3A.08 Competencies

At the turn of the century, medical education, inspired by a renewed emphasis on the essential abilities physicians need for optimal patient outcomes and on preparing students for clinical practice, switched from problem-based learning to an outcomes-based or competency-based approach. The CanMEDS competency framework, which was developed in the 1990s, is probably the best-known example of this approach [1]. Nowadays, all Dutch medical-specialist curricula are based on this competency framework [100]. The CanMEDS framework comprises numerous competencies organized thematically around seven meta-competencies or roles that a physician should master. At the heart of the framework lies the physician's role as Medical Expert, complemented by six generic roles such as Communicator, Collaborator, and Manager. As medical experts, physicians integrate all areas of expertise defined by the CanMEDS framework. Thus, expertise that is defined as the superior and stable ability to handle challenging situations [101], is the benchmark for the assessment of physicians' ability to handle clinical situations. Challenging patient-education issues that are mentioned in the CanMEDS framework are: obtaining informed consent; delivering bad news; addressing anger, confusion and misunderstanding; and dealing with non-adherence. The introduction of the CanMEDS framework in undergraduate and postgraduate curricula influenced the teaching of communication skills in several ways. Firstly, since the key competencies of the communicator role explicitly refer to patient-education competencies, the teaching of patient-education skills was gradually implemented in undergraduate curricula [102,103] and in postgraduate courses [104]. However, during their internships, students still focus their attention on history-taking and time-management, and are still not supposed to educate their patients [105]. Secondly, the concept of patient-centeredness was criticized and regarded as being unsuitable as a leading concept for communication programs [14,41]. Today, a functional approach is advocated, in which the physicians' communication tasks and matching skills are derived from the goals and desired outcomes of the consultation [40-42,106]. Thirdly, workplace-based learning came into focus. Workplace-based learning means that students and residents improve their competencies by applying their knowledge and practicing their skills in supervised clinical situations followed by constructive feedback and reflection. New assessment methods matching workplace-based learning were also developed, such as the mini-clinical evaluation exercise (mini-CEX), the direct observation of procedural skills (DOPS), and multisource feedback [107,108]. All the assessments, feedback, and reflections that a learner has collected are documented in the learner's portfolio. As mentioned previously, communication assessment and feedback based on videoed consultations already existed in primary care and general-practice vocational training. In undergraduate education several initiatives have since been developed using videoed consultations for self-assessment, feedback, and reflection [109]. However, we have found no study that has used videoed consultations for communication assessment and feedback in medical-specialist training.