Assessing and Sustaining Competence in Rural Practice

“Competence depends on habits of mind, including attentiveness, critical curiosity, self-awareness, and presence. Professional competence is developmental, impermanent, and context dependent.”¹

Competency-based approaches to physician education and training have made important contributions to our effectiveness as educators in medical school and residency. The scoping review by Schmitz et al in this issue of Family Medicine is yet another important call to continued research into the curricular content and outcomes of training programs designed to prepare physicians for rural practice in the United States.^2,3

Their review also represents a call to curricular redesign and the continuing pursuit of new measures of competence useful to daily practice. In 2008 and 2016, medical educators struggled to measure what mattered most in competent rural practice.⁴ We identified domains of competence that, although not necessarily unique or restricted to rural practice, seemed uniquely important.

• Adaptability,

• Agency and courage,

• Collaboration and community responsiveness,

• Comprehensiveness,

• Integrity,

• Abundance in the face of scarcity and limits,

• Reflective practice, and

• Resilience.

Several of these domains were elaborated in a series of teaching kits still available online, including “Good Fences,” which explores the domain of integrity and navigating the dual relationships so prevalent in rural practice.⁵ These domains proved difficult to quantify and were not easy to fully capture in a list of observable behaviors and measurable competencies. We concluded that perhaps they were better not deconstructed but kept whole as character traits or virtues.

For several decades our energies as medical educators have been substantially consumed with competency-based education (CBE) in a variety of forms, both nationally and internationally. These approaches have generally reduced competence to checklists of behaviors, competencies, and milestones at selected points in time, conflating the sum of these competencies with true competence. Unfortunately, the literature in CBE still frequently uses the terms “domains” and “competencies” interchangeably and without definition. The lack of a framework that includes effective assessment and ongoing self-assessment of character represents a key gap and barrier to further collaboration in research and curricular development across geography and disciplines. Recently, there have been increasing calls for a necessary correction and a path toward virtue and character.^6,7

Competence in any setting is a matter of both performance at graduation and habit in life, a matter of both phronesis and praxis, as broadly defined in a seminal JAMA article and editorial in 2002 (quoted above) and reiterated in the literature several times since.^1,8,9 It requires both important knowledge, attitudes, and skills and character. The domains of competence we identified in 2016 seemed less about the former and more about the latter, perhaps more suited to a role as attractors and beacons guiding character development and lifelong commitment to excellence. Like hiking in the wilderness, practicing in a rural community requires both a credential and a compass. This is not unique to rural practice, even if it is uniquely important in that setting. Urban practice, where despite abundant street signs it’s still easy to get lost in a crowd, requires a compass as well. But competent practice may take different forms in rural and urban contexts.

Character development in education and training intended to sustain competence over a lifetime requires a curricular strategy that is competency-based but not competencies-bound. In nurturing sustained competence, we proposed an approach that is both competency-based and virtue-oriented, with each strategy being complementary to the other. Such an approach is emergent, context dependent, and oriented toward domains that function more as attractors than as measurable skill sets.¹⁰ Documenting progression of this element of competence requires holistic measures and tools for accurate self-assessment and reassessment over a lifetime.

A character-oriented approach to curriculum design and development must go beyond “knowing about” (defined by content), to “knowing how” (defined by process and intermediate outcomes), to sustained “knowing and doing in context” (competence defined as a habit and a virtue). This framework extends the linear Dreyfus model (novice to master) to include lifelong cycles of competence renewed: from unconsciously incompetent, to consciously incompetent, to consciously competent, to unconsciously competent, only to enter the cycle yet again.¹¹ In ths process, measures of competence must function both as compass and credential.

The best doctors become more competent over time. They continually improve through daily recalibration in responding to feedback, to changing circumstances and contexts, and to changing knowledge, making moment-by-moment corrections, always with a vision and equipped with tools that guide them. This constant recalibration leads such doctors toward excellence and keeps them grounded in the needs of their patients and community.

Revisiting the construct of the “good doctor” is essential to reframing our approach to medical education and training from a purely technical task to one that is adaptive to context. The “good doctor” develops character in the pursuit of excellent patient and community care as well as personal and professional development. Just as virtue ethics complements principle-based ethics, so also competency-based education and training must pair with character development and growth of moral agency in communities where “the virtues flourish.”^12,13

This process begins already in medical school and residency. The competent student who enters medical school with a strong moral compass and later becomes a competent physician adapts their growing list of competencies to specific community settings, pursuing excellence over a career and a lifetime. The question of competence becomes a daily one, “Was I competent today?” and “Am I headed in the right direction?” Learning to calibrate that compass in residency requires a curriculum designed to build character, something not so much taught as caught and shaped through the example of peers and faculty mentors and through facilitated reflection on experience.¹⁴ It requires a more holistic and directional approach to self-assessment.

Taking such an approach could restore the emotionally powerful language of competence to its full measure.¹⁵ As we prepare physicians for rural practice, or in any setting in general, our challenge is to build a curriculum that is effective in assessing and sustaining competence in continuing practice. I challenge readers at any stage of their career to share their compasses with others, build a base of evidence for its calibration in training and practice, and as Schmitz et al call us, continue the work of refining that CBE credential—through research, dialogue, and example.