Professional Competence

Introduction

The American Academy of Physician Assistants (AAPA) has had a long-standing interest in identifying the determinants of professional competence and in assisting PAs in maintaining their competence. AAPA has an important role in helping PAs acquire and maintain the knowledge, skills, and attributes needed to deliver high quality healthcare. At no time since the earliest days of the profession has it been more important to assure the appropriate assessment and maintenance of professional competence. A national focus on medical errors, patient safety, and emphasis on the delivery of cost-effective, quality care has sharpened the attention of the public, legislators, regulators, employers, educators and health professionals on the importance of maintaining and demonstrating professional competence. The purpose of this paper is to update the Education Council’s original policy paper on professional competence which although it still contains valuable information has become dated since its publication in 1996.

 

Maintenance of professional competence is a lifelong process and is motivated by a number of factors, including curiosity, self-identified gaps in knowledge, and the desire to provide the very best care to patients.  It requires that the PA continually develop his or her knowledge and skills through traditional continuing medical education (CME), more cutting-edge technological, self-reflective and practice improvement based CME, and other activities, such as case consultation with colleagues, chart review, peer review, and regular reading of professional journals and other relevant publications. Certification and recertification through the National Commission on Certification of Physician Assistants (NCCPA), which are required by many employers and in some states in order to practice, are also part of the process of maintaining and demonstrating professional competence.

 

Competence, competencies and competency-based education

The concept of professional competence has evolved over the last 30 years from a one-dimensional construct representing “specialized knowledge” to a more global one which includes the application of specialized knowledge. Furthermore, competence implies a minimum level of proficiency or a threshold in performance. The most common definition of professional competence used today is Epstein and Hundert’s which defines it as “the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served.” (1)

 

The distinction between “competence” and “competency” should be made, as the terms are often used interchangeably. Webster’s dictionary defines a “competency” as an “ability or fitness.” A competency is a single skill or function, yet it includes the underlying knowledge, abilities and attitudes necessary for optimal performance. It must be performed to a specific standard under specific conditions. A competency is usually written as a broad composite statement detailing an observable set of behaviors reflecting components of knowledge, skills and attitudes. Competence, on the other hand, is more expansive and all encompassing. It represents the totality of knowledge, skills, attributes, behaviors and attitudes (or competencies), as well as, the ability to orchestrate these competencies into the full range of activities necessary for professional practice. Competence also implies a minimum level of proficiency or threshold in performance.

 

To prepare for professional practice, PAs complete a competency-based educational program. Programs consist of didactic and clinical experiences designed to provide a core of clinical knowledge, technical skills, and problem-solving abilities fundamental to competent clinical practice. Upon completion of an entry level program, it is assumed that a practitioner possesses the general characteristics and has acquired the requisite proficiencies during professional education. Initial certification conferred by the NCCPA verifies that an entry-level practitioner has demonstrated a minimum level of knowledge and skills.

 

The profession sometimes has difficulty explaining what competency-based education is to legislators and regulators. Competency-based education was first introduced in the United States addressing teacher education in the early 1960’s. Health professions began looking at the framework in the 1970’s and generally stated competencies were created. For 20 years the physician assistant profession was one of the few health professions to embrace competency-based education and created unique assessment tools to measure student competence. Interest in competency-based education in the health professions grew in the late 1990’s resulting in the transformation of other health professions education programs from traditional time-based education to competency-based education.

 

In 2002, the Accreditation Council for Graduate Medical Education (ACGME) announced that graduate medical education would be shifting to competency-based medical education largely from a need to increase public accountability. The Liaison Committee on Medical Education (LCME), which accredits medical schools, is also shifting its emphasis to demonstration of competencies in undergraduate medical education. It has recently added this education objective to its accreditation standards: “The objectives and their associated outcomes must address the extent to which students have progressed in developing the competencies that the profession and the public expect of a physician.” (2)

 

The Association of Physician Assistant Programs (APAP), with funding from the Health Resources and Services Administration, has published a document entitled, “Meeting the Objective: Physician Assistant Education, Curriculum Objectives Resource Guide.” (3) This web-based document assists programs in focusing on outcome-based education which is a primary principle of competency-based education. Integration of outcome-based education into physician assistant education will help ensure PAs are adequately prepared with the appropriate clinical competencies to enter a dynamic healthcare environment.

 

The physician assistant profession with the participation of AAPA, APAP, NCCPA and the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) are working together to identify and publish a list of clinical competencies for the practicing physician assistant. Six general areas of competency have been identified for competent PA practice including:

·         Patient care, including clinical reasoning

·         Medical knowledge

·         Practice-based learning and improvement (including information management)

·         Interpersonal and communication skills

·         Professionalism

·         Systems-based practice

These competencies are based on the ACGME model for physicians but also identify areas specific to PA practice. An overarching competency PAs must possess is the ability to practice collaboratively in the physician/PA team: A skill that requires medical knowledge, professionalism, and interpersonal and communication skills, but is more than the sum of these parts.

 

Assessment of Competence

Most aspects of professional competence, and certainly overall competence, are difficult and expensive to measure.  Many (if not all) medical specialties require significant efforts from physicians to show ongoing professional competence. This includes the need to take written exams, which measure one aspect of competence—medical knowledge.  Additionally, evidence of peer-review and self-assessment are required by many certifying boards for on-going certification in a variety of medical specialties. (4) Since competence is multidimensional, its assessment should also be multidimensional, preferably having a performance-based component. These assessment exercises sample behaviors performed in the artificial testing situation. In order to measure competence, one needs to be able to evaluate the knowledge, skills, and abilities represented by those behaviors in the actual practice setting. Medical specialties have long used performance-based tests, such as patient management problems (PMPs), objective structured clinical examinations (OSCEs), and standardized patients (SPs).  The PA profession is now in the process of determining how best to produce methods for assessing competence that are psychometrically sound and representative of the activities comprising clinical practice.

 

The physician profession under the leadership of the American Board of Medical Specialties has moved to a model called “maintenance of certification.” (5) Maintenance of certification (MOC) is an ongoing process of assessment and improvement in four components. The first component is evidence of professional standing, such as licensure. The second component is evidence of commitment to life-long learning and self-assessment, such as CME. The third component is evidence of cognitive expertise based on a valid and reliable examination. The final component is demonstration of evaluation of performance in practice including such skills as communication and professionalism. Although there is some physician resistance to the way in which MOC is being implemented in various specialties, it could be a model for demonstrating the competence of physician assistants.

 

The Role of Continuing Medical Education

To retain certification, and licensure in many states, PAs must obtain 100 hours of CME every two years.  Often, CME offerings address only knowledge and skills.  Traditional forms of clinical CME, such as lectures, web-based programs, or home study, are not always designed to assist PAs in informing their work in content areas such as attitudes, emotions, values, and reflection in daily practice.  Incorporating these and other competencies, such as practice-based learning and improvement, and systems-based practice, into CME programs, may be done explicitly, or integrated into programs on specific disease topics.  PAs are encouraged to choose CME offerings that encompass all areas of overall competence, and not simply those that address knowledge and skill.

 

The Context for Assessing Competence of PAs

In three recent reports, the Institute of Medicine calls for major revisions in the health care delivery system (4,6,7).  To meet the challenges of making necessary changes in the U.S. healthcare delivery system, PAs will need competencies in addition to a good knowledge base, a high degree of skill, and good communication skills.  Reducing medical errors will require sophistication in systems-based practice.  Improving care with evidence-based decision making, and working cooperatively in interdisciplinary teams will require training and continuing education in practice-based learning and improvement.  Overall, lack of these skills and abilities will prevent PAs from contributing to patient care at the highest possible levels to which they are capable. The broad definition of competence by Epstein and Hundert gives guidance as to what is expected of health care professionals in the 21st century.

 

Between 1997 and 2000 AAPA undertook research to determine the core competencies that represent the knowledge, skills, and abilities that contribute to high quality PA practice. (8) Data were collected by the AAPA via surveys of PA programs and diverse focus groups of clinically practicing PAs in several cities. Types of knowledge, skills, critical reasoning, communication, and personal attributes required for competent practice were determined (Table 1). Data demonstrated differences between the educational objectives of PA program curricula and the content areas identified as important to practice by PAs.  Programs focused on clinical knowledge and skills, while practicing PAs reported that communication skills and personal attributes (such as sense of humor and work ethic) were most important. Some of these qualities, such as personal attributes, were developed prior to entering a program. Other qualities can only be developed with professional experience after leaving the educational program.  PA programs are currently and will continue to promote improvement of all cross-cutting qualities.  Individual PAs must continue to develop these qualities throughout their careers.  All of the cross-cutting qualities may be built on or developed within a PA program, but must continue to develop throughout the professional career of the PA.

 

The key contribution of the core competencies research was that competence is indeed a life-long process encompassing personal and professional development prior to PA education, during PA education and after formal PA education. At different points in a PA’s professional career some competencies are more important and relevant than others. Therefore, assessment of professional competence needs to take into account not only the PAs current specialty and setting but also where they are in the evolution of their career. Development of tools to assist PAs in assessment, maintenance, and improvement of their overall clinical and professional competence is an important challenge to the PA profession.

 

Table 1

Steps in the Clinical Process

Cross-Cutting Qualities

Gather patient data

Awareness

Diagnosis

Effective communication

Patient management

Critical reasoning

Ongoing follow-up and management plan change

Clinical knowledge

Consultation/referral

Clinical skills

Health promotion

Professional responsibility

Practice management

Personal attributes

Systems knowledge

 

Conclusions

Professional competence is multidimensional and the dimensions of competence evolve as a PA’s career evolves. Identifying the required knowledge, skills, abilities, attitudes and behaviors, or core competencies of practicing PAs, is essential to the effectiveness of both the maintenance and assessment of competence. It is a life-long process motivated by both self-interest and a commitment to providing the highest quality care possible to patients. At the entry level, the two defining elements of being a PA are graduation from an accredited PA educational program; and successfully passing the national certification exam. Safeguarding the public begins when the PA becomes certified, but this initial certification does not assure continued competence. It merely verifies that an entry-level practitioner has demonstrated a minimum level of knowledge and skills.

 

Recertification represents part of a process that should encourage PAs to remain competent through periodic reassessment of strengths and deficiencies, as well as participation in professional development activities.  Additionally, the process should identify marginal clinicians.  Although a periodic written examination can yield a useful measurement of cognitive ability, only a multidimensional assessment process can truly reflect the competence that comes from the pursuit of lifelong learning. Current efforts to identify the core clinical competencies of PAs will result in more accurate ways to help PAs assess their competence. The adoption of the ABMS’s model of maintenance of certification for PAs should be thoroughly studied and discussed before implementation.

 

The PA profession is committed to protecting the public and delivering the highest quality patient care possible.  In order to accomplish this, it is important that each PA participate in a process of lifelong learning in order to maintain professional competence.  The public is demanding more rigorous accountability from healthcare professionals. Whether it is a focus on competency-based education or regular recertification the PA profession has long been a leader in demonstrating its commitment to competence. Likewise, AAPA is committed to helping PAs assess and improve their abilities to provide the highest quality healthcare.

References

1. Epstein, RM and Hundert, EM; Defining and assessing professional competence. JAMA; 287(2): 226-235.

2. Liaison Committee on Medical Education. LCME accreditation standards. Http://www.lcme.org/functionsnarrative.htm. Accessed March 18, 2005.

3. Association of Physician Assistant Programs. Meeting the objective: Physician assistant education, curriculum objectives resource guide. Http://www.apap.org – members only section. Accessed March 12, 2005.

4. Institute of Medicine. Crossing the quality chasm: A new health system for the 21st century. National Academy Press; Washington DC; 2001.

5. American Board of Medical Specialties (ABMS). What is maintenance of certification. www.abms.org.  Accessed March, 2004.

6. Institute of Medicine. To err is human: Building a safer healthcare system. National Academy Press; Washington DC; 2000.

7. Institute of Medicine. Health professions education: A bridge to quality. National Academy Press; Washington, DC; 2003.

8. Unpublished data presented by Steve Crane, AAPA, to the Education Council in November 2003.