TRAINING OF PHYSICIANS IN AND FOR A HUMANISED AND FAIRER GLOBALISED WORLD

Can we and should we continue training our residents with the same professional profile of as little as three years ago? What new skills must we introduce and work with in training to make future professionals more responsible and capable of managing universal and growing healthcare demands, with limited resources; professionals who have to continue acquiring knowledge (both scientific and technical) in a globalised world, full of uncertainty that should be moving towards greater equality?

We live in a delicate, historic time due to the major changes that society has experienced in recent years. Our lives revolve around problems occurring elsewhere on the planet, distant each from each other and thousands of kilometres from us. Just three years ago we were far less conscious of the impact that the decisions of others could have on our lives, with consequences (the current economic crisis) that are significant for our society and that will permanently affect the political, sociocultural, and moral environment of all societies. We are seeing the other side of the coin of globalisation; a phenomenon of economic interdependence that has been intensely experienced since the 1990s and that has resulted in the neoliberal politics we see today. Globalisation is taking place in the financial sector, but also effects politics, science, culture, education and healthcare1.

In terms of the training of healthcare professionals of any kind we should ask ourselves: For what (world) and for whom (people) are we doing this training? The direction that training institutions (universities, educational centres, and health centres/hospitals) should take is based on the need to humanise society2. In this respect, a goal of the process of training professionals must be to encourage a consciousness of universal citizenship, which will facilitate the process of change towards a new understanding of citizenship. Some time ago, organisations such as the World Health Organisation (WHO) recommended that, within the teaching environment and the practice of medicine, measures must be taken to provide education aiming to achieve equitable, efficient and comprehensive care for patients, families and communities, according to the needs and values of their society.

Medical training must undergo certain changes if it is to contribute to the amelioration of some of the deficits resulting from globalisation. The commitment of training institutions must be to enable the training of professionals by and for the community, teaching them about community values of solidarity and empathy, and to be able to put themselves in the shoes of others. This commitment must not be on paper alone, but should manifest itself through training programmes and the actions of teachers. This commitment should focus on training that strengthens, among other aspects, the bonds between different cultures, life-long learning, autonomy and personal and professional responsibility, a universal vision, and, lastly, caring, creative and critical thinking1. Training based around competencies and their evaluation allows us to tackle these challenges and commitments.

THE EUROPEAN AREA AND MEDICAL TRAINING IN

A CHANGING SOCIETY

Medical training in Spain is facing new challenges resulting from an important change in the educational scene in Europe: the European Higher Education Area (Bologna Declaration of 19993). A process of convergence has begun that has as its aim to facilitate the mobility of graduates and adapt the content of university studies to social demands. It is an attempt to create a Europe of knowledge (a knowledge society, an expression coined by Peter Drucker in 19694, not linked to the quantity of knowledge but rather to its productivity, that is, its economic impact). The Bologna Declaration states that «A Europe of Knowledge is now widely recognised as an irreplaceable factor for social and human growth and as an indispensable component to consolidate and enrich the European citizenship, capable of giving its citizens the necessary competencies to face the challenges of the new millennium, together with an awareness of shared values and belonging to a common social and cultural space».3  This does not just involve the mobility students, but also of professionals with the consequent recognition of qualifications, which implies a profound change in medical training models both at the university level as well as in specialty training. In addition, continuously changing social needs require dynamic health systems that must offer safe, effective, efficient, and high quality responses to the needs and expectations of citizens5.

The competency profile for health professionals should take into account the need for this responsiveness. Specifically, the profile must continuously be adapted and developed with new competencies, which in turn lead to modifications in learning and evaluation systems. This is important to guarantee, in the case of physicians, a good doctor-patient relationship in which there is a direct influence of  demographic, epidemiological, financial, legal, and scientific-technical changes, cultural aspects, ethics and values, and new models of organisation and healthcare management (clinical management), as well as of the media and the culture of consumption6. Regarding these changes, A. Jovell and M. Navarro7 highlight three social phenomena: changes in the labour structure of health professions, the appearance of a new patient/citizen model, and the transformation and increase in the complexity of knowledge management. To that, we must add the collectivisation of the provision of health services as a strategy to guarantee equitable access. The challenge for today’s physicians is to know how to respond effectively and efficiently to the needs of the 21st century and to the confidence placed in them by patients5.

Therefore, “the simple idea that a competent professional is one who possesses the knowledge and abilities that can lead to success in a specific profession is out of date. This idea has been replaced by the understanding that professional competency is a complex phenomenon which expresses the potential of individuals to direct their actions in the exercise of their profession with initiative, flexibility and autonomy, in diverse scenarios, based on the integration of knowledge, skills, motives and values, and is demonstrated by efficient, ethical, and socially committed professional work. It is necessary to eliminate fear of the unknown and join in the adventure of change from within; innovate and comprehend the new reality; and face up to the future and understand our role in this reality» (Pilar Martínez Clarés). Today’s training of tomorrow’s specialists means providing the competencies necessary to confront the uncertainties of future clinical practice, and appropriately manage future changes in society and within the medical profession itself (the areas of specialisation and collaboration between them, for example), as well as identifying and understanding the role of the physician among the various stakeholders that influence the profession of medicine (the state/governments, health organisations/corporations, the health technology and pharmaceutical industry, citizens and other health professionals8,9).

It is within this context of ever greater and more complex transformations that competency-based training (CBT) emerges to enable the better adaptation and development of individuals10, in this case, physicians. CBT focuses on learning and not on teaching, and on reaching specific objectives, i.e., on the results of learning, integrating knowledge and knowing how to do, be and act11.

THE RESIDENCY SYSTEM (SPECIALISED HEALTH TRAINING), NEW CHALLENGES AND OPPORTUNITIES

Training medical specialists involves the gradual integration of recent graduates in medicine into the care activities of a health centre or hospital with growing responsibility and decreasing supervision over time. Is it possible to carry out this professional training without having the tools and resources necessary to guarantee that this integration is appropriately planned and supervised, and that the final result (a competent medical specialist) is the consequence of completing a programme designed to meet current healthcare demands?12

The Spanish system for medical graduate training, known as the MIR, was born in the 1960s as a result of the “Seminario de Hospitales” (a meeting bringing together representatives of major hospitals from across Spain: Hospital de la Santa Creu i Sant Pau, Clínica Puerta de Hierro, Hospital Marqués de Valdecilla, Fundación Jiménez Díaz, Hospital de Basurto, and Hospital General de Asturias )13. It is based on learning on-the-job and has been one of the most important drivers of the modernisation of medical practice in Spain. The system, as regulated in 1984, has a strong state structure controlled from the Spanish Ministry of Health and Social Policy14. The following characteristics of the system should be highlighted: the accreditation of healthcare centres and teaching units (clinical departments), whose guarantee of quality training is monitored through regular audits; a universal entrance exam; and the definition and classification of specialties and associated programmes, as regulated by the corresponding National Specialty Commissions and a National Council. However, there are considerable weaknesses in the way in which the system is put into practice within healthcare institutions. The Order on Teaching Commissions of 199515, which regulates their powers and operation, as well as those of the directors of studies and tutors (educational supervisors), has not been thoroughly implemented and the evaluation system it proposed, the one currently operating, is more a system of certification of completion of a series of rotations or placements in certain care units, than a true training and assessment of competencies. A study by the National Commission on Nephrology revealed some of these weaknesses in the training of specialists, from irregular allocation of human and material resources within teaching units, to failures to fulfil teaching objectives and the role of mentoring (tutor), run on a voluntary basis, being little recognised16. With the new law, Real Decreto 183/200817, the entire National Health System has had a great opportunity to develop and improve the system for specialised medical training, providing the framework for competency training and assessment, addressing, among other points, the challenges of multi-professional units, and a controversial but fundamental issue, the core curriculum. You must first be a doctor and only then a specialist.

However, as noted by J. Cobo-Reinoso, the mere passing of legislation does not guarantee its successful implementation18; this author highlights the elements that should comprise a residency programme for it to be both effective: 1) the definition of a training programme consistent with training objectives; 2) establishment of monitoring protocols; 3) adequate communication with tutors; 4) a comprehensive assessment system, essentially educational, and more demanding; and 5) quality control by the Teaching Commission. This is not possible without funding and a definitive consolidation of healthcare organisations, educational structures and training agents (directors of studies, tutors, trainers and other teaching staff), and, in Spain, this is the responsibility of the regional governments.

PROFESSIONAL COMPETENCIES

M.O. Bunk defines competence as behaviour resulting from a set of attitudes, skills, abilities, knowledge and values that people use to deal with specific situations related to their life and profession19. It is, in short, the effective ability to successfully carry out a clearly specified work activity. Professional competence is not a measure of the probability of success in the execution of a profession; it is a real and demonstrated ability that can be evaluated based on results.

The start of the competency movement can be traced back to a paper published in 1973 by David McClelland, who asserted that not only aspects such as knowledge and skills, but also feelings, beliefs, attitudes and behaviours can predict high work performance20. We are referring to empathy, intuition, integrity, perception of reality, the spirit of community, self-confidence, flexibility, and the domain of the individual. These concepts are fully applicable to the world of healthcare and indeed are today recognised as being fundamental aspects of the competencies of a medical practitioner. A Gual et al9 agree with this, stating that for the future we require: physicians who adopt a critical approach, who are communicative and empathetic, individually and socially responsible, make decisions which are good for the patient and the health care system, leaders of the health team, competent, effective and safe, honest and reliable, committed to patients and the organisation; physicians who treat patients, not diseases. In summary, the competencies of a professional combine knowledge (Know), skills and abilities (know-how), attitudes and behaviours (how to act), and values and beliefs (how to be).

Faced with the aforementioned changes and challenges of the 21st century, academic and health organisations in various countries began to define basic competencies for physicians in the 1990s and early 2000s including: Tomorrow’s Doctor21and Scottish Doctor22 (UK), CanMEDS Roles23,24 (Canada), the Outcome Project of the Accreditation Council for Graduate Medical Education25,26 (USA) and the Institute for International Medical Education (IIME) in New York27 (Table 1). The competency domains defined in these models are perfectly applicable to any specialty. Specifically, CanMEDS and the Outcome Project define what all residents must demonstrate upon completing their training. Along these lines, in 2008 the Medical Teaching Unit at Cruces Hospital (in its Competency-based Postgraduate Medical Education (CBPME) project, which started in 2004)28 defined its model of «Being a Physician/Medical Professional» (Teaching Vision29) for all specialties of the centre, based on the model of the IIME, and incorporating concepts from the Outcome Project, CanMEDS and the American Board of Medical Specialties30. Table 2 summarises the model «Being a Physician/Medical Professional at Cruces Hospital», which is to be the foundation of our competency evaluation system.

These approaches do not mean that doctors, to date, have not been trained in such competencies; the difference is that in the CBPME project they are made explicit, and those competencies necessary to address changing social and healthcare needs are emphasised31. Working with such a model facilitates the development and adaptation of the learning process (learning objectives derived from the competencies, activities, specific tasks, training plans, schedules, methodologies and teaching resources) and the implementation of a final competency assessment (outcome-based assessment). To bring about the changes required, it is very important that all professionals adopt the same approach and language, a task that will take time.

THE EDUCATIONAL PROCESS IN THE CONTEXT OF THE WORKPLACE AND THE ROLE OF INSTITUTIONS IN PROFESSIONALISATION

Training in the workplace professionalises the resident by developing their understanding of the knowledge, skills, abilities, attitudes and values that are present, these days, in the medical profession. However, it can also de-professionalise, as it is difficult to implement educational practices in each and every care setting in which residents train. The workload and other factors associated with healthcare organisations and their management do not facilitate interaction between tutors and residents. Though the residents should not forget that they are primarily responsible for their own training and must be proactive, this climate occasionally leads tutors and staff to forget their teaching role and that the residents are professionals in training. Institutions must guarantee: 1) the exercise of leadership from senior and middle management (directors of studies, heads of department, tutors); 2) the planning and development of a teaching strategy, with the involvement of all relevant parties (tutors and staff), facilitating decision-making and accountability, including on the part of residents; 3) the resources (structural, material, financial and organisational); 4) the development of programmes integrated into the care system in accordance with a defined profile of medical specialist; and 5) the qualitative and quantitative measurement of results. It is within this scheme that the tutor is essential as a manager of a programme of specialisation within the teaching strategy of the centre. Duties and training tasks should be specified in the training programme contracts of the centres and in the portfolio of services of teaching units. This is a reflection of the duty they have to society as accredited teaching institutions12.

Therefore, the objective is to provide a professional with: 1) broad and essential training, based on ethical values, behaviours and attitudes and that encompasses  humanistic, scientific and technical aspects; 2) an understanding of the scientific method and ability to put it into practice, and to manage complexity and uncertainty; 3) a command of scientific language and skills enabling the proper use of computer technology, to facilitate independent learning; and 4) sufficient experience in the field of interpersonal relations to encourage initiative and teamwork, and the development of skills for personal relations and for effective democratic participation in society32. To achieve this goal, healthcare centres and teaching units (clinical departments) should be aware that there must be consistency in the training process, taking into account the three stages of the teaching/learning cycle: before, during and after. Before provides for the social environment of the specialty, the skills to be developed by level, the role of the tutor, the resident, the other trainers and the institution. During (interaction) includes training contexts, how learning will be enhanced in each of the contexts; specific, joint and individual tasks; methodological strategies; and ongoing or formative evaluation. After, involves evaluation of the learning of the resident, tutor performance, the development of the training process, the programme, the trainers and other agents of the support structure32. The tutor, as the pivotal figure in this complex process, with a high level of social responsibility, must acquire and develop certain teaching competencies33.

EVALUATION WITHIN THE TRAINING PROCESS

Concepts and general principles

Rigorous and transferable evaluation is the great unmet challenge in the specialised training system, and it will never be possible if all training agents (not just the tutors) are not sure what to evaluate, i.e., if there is not a clearly defined programme with competencies to be achieved34 (a professional profile, of the nephrologist in our case) and with instruments accepted throughout the institution. The evaluation (the after) is a moral obligation to society, the institution, and the resident (it is their right, for the purpose of guiding and supporting them in their learning, and in the acquisition and improvement of their competencies). Evaluation forms part of a complex training process and should be well defined a priori. Indeed, it is also a process in itself that generates data through assessment applying reference criteria, and this information is used to make judgments and decisions. These decisions can take many forms, but can be categorised under two broad types: a qualifying decision, a sanction, pass/fail, with no possibility of rectification, except by undergoing a new evaluation process (this type is called a summative assessment) and another type which can use the same instruments but is based on results. This latter type of evaluation allows the candidate to understand their strengths and weaknesses and create plans for improvement (it is known as formative assessment). Both demand an equal degree of rigor in their procedure and documentation. In the current training system, we must move away from the ingrained cultural concept of «pass/fail», and thoroughly develop formative assessment. It should be realised that an evaluation process tends to fail if the following questions have not been clearly answered beforehand34: Which competencies are to be evaluated?. How? (with what instruments?). Why evaluate? (what is the objective?). When?. By whom?. With what resources?, and is there collaboration across the entire team?. Therefore,  every evaluation should conform to the following principles35: it should be; 1) appropriate to the purpose (why?); 2) based on the program content (what?); 3) use methods selected in terms of validity, reliability and feasibility (based on the best available evidence); 4) have standardised, transparent and public documentation and methods; 5) provide important and positive feedback (educational evaluation); 6) be overseen by evaluators with demonstrated ability and willingness to collaborate (who?); 7) allow for lay people to assess or examine areas in which they are competent (e.g., communication, professionalism); 8) receive sufficient resources, and 9) have a comprehensive system of quality assurance. The evaluation should not be limited to the resident but rather must embrace the programme, process, structure and training agents, as the key to improvement.

What to evaluate and how to assess the competencies of a professional

Evaluation of residents has, as its objective, to improve and facilitate the development of knowledge, skills, abilities, attitudes and values. To achieve this objective will require ongoing assessment of the resident in their acquisition of knowledge, skills and attitudes, and monitoring of the successes or failures of the design and operation of the training programmes. The assessment of professional competence involves various dimensions that are reflected in actions22: 1) what the doctor is able to do: technical intelligences (clinical competencies and skills), 2) how the doctor approaches their practice: intellectual (basic knowledge), emotional (attitude), the creative and analytical (reasoning) intelligences, and 3) the doctor as a professional: personal intelligences (values, ethics, professionalism). There are many validated tools and methods to assess each of these areas, which when combined, allow us to judge the competence of a professional. A description of these and their application is beyond the scope of this article, and there are excellent reviews on the subject36,37.  A particularly useful document is the Toolbox (Outcome Project, ACGME38), which describes each instrument well, its underlying concept, psychometric qualities, utility, validity and reliability. Based on that document and grouping competencies into seven domains, as described in Table 2, the potential assessment tools for each domain would be:

1. Professional values, attitudes, behaviour and ethics: Multiple source feedback (MSF)39, commonly used in the private sector, patient point of view, and objective structured clinical examination (OSCE)40.

2. Clinical skills (clinical healthcare expert): standardised patients, simulations, OSCE, clinical evaluation by direct observation of clinical practice in the workplace (Mini-CEX - Mini-Clinical Evaluation Exercise, DOPs - Directly Observed Procedural Skills41,42), questionnaires, case studies, clinical records, audits, peer reviews, quality indicators, reports, and portfolios43. In relation to this, Cruces Hospital is developing its own model of reflective logbook/report to form the basis of future portfolios44,45. Note, however, in terms of the clinical evaluation tests by direct observation, they have been developed in the Anglo-Saxon world to deal with a concern that Norcini highlights in his article41, that the trainees are seldom observed, so the circumstances in our environment may be different.

3. Scientific foundations of medicine (medical knowledge): testing all types of knowledge, multiple-choice questions (MCQs), extended-matching items (EMIs)46, structured cases, simulations and models.

4. Communication: patient opinions, MSF, standardised patients, and OSCE.

5. Public health systems (health promoter and manager of resources): MSF, questionnaires, and patient opinions.

6. Information management: computer simulations, and cases.

7. Critical analysis and research, and self-directed learning: portfolios, reflective reports, and standardised cases.

To evaluate the competencies of a professional many dimensions must be considered, it being necessary to extrapolate from partial data to arrive at a complete picture. Nevertheless, we should start with very simple, inexpensive instruments, accepted and understood by all clinical staff and the resident, and that provide added value to our Postgraduate Medical Education system.

CONCLUSION

Specialised training based on competencies is the answer to a globalised world in permanent change. To take this forward, medical centres and services should develop their own projects, as allowed for within the existing regulatory framework. Health institutions should be aware of their duty to society given their accreditation as teaching bodies. However, if they are to exert effective leadership in the development of training programmes it is essential that structural, organisational and human resources are made available. In Spain, this is already provided for in current legislation, and the regional governments are responsible for implementing and developing this infrastructure without further delay.

Acknowledgements

Acknowledgements to Pilar Martínez Clarés, Professor in the Department of Diagnostic and Research Methods applied to Education, Faculty of Education (University of Murcia) for her personal contribution to the content of this text, to the Tutors of the Competency Assessment Group (Andima Basterretxea, Elena Bereziartua, Milagros Iriberri and Agustín Martínez-Berriochoa) and to Mª Jesús González-García, secretary of the Medical Teaching Unit at Cruces Hospital.

10559_108_10783_en_10559_108_10783_en_w477710581710559_18107_7509_es_10559_18623_7509_es_tabla_1_en.doc

Table 1. Models of competency domains

10559_108_10785_en_10559_108_10785_en_w477710581610559_7511_es_10559_18623_7511_es_tabla_2_en.doc

Table 2. Physicians/Professionals at Cruces Hospital (2008)