Becoming a Doctor: One Physician's Journey Beyond Competence.

Abstract

Competencies. Milestones. Entrustable professional activities. These concepts are now on medical education's center stage as medical student and residency educators work to implement them in their programs.1–,3 As a teacher, I appreciate how they offer objective criteria by which to assess the progress of trainees and help in the application of new practice models, such as population health and the patient-centered medical home.4–,6 As a clinician, however, looking back on my educational trajectory from medical school, through residency and fellowship, and traversing more than 20 years of practice as a family physician, I have been witness to different realities of progress. My growth as a physician, my development from a student fearful of making mistakes to a confident practitioner of the art and science of medicine, has been less a compilation of particular attributes and more a journey in self-understanding. Somehow, I was always good at getting boxes of accomplishments checked off along my way to becoming proficient, and I worked hard to fill in gaps in knowledge and add to my repertoire of abilities. Just as it took me until several years after residency, however, to understand what it meant to practice medicine as an integrated whole,7 so it has taken much longer for me to see the “bigger picture” of my professional talents: I am adept in the work I do; I convey and receive both trust and respect in and beyond my work environment; and I am able to offer, beyond my acumen for diagnosis and treatment, something deeply meaningful and therapeutic to my patients, their families and loved ones, and the communities in which they live.8,9 Reflecting back over my education, I can identify several stages of professional growth through which I have passed to appreciate these convictions. Competence is only the first of 5, and while I have not forgotten about it—competence represents a fundamental standard of practice for all medical professionals throughout their careers—the other stages of capability, responsibility, capacity, and citizenship have sequentially been layered upon it as I have matured in my appreciation of my work (table). TABLE Developmental Periods, Stages of Professional Growth, and Example Concerns Much has been written about competence in medical education, including the fine nuances of how to measure it, its strengths as an informative tool for both educators and students alike, and its limitations as a valid reflection of high-quality professional practice.10–,12 For me, while I confronted an assortment of associated worries and hopes at every step on my educational path, the idea of competence, in all its nuances, was contained in the answers to 2 fundamental questions relating to the performance of any single professional activity. One, could I do it? Two, would others recognize I could do it? Second came capability, the sense not only that I had grasped the appropriate knowledge base and technical skills, but also that I could apply that knowledge and those skills independently apart from other colleagues and supervisors. As well, capability meant that I could add to the professional mix those ingredients that made the daily work of medicine my practice: the nature and qualities of my style (my uniquely personal stance in respect to my patients) in response to the various needs and demands of those in my care. That my practice was located in a safety net clinic (in a geographic and cultural setting quite different from that in which I was raised and educated) meant I had to pay particular attention to the social dynamics that influenced my work.13 This attention helped me hone my own relational awareness and was instrumental in my coming to acknowledge myself as a capable practitioner. Soon thereafter I recognized responsibility as the third key determinant of my professional growth, a responsibility not so much for as with. This responsibility meant, above all, accepting my presence in other people's lives as their personal physician, as a guide and coach, as a member of a team of caregivers, and as both a teacher and learner in the shared process of working to lessen the burden of disease and illness.14 Thus, I was responsible with my patients, their companions, and their families. I was responsible with my day-to-day coworkers (members of the clinic administration, nurses, medical assistants, ancillary staff members, and front desk receptionists). I was responsible with emergency department staff members, subspecialty consultants, and hospital personnel, all of whom at one time or another had important roles in the diagnosis and treatment of patients in my care. I was responsible for doing my work, in all its dimensions, tending to and accompanying patients as best I could on their illness journeys. The fourth step: capacity. Have I the capacity to look beyond all the challenges and complexities that are inherent in today's medical environment and find creative ways to thrive in my work as a physician? Have I the knack to move beyond my own borders of professional comfort and expand my repertoire of responses in the face of the difficult life circumstances with which patients present? Can I engage the technologic innovations of modern day practice in the context in which I practice, including desktop medicine, examination room computers, and system-based measures of quality? Have I enough clinical and moral imagination to see beyond the frustrations of day-to-day practice and grow the space of my healing presence? Can I find a way—in spite of unforeseen professional setbacks and unavoidable course corrections—not only to muddle along in the face of change but also to flourish? Lastly, citizenship. In general, how do I better contribute to the communities in which I live and work? Not just to individual patients but also to those who may be affected by the inevitable ripples I cause as I make my way in professional life. Specifically, am I able to return, in kind, a small part of the richness of human experience I have been privileged to witness and participate in as a physician? Can I contribute in some small way to a local and global sense of collective well-being? That I frame capacity and citizenship in the present tense and with questions is no accident. I am still working on them both. Even now, I am in the thick of things, tending to people's medical needs, learning new professional insights, enjoying successes, and enduring mistakes. That I am not entirely sure of what I have yet to face suggests that there exists a delicate balance between not being able to see into the future and knowing I am moving toward it. Assuredly, more stages lie ahead. My development from competence through citizenship and beyond may be an exception to the common thinking now guiding current educational planning, and other physicians likely see the arc of their own evolutions much differently than I see mine. Yet in sharing this snippet of my history, I hope that we, as fellow medical educators, may at once and at the same time both use, and look beyond, competencies, milestones, and entrustable professional activities as measures of professional maturity. As we check a requisite box, may we remember the progress of our own advancement. As we fill in a standardized evaluation, may we recall the meaningful events that have sustained us in our practice and teaching roles. As we plan a curriculum, may we encourage our students and residents to reflect on their own professional growth. Only then, can we visualize as our overriding objective the much more expansive and ongoing process of becoming a physician and help those in our tutelage along their personal paths toward that goal.