patient care skills is difficult. Knowing that trainees can perform a number of distinct tasks when observed does not mean that they can, in fact, adequately examine and treat a patient. In the same way, an individual may know and perform each of the tasks essential to flying a plane but be completely unable to pilot one. We must develop new assessment tools to inform us of our students' skills in addressing the complex actions involved in patient care. Such tools are essential if we are to adequately ensure the public of the abilities of our nation's physicians. I applaud the motive behind Jones and colleagues' proposals, but I think the proposals themselves—specifically, the EPAs and their use—may end up looking like today's core competencies.
We must not forget that students see ensuring their competence in patient care as their primary concern. Obtaining this ability is what organizes the lives of medical students and residents. Physicians' clinical competence is also the key construct that we all use in selecting a physician to make a difficult diagnosis or perform a complex procedure. Most, if not all, of us, if asked to be cared for by a television doctor if we had a serious medical problem, would select Dr. Gregory House of the TV series House. He would fail most of the core competencies except for knowledge and skill.
Sidney Herman Weissman, MD
Professor of clinical psychiatry, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; [email protected].
1 Jones MD, Rosenberg AA, Gilhooly JT, Carraccio CL. Perspective: Competencies, outcomes, and controversy—Linking professional activities to competencies to improve resident education and practice. Acad Med. 2011;86:161–165. http://journals.lww.com/academicmedicine/Abstract/2011/02000/Perspective__Competencies,_Outcomes,_and.11.aspx
. Accessed July 22, 2011.
2 ten Cate O, Scheele F. Competency-based postgraduate training: Can we bridge the gap between theory and clinical practice? Acad Med. 2007;82:542–547. http://journals.lww.com/academicmedicine/Fulltext/2007/06000/Viewpoint__Competency_Based_Postgraduate_Training_.4.aspx
. Accessed July 22, 2011.