Fig. 21.1
The CanMEDS Roles Framework. (Copyright © 2015 The Royal College of Physicians and Surgeons of Canada. http://www.royalcollege.ca/rcsite/canmeds-e (Reproduced with permission)
For this chapter, our point of departure was the 2005 version of the CanMEDS. Because this model is constantly in flux, to a certain extent the roles are also described on the basis of the 2015 draft version of CanMEDS 2015, in which the roles have been defined in even greater detail. We will distinguish the following seven roles:
Professional
Collaborator
Communicator
Manager (also leader/organizer)
Scholar (also knowledge worker/tutor)
Health advocate (also innovator/ethicist/lawyer/quality manager)
Medical expert
Occasionally, the related secondary roles such as leader, tutor, organizer, etc., will also be touched upon in this chapter.
A great advantage of thinking in terms of meta-competences is that it offers a common frame of reference—a universal language to describe what a person needs to do and not do in order to become, to be, and to continue to be a good professional. The disadvantage of a meta-level approach is that the ideas and terminology that go with it soon tend to become abstract and incomprehensible. At present, this is reflected in the world of medical training, which is changing at an ever-increasing pace. The gap between the education architects and the clinical lecturers who do the actual teaching is growing wider every day. Because of all the different educational concepts and jargon, often clinicians can no longer see the educational wood for the trees. For this reason, the main aim of this contribution is to provide insight into thinking in meta-competences as an aid to shaping teaching and training in practice. The following topics will be addressed:
A literature review – a compact outline of the principles on which working with meta-competences are based, as applied to clinical settings.
A small-scale empirical study of what authors in a specific sub-domain of healthcare, psychosomatic obstetrics, and gynecology, regard as core competences.
An ongoing case report, which illustrates the links between theory, empirical research, and practice. We will follow the experiences of a number of colleagues who have to deal in various ways with an external review of the teaching given to trainees in obstetrics and gynecology. They take on changing roles, as is highlighted by putting those roles in parentheses in italic type.
Case Report
Prof. Esther Crimson feels honored but also a little apprehensive. She has been asked to chair the assessment committee for an external peer review of training in a regional training hospital. She is honored first and foremost because she has finally reached a position in which she can make a difference (innovator, leader). As an expert in her field, she knows better than anyone else where the shortcomings in training lie (knowledge worker).
If she is honest with herself, her vanity also plays a role because of course “the Crimson Committee” sounds very flattering (professional). However, she also feels uncomfortable because she feels that as an educator she is not really a star (knowledge worker, trainer). While she scores above average for her lectures and seminars, this is not the same as developing “competence-oriented training in a learning landscape centered on co-creation and co-leadership” (innovator).
Fortunately, she will be supported by an expert staff member, David Olive, with whose help she can also select the other members of the committee (collaborator, knowledge worker). Of course there is also a manual setting out the procedure, and the primary focus is on self-evaluation by the institution itself (leader). To prepare herself as well as possible, Esther immerses herself in the information David has sent her in order to learn as much as possible about the self-evaluation report, the criteria for selecting committee members, and above all in “competence-oriented training” (knowledge worker, trainer).
21.2 Further Examination of Theory
- 1.
The concept of competence
- 2.
Thinking tools
- 3.
Educational architecture
- 4.
Training in practice
- 5.
Conclusions (based on the literature)
21.2.1 The Concept of Competence
Even in ancient Greece and Rome, people were interested in the question of how to tackle problems competently. Odysseus is regarded as the model of a clever and pragmatic problem-solver. In the past, competence has been more or less synonymous with the ability to act. Over the past century, the concept has broadened considerably and related terms have been introduced, such as “habits” [2, 3], “tacit knowledge” [3], “embodied cognition” [4–6], “capital” [7], “agency” [8], “capabilities” [9], and “thinking tools” [10].
For the purposes of this book, we will use the following pragmatic definition:
“Competences consist of the repertoire of behaviors and actions a health professional can use to solve complex problems in a wide range of situations in an inventive and creative way.” This definition is closely linked to the six characteristic properties attributed to competences by Merriënboer et al. [11]:
- 1.
Competences are context-dependent: the choice made from the broad repertoire of behaviors depends on what is required at a particular time, in a specific situation.
- 2.
Competences are indivisible: they are clusters of skills, knowledge, attitudes, characteristics, and understanding which in terms of content are inseparable from each other.
- 3.
Competences can change in the course of time and evolve as personal attributes over the years along with the health professional’s lifelong learning.
- 4.
Learning and development processes are crucial to the acquisition of competences.
- 5.
Competences are linked to specific activities and tasks; they are manifested in behavior that is visible and can therefore also be tested.
- 6.
Competences are related to each other in a certain way. The acquisition of a competence requires the presence of other competences.
These characteristics make it possible to use competences as building blocks to arrive at an inventive and creative solution for each problem. Regardless of whether the problem to be solved is a clinical one or, for example, how to implement a new training curriculum, in all situations the health professional, like an architect, has to design the ideal plan. Perhaps this sounds somewhat abstract and technocratic, but to thinkers, concepts and theories are what tools are to tradesmen. Concepts are the mental tools that enable people to cope, to exercise a certain degree of influence on their environment, and to act effectively and efficiently in a variety of contexts [12].
Case Report: Continued
When Esther Crimson and her team arrive at the hospital, she is cordially welcomed by an enthusiastic pair. Juliette Sapphire introduces herself as the trainer (leader) and Pascal Orange as her deputy trainer (collaborator). Together they form a kind of training tandem and as such they have taken on the worthy but labor-intensive task of writing the self-evaluation report. This report will serve as a starting point for the entire review procedure and also as a common thread running through it.
They have also drawn up a schedule for the review team to talk to the training group, the trainee gynecologists, the dean of the faculty, co-trainers from other disciplines in the hospital, the Chair of the Board of Management, the clinical midwives, the nurses, and the manager of the hospital’s Learning Center. In short, a wide variety of people will make an appearance, with Juliette and Pascal acting as a uniting factor.
Although there is a full—if not overloaded—agenda, Esther thinks it is important to take plenty of time to get to know their hosts for the day personally (communicator, collaborator). She always does this with her patients, and in this case too, her investment in the relationship pays itself back many times over. By first asking Juliette and Pascal what they are proud of, she immediately creates an open and pleasant atmosphere.
Because they feel safe, Juliette and Pascal soon have the confidence to confess that in spite of their careful preparation, something has gone wrong. Some of the information requested is not available (leader, organizer). Fortunately, most of the basic documents such as the annual reports about procedures (operations and deliveries) and patient numbers are in fact present, as are the minutes of the training meetings over the past year and the dates and topics of the teaching sessions. What is missing is the results of the annual internal surveys about the training environment (leader, trainer).
Even though contacts with the trainee gynecologists usually go smoothly (collaborator), the evaluation of perceptions of this kind is always somewhat stressful, because it reflects the trainees’ subjective perception, and just as with patient experiences, it is always subject to the mood of the day. What a person says about yesterday’s experience depends on both today and yesterday. Esther realizes immediately that this is a good time to make a virtue of necessity (leader, innovator), precisely because this is a matter of subjective perception. She resolves to simply ask the trainees about this when she talks to them. After all, a dialogue is a much better tool for assessing mood and atmosphere than a written survey (communicator). However, she also decides to use this omission as a test case for the organizational creativity and stress resistance of the training tandem (leader, professional). And just as she thinks of this, she also realizes that in the same communication action she can make it clear that responsibility must always be placed where it belongs (professional).
“So what do you suggest now?” she asks, in a tone that is both friendly and firm. Fortunately, it turns out the trainers are made of the right stuff; they suggest that no matter how stressful this may be for themselves, the trainees’ evaluation should simply be put on the agenda of the interviews with the trainees (professional). They will get back to the Central Training Committee about the missing survey results. When this suggestion seems to meet with everyone’s approval, Esther remembers the wise words of one of her own trainers: “Medicine may be a career for doers, but words are the deeds of the powerful” (communicator).
David Olive uses the natural pause that follows to raise a more formal point. “Madam Chair, I have noticed that over the past year many training meetings have been cancelled (Leader, Knowledge Worker). The meetings of this Trainers’ group also have a relatively low attendance rate. Can anybody here explain this to me?”
Juliette replies slightly annoyed, “Yes, just in terms of our own teaching, this is actually a difficult issue. To encourage the trainees to make their own contribution, 2 trainees are given responsibility for each session in the teaching program. Some pairs are more active than others, but there are other factors as well. All the gynecologists, and sometimes guest speakers, take turns to give lectures. Everyone agreed to this, but apparently in practice it’s very difficult to leave the operating theater or the outpatient clinic on time. Even though the secretary makes sure the colleagues in question are scheduled not to be working with patients at those times, it sometimes happens that the teaching session has to be cancelled at the last minute because there is no lecturer (Organizer). A second factor is the presence of the trainees themselves. Either they’re still in the operating theater, or they’re still working in the delivery rooms, or they’re at a different location, they’re off duty after their work, they’re on holiday, pregnant, or whatever, so that there are never enough trainees present at the teaching sessions. It drives me mad.”
Esther sees the frustration on Juliette’s face and uses the same strategy as before, asking “And what have you done to solve this problem?” Pascal answers quickly. He knows Juliette. If she is frustrated about something that is not going the way she wants it to, she can sometimes go overboard in her reaction (collaborator, communicator, professional). He says calmly, “That is a very legitimate question. I think up till now we have all just been very irritated, but no-one has felt called upon or able to do anything about it.” Juliette nods as he speaks, a little embarrassed (communicator). Pascal then speaks to her directly, “Juliette, I do think it would be a good idea to discuss this point with the whole training team some time. After all, it’s our joint responsibility, not just yours or mine. I also think it would be good to have a meeting with the trainees and see if we can come up with some creative solutions for the teaching program (Innovator, Knowledge Worker). I recently saw an option for a simple digital connection that enables people at other locations to follow a presentation. I already wanted to talk to you about that, but this is a very good reason to do so” (communicator, collaborator, leader). Esther and David exchange a quick glance. Then Esther summarizes the intentions stated and David records them in the minutes. Esther concludes by saying, “Thank you for your thoughtful answer.”
21.2.2 Thinking Tools
Just as there is a world of clinical reasoning hidden beneath clinical actions, the CanMEDS roles and the meta-competences that go with them are above all the product of methodical problem-solving thinking. To put it more strongly, they themselves can be characterized as thinking tools [10]. Building on Popper’s 3-world theory [13], Veening et al. [14] differentiate domains in which these thinking tools can be used: the physical domain, the psychological domain, and the social and cultural domain. Since ideas about these three domains form the core of the biopsychosocial (BPS) model (see also Chap. 24), we will discuss them briefly in the sections that follow.
21.2.2.1 The Physical Domain
The basis of our problem-solving capacity is physical. Based on neurobiological research, Damasio stresses that intelligence cannot be localized to one area of the brain and is not limited to the seat of our consciousness [5, 6]. A certain type of thinking activates several parts of the nervous system. In this context, Den Boer refers to “embodied cognition”: The brain is in constant interaction with the body and the environment [4]. The brain is not static but plastic. Stressful circumstances have a negative impact on the micro-architecture of the brain. Polanyi draws attention to the importance of sensorimotor knowledge, which is literally embodied [3]. This knowledge is tacit and partly also preverbal, which is why it can only be made explicit to a limited extent. In other words, we know more than we are aware of. This is, in fact, essential, because this implicit background knowledge enables us to focus on complex problems that require our attention. While sensory knowledge can be converted into symbolic and theoretical knowledge [15], experienced professionals generally rely on their physical behavioral repertoire when solving problems. This is why gaining clinical experience—building up “flight time”—is so important.
21.2.2.2 The Psychological Domain
We need symbols and concepts, such as images and language, to make physical knowledge explicit. Through communication we share our knowledge and experience and gradually develop something like a shared sense of common practice. Emotions, as a hybrid of physical experiences and mental representations, play an important role in communication. In particular, intense emotions such as rage, disgust, or horror can have an adverse effect on clinical reasoning because emotions of this kind are accompanied by irrelevant or irrational thoughts. One of the characteristics of professionalism is the ability to regulate one’s own behavior in spite of the emotions that will inevitably arise. This ability to control one’s own behavior—referred to as self-management—is based on insight into one’s own personal and professional values. Relating these values to the demands of the context enables a professional to reconcile even fundamental contradictions. This is referred to as “clinical leadership.” A few examples of dilemmas in which leadership is essential are those involving
Professional autonomy versus interdependence
Individual interests versus group interests
Loyalty to the patient versus loyalty to the organization
Identification with one’s own profession versus identification with the organization
Professional interests versus financial interests
Work interests versus private interests
To be able to weigh the conflicting interests against each other, you must be able to put yourself in the conflicting positions that go along with these interests. This ability, to put yourself in different positions, is known as empathy. Empathy is one of the most fundamental prerequisites of leadership and professionalism.
21.2.2.3 The Social or Communal Domain (of Ideas and Theories)
Effective action also depends on the social and cultural environment in which one is acting. A professional can be dysfunctional in one context but act effectively in a different situation using the same competences. Behavior depends on the situation and the context. Every profession has its own special features, such as clothing, language (professional jargon), etc., by which the members can recognize each other. In addition to this recognizability, conventions and symbols also give the professionals in the group something they can rely on. However, while conventions and symbols may provide a kind of support, they can also lead to rigidity and irrational behavior.
To summarize, we can imagine that competences are like a Rubik’s cube: the core is an indivisible unit whose exterior always manifests itself integrally in the biological, psychological, and sociocultural domains (Fig. 21.2).
Fig. 21.2
The Rubik’s Cube® (Rubik’s Brand LTD, London, UK) reflects competences: core as indivisible unit; exterior manifests itself integrally in the biological, psychological, and sociocultural domains. (Left photo by Hangsna https://commons.wikimedia.org/wiki/File:Rubiks_cube_inside.JPG#file. Used under Creative Commons license: CC BY-SA 3.0: http://creativecommons.org/licenses/by-sa/3.0; Right photo: Rubik’s Cube® (Used by permission of Rubik’s Brand LTD, www.rubiks.com)
This approach to competences as thinking tools to shape the development and training of healthcare professionals is completely in line with the BPS model, which is the core of the psychosomatic approach to disease and health.
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