Assessment of competence

Few issues in medicine are as controversial as the assessment of competence for practising clinicians. Even the assessment of competence to begin practice varies widely from one specialty to another. Given that the initial assessment of competence by either the Royal College of Physicians and Surgeons of Canada or an equivalent body is highly disparate, it is not surprising that the assessment of competence at some time after the physician has entered practice is also fragmented and highly variable.

For interventional specialties such as Surgery, the initial assessment of competence by examination rarely, if ever, includes a technical component. The assessment of technical skill resides primarily with the faculty members of the training program and is attested to by the program director at the time the candidate sits the fellowship examination. Therefore, in the measurement of competence for practising physicians there is no practical replacement for this assessment. Since competence in interventional specialties should test both cognitive and technical skills, it is imperative that whatever method of assessing continuing competence is adopted, both skill sets are examined.

At present there is no mandatory recertification of practising surgeons in Canada. Demonstrated continuous professional development is accepted as evidence of mintenance of competence. Is this appropriate? Would anyone accept an initial assessment of competence (i.e., entry into specialized practice) on the basis of a residency program in which the requisite number of hours of both didactic and practical learning had been completed, but no assessment of knowledge or skill was included?

Almost all American boards now have mandatory recertification for practitioners originally credentialled by them. There are several pathways to recertification, but all require an examination of either knowledge base or clinical skill or a combination of the two. In those surgical specialties that offer either a written examination 10 years after entering clinical practice or an oral examination based on the certificant’s own practice, the pass rate on the written examination is extremely high (virtually 100%) but on the oral examination is substantially lower. This suggests that true peer review of one’s practice may provide a better assessment of competence.

As the public moves toward closer scrutiny of physician credentialling and competence, it is imperative that surgeons demonstrate a willingness to develop meaningful methods of assuring continuing competence in their chosen specialty. Surgical specialties should each set their own programs for assuring continued competency of their membership. These programs should be undertaken with the full participation of the membership of the specialty organization, and compliance with the program should be strongly encouraged. Provincial colleges who bear the responsibility of ensuring that physicians who work within their jurisdiction are competent would be receptive to suggestions from the profession as to the best way to assess the competence of practising surgeons. We should help, not hinder, this process, and our professional associations should enter into a dialogue with provincial colleges to ensure this important process is fair and effective.