What we see and don’t see when we look at ‘competence’: notes on a god term

Abstract

‘Competence’ is one of health professional education’s most cherished ideas. It’s what the 20th century rhetorician Kenneth Burke would call a ‘god term’ (Burke 1952): a sort of education idol, an ‘‘expression to which all other expressions are ranked as subordinate’’ (Weaver 1953). This god term presides over many of our conversations in health professions education, conversations including curriculum reform, evaluation systems and program accreditation, to maintenance of certification. And, like other god terms of our era (‘patient safety’ has recently emerged as one, ‘objective assessment’ has long been another), ‘competence’ is a rhetorical trump card, regularly played as the last word in debates about how health professions education should function. To a rhetorician, any bit of language with that kind of power cries out for a closer look. ‘‘Every way of seeing is also a way of not seeing’’, as Kenneth Burke asserted (Burke 1935). He drew attention to how words function as ‘‘terministic screens’’: ‘‘even if any given terminology is a reflection of reality, by its very nature as a terminology it must be a selection of reality, and to this extent it must function also as a deflection of reality’’ (Burke 1966) (emphasis in original). What aspects of competence are we attending to, and what aspects are we avoiding? What actions and values are made possible by our way of seeing competence in health professions education, and what actions and values are rendered impossible? This editorial presents a preliminary teasing apart of our way of seeing competence, in order to draw critical attention to what the god term invokes and what it elides. In its conventional usage, competence is an individualist notion. The emphasis is on producing and maintaining ‘‘the competent physician’’ whose knowledge and skill is performed and assessed over the course of his or her training and practice. In this regard, the god term reflects the reality of health professional education’s focus on the individual.