University Medical Center Utrecht, Utrecht, The Netherlands.
Mid-West Intern Network, University of Limerick, Limerick, Ireland.
Med Educ. 2024 Jan;58(1):93-104. doi: 10.1111/medu.15162. Epub 2023 Jul 16.
The conceptualisation of medical competence is central to its use in competency-based medical education. Calls for 'fixed standards' with 'flexible pathways', recommended in recent reports, require competence to be well defined. Making competence explicit and measurable has, however, been difficult, in part due to a tension between the need for standardisation and the acknowledgment that medical professionals must also be valued as unique individuals. To address these conflicting demands, a multilayered conceptualisation of competence is proposed, with implications for the definition of standards and approaches to assessment.
Three layers are elaborated. This first is a core layer of canonical knowledge and skill, 'that, which every professional should possess', independent of the context of practice. The second layer is context-dependent knowledge, skill, and attitude, visible through practice in health care. The third layer of personalised competence includes personal skills, interests, habits and convictions, integrated with one's personality. This layer, discussed with reference to Vygotsky's concept of Perezhivanie, cognitive load theory, self-determination theory and Maslow's 'self-actualisation', may be regarded as the art of medicine. We propose that fully matured professional competence requires all three layers, but that the assessment of each layer is different.
The assessment of canonical knowledge and skills (Layer 1) can be approached with classical psychometric conditions, that is, similar tests, circumstances and criteria for all. Context-dependent medical competence (Layer 2) must be assessed differently, because conditions of assessment across candidates cannot be standardised. Here, multiple sources of information must be merged and intersubjective expert agreement should ground decisions about progression and level of clinical autonomy of trainees. Competence as the art of medicine (Layer 3) cannot be standardised and should not be assessed with the purpose of permission to practice. The pursuit of personal excellence in this level, however, can be recognised and rewarded.
医学能力的概念是其在以能力为基础的医学教育中的应用的核心。最近的报告中呼吁“固定标准”与“灵活途径”，这需要明确界定能力。然而，由于标准化的需要和承认医疗专业人员也必须作为独特的个体得到重视之间存在紧张关系，使能力变得明确和可衡量一直很困难。为了解决这些相互冲突的需求，提出了一种多层次的能力概念化，这对标准的定义和评估方法都有影响。
阐述了三个层次。第一层是核心层的规范知识和技能，即“每个专业人员都应该具备的”，独立于实践背景。第二层是依赖于背景的知识、技能和态度，通过医疗保健中的实践可以看出。第三层个性化的能力包括个人技能、兴趣、习惯和信念，与个性相结合。这一层，参考了维果茨基的“体验”概念、认知负荷理论、自我决定理论和马斯洛的“自我实现”理论进行了讨论，可以被视为医学的艺术。我们提出，完全成熟的专业能力需要这三个层次，但每个层次的评估是不同的。
对规范知识和技能（第 1 层）的评估可以采用经典心理计量学的条件，即对所有候选人采用相似的测试、情况和标准。依赖于背景的医学能力（第 2 层）必须以不同的方式进行评估，因为评估条件不能在候选人之间标准化。在这里，必须合并多个信息来源，并以专家之间的共识为基础，做出关于学员的进展和临床自主性水平的决定。医学艺术层面的能力（第 3 层）不能标准化，也不应该评估其是否具备行医许可。然而，在这个层面上追求个人卓越是可以得到认可和奖励的。
