This document discusses issues related to competency and professionalism in healthcare. It raises questions about how competency is defined and assessed, and whether the current focus on competency is sufficient. It suggests competency may be better defined by a professional's engagement, interpersonal skills, and commitment to doing their best rather than just technical skills. A strictly legalistic or bureaucratic approach is not optimal and does not address important psychological and social factors like workplace engagement that influence professional practice. Multiple perspectives are needed to understand and address issues of quality, safety and professionalism.

1. Zubin Austin BScPhm, MBA, MISc, PhD
Professor
University of Toronto
Canada

2. What keeps you
awake at night?

3.  High-profile cases of “breach of duty of care”
amongst professionals
 Growing calls for accountability – and “action”
- from politicians and the public
 Tension between professional expertise and
an increasingly well-educated public with
unfettered access to information

4.  Declining public esteem for professionals
 Shifting self-identity of professionals from
“vocation” to “job”
 Squeaky wheels getting oiled within an
environment of austerity and scarcity
 General narrative of “decline” and “self-
reliance” vs “common goods” and “trust”
 In a world where some patients know more
about their health care than practitioners
do…what does it mean to be a professional?

5.  Who actually still believes that “professionals”
solve problems and make society better?
 Does anyone believe that another Mid-Staffs
(or HSC or Royal Winnipeg Hospital) really
won’t happen again?

6.  A nurse has been badgering a physician for a
prescription for a patient. Finally, at 9:00pm,
the prescription is written, and the nurse
sends it off to the pharmacy…which closed at
9:00pm.

7.  A physiotherapist is trying to assess a
patient’s mobility and joint status and needs
an x-ray ordered to do so properly. He
approaches a medical resident from the team,
and is informed that the patient in question
“…isn’t mine”.

8.  “The quality of being adequately or well-
qualified, physically or intellectually”
 The basis for evaluating success, and
defining readiness for practice, in education,
regulation, and employment
 In reality, means different things to different
people at different times in different
contexts, yet….

9. What do patients want from health care
professionals?
- Accessibility
- Affability
- Acknowledgement

10.  Complaints about practitioners are rarely due
to “an honest mistake”
 Impoliteness is the most frequent cause of
complaint
 <2% of practitioners are generally complained
about within most professions and even
fewer end up before a disciplinary or fitness
to practice committee
Competency = interpersonal savvy

11.  Day-to-day professional practice is
tough…and getting tougher
 Decreasing autonomy, increasing demands,
burnout, and fatigue
 Legalism dominates clinical judgment
 In the context of error, “…there but for the
grace of God go I…”
Competency = good luck and NOT being in the
wrong place at the wrong time

12.  Safety: of the public
 Transparency: for members
 Accountability: to multiple stakeholders
 Consistency: like cases being judged
similarly
 Adversarial: follows principles of
administrative law
Competency = a contested and contestable
(political?) construct

13.  Tension between developmental and
psychometric dimensions…and increasingly
financial constraints
 Idealistic desire to prepare individuals for a
life time of practice, not simply to pass
tomorrow’s test at odds with financial reality
and league-table mentality
 Certification function trumps most others –
commodification of personal/professional
development
Competency = “our name is on this product”

14.  Operational efficiency and economies of scale
drive “production model” of care delivery
 SOPs dominate practice to facilitate
standardization, predictability, efficiency
 Data, workload measurement dominate
resource allocation and decision making
Competency = fitness for purpose/context

15.  Most frequently used tool currently available
to address multiple stakeholder needs/wants
 Built upon competency frameworks which
purport to define “the good practitioner”
 Significant allocation of time, resource and
energy…
 ….yet has this actually PREVENTED problems
from occurring? And has our focus on
competency assessment blinded us to other
ways of “seeing” professional practice?

16.  Attendance at CE does not translate into change
 Completion of CE does not predict whether
individuals will meet objectively defined
competency standards
 Individuals at greatest risk for competency drift
are: i) older (>25 years post-graduation); ii) work
in sole proprietorships; and iii) internationally
educated
 Only a very small number of practitioners are
ever found to be incompetent and sanctioned for
it
 We have no idea how many are at some stage of
competency drift

17.  Self-reporting: concerns regarding veracity, value, effort
and outcomes
 Complaints-driven: subjectivity/bias issues
 Mandatory CE: no evidence of impact
 Peer review: lack of standardisation, “n-of-1 problem”
 Patient satisfaction: “Dr. Shipman problem”
 Standardised test of knowledge: translate into
performance?
 Standardised test of performance: “trained monkey
problem”
 Revalidation: reinforces previous validation problems
 Secret shopper methods: ethics, culture of surveillance
 Outcomes measurement: too many confounders

18.  “It’s not my job”
 “If I answer this question, everyone is going
to come to me”
 “If I stay late this time, the nurses will never
learn that we close at 9:00 pm”
 “It’s just a job”

19. What if we were to define competency not as
“the quality of being adequately or well-
qualified physically or intellectually” but instead
defined it as “demonstration that you are firing
on all pistons, giving it your all?”

20.  Identified as a “root cause” of error in many health care
systems
 Traditionally used interchangeably with “satisfaction”:
focus is on creating organisations that “satisfy” workers –
frequently results in system-wide “bottom-up decision
making”, or “collaborative practice” models
 Psychologically, engagement refers to the balance point
between personal skills/interests and environmental
challenges, and is characterized by timelessness,
productivity, purposefulness, subjective connection
between individuals (“synchronicity” or “chemistry”)
 Do macro-level interventions produce micro-level
psychological changes?

21. Within a regimented, legalistic, bureaucratised
system….“(w)e cannot become attached to
higher aims and submit to a rule if we see
nothing above us to which we belong.”
E.D. ‘97

22. Anomie: condition in which (society) provides
little socio-ethical guidance to individuals; the
breakdown of social bonds between individuals
and the community results in fragmentation of
social identity and rejection of self-regulatory
values.

23.  Educators: emphasis on technical/procedural
mastery through hoop-jumping…in the name
of competency
 Regulators: legalistic constraint/replacement
for professional ethos…in the name of
competency
 Employers: mass-regimentation of
professional practice…in the name of
competency
 The problem of “do something…anything!”
and the need to be seen to act with certainty

24.  To think – apply complex and adaptive cognitive
skills to address ambiguous problems
 To observe – and not ignore cues and signals
 To care – about what they do and who they do it
to
 To connect – with their profession, their practice,
and their patient
 To try – to the best of one’s ability
 To understand – right answers vs “least worst
alternatives”
 To fire on all pistons – to bring the best of
themselves to their work and not simply think of
it as “a job”

26.  No one-size-fits all pattern or model seems to
apply; desire to proceduralise synchronicity is
itself a barrier to engagement
 Emotional intelligence emerging as a critical –
and under-examined – form of competence,
particularly in an interprofessional context
 Flexible, adaptive, authentic repertoire of
behaviours/responses best describe
synchronicity – defying attempts to formalise,
codify, or regulate
 Strong individual relationships with peers/team
may be associated with clinical success and
improved patient outcomes

27.  “To a hammer, everything looks like a nail”
 Complex issues defy simplistic
bureaucratised solutions
 Multiple factors require multiple stakeholders
to work in tandem with one another
 Rush to act following high-profile crises may
be politically satisfactory but ineffective
 There may not be a “right answer”, only “least
worst alternatives”

28.  Psychological needs of health and care
professionals for engagement, synchronicity,
interpersonal chemistry, and feeling of
belonging have not been adequately
examined
 While patient-focus is necessary, is it
sufficient to drive professional practice?
 While competency assessment is necessary, it
is probably not sufficient to ensure quality,
safety, and efficacy

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