EDITORIALS Editorials represent the opinions

of the authors and THE JOURNAL and not those of

the American Medical Association.

Competence Is a Habit
David C. Leach, MD and more recently, master add depth and breadth to conver-
sations about competence and offer alternatives that reflect

C
ONCERNS ABOUT PATIENT SAFETY , GEOGRAPHIC the developmental nature of competence. Coupled with the
variations in patient care unrelated to medical sci- 6 general competencies, this model moves closer to the real-
ence, and poor “customer service” for patients have ity of how physicians learn. For each of the 6 competencies,
called into question the competence of physi- there are rules that must be learned (novice, advanced begin-
cians and the health care systems in which they work.1-22 ner), and these rules must be applied in increasingly com-
Many physicians are unhappy in practice, some feeling that plex contexts (competent, proficient, expert, and master). Just
their education has not prepared them to lead complex de- as there are many levels of skill, so also there are many levels
livery systems; others, that their values are in conflict with of lack of skill. For instance, gifted communicators may not
their daily work.23-26 know the rules necessary for clinical care, while rule-bound
The Accreditation Council for Graduate Medical Educa- individuals may be incapable of functioning in the ambigu-
tion (ACGME) and the American Board of Medical Special- ous situations that characterize much of medical practice. Resi-
ties (ABMS) have developed initiatives designed to im- dency education should systematically foster development from
prove graduate medical education by using educational advanced beginner to competent. Correctly conducted, such
outcome assessments as an accreditation tool (ACGME) and development forms individuals into physicians who have the
to strengthen the education of residents and practicing phy- habit of competence. This area is of great interest to the
sicians by using assessments that demonstrate achieve- ACGME, the 7800 residency programs in the United States,27
ment of certain competencies (ABMS). Both organizations and the 100000 residents whose formation is being nurtured
have agreed on 6 general competencies that frame and to (or not) in these programs.
some extent define the substance of medicine independent To be competent, residents must be involved enough to
of specialty and delivery model. The 6 competencies are pa- be accountable. In the Dreyfus model,29 moving from ad-
tient care, medical knowledge, practice-based learning and vanced beginner to competent means less detachment and
improvement, interpersonal and communication skills, greater immersion in particular contexts. Medical schools,
professionalism, and systems-based practice.27 These com- residency programs, and serious lifelong learners can ben-
petencies and attempts to assess them contribute to the medi- efit from understanding the Dreyfus model. Although life
cal profession’s attempt to regulate itself. is not condensable, models can help with understanding life.
Epstein and Hundert28 contribute substantially to the Ideally, medical students progress from novice to ad-
discussion about the definition and assessment of physi- vanced beginners; residents, from advanced beginners to
cian competence. They require “the habitual and judicious competent. Dreyfus30 characterizes this progress as mov-
use of communication, knowledge, technical skills, clini- ing from rule-based behaviors to context-based behaviors.
cal reasoning, emotions, values, and reflection in daily prac- As residents encounter particular patients and attempt to
tice for the benefit of the individual and the community being apply the correct rules, they are forced to select a perspec-
served.” This is the language of enlightened humanists and tive. Not all the details of a particular case are equally sig-
is refreshing. nificant; some are more relevant than others. Learners se-
Skill acquisition is a developmental process. Although in- lect which details are relevant and in doing so select a
sights may occur suddenly, competence develops over time perspective from which to view the case. “At this stage [com-
and is nurtured by reflection on experiences. To use the lan- petent], the result depends on the perspective adopted by
guage of Epstein and Hundert, it is a habit. A model of knowl- the learner; the learner feels responsible for his or her choice.”
edge and skill acquisition that is simple, elegant, and rel- Two paths become apparent when a mistake is made. The
evant for medicine has been developed.29,30 The named stages first involves detachment and the creation of new rules that
of novice, advanced beginner, competent, proficient, expert,
Author Affiliation: Accreditation Council for Graduate Medical Education, Chi-
cago, Ill.
See also p 226. Corresponding Author and Reprints: David C. Leach, MD, ACGME, 515 N State
St, Suite 2000, Chicago, IL 60610 (e-mail: [email protected]).

©2002 American Medical Association. All rights reserved. (Reprinted) JAMA, January 9, 2002—Vol 287, No. 2 243

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 EDITORIALS

will prevent that mistake from recurring. The learner returns among the individuals in these programs? Humans are de-
to the clinical arena with an ever-heavier rule book. That re- signed for learning. Physicians need to have the integrity,
sponse, according to Dreyfus, arrests development in a cycle motivation, and capacity to discern good learning and good
between advanced beginner and competent and back again. health care but should be restless until they get it right. Ep-
The second path, which leads up to and beyond competent, stein and Hundert have provided an important reminder that
requires a more complete engagement of all human faculties. competence is a habit that engages all human faculties. By
Involvement, not detachment, leads to accountability. Drey- extension, the competence of the profession must engage
fus suggests that it is necessary to feel bad to become compe- all physicians. It is a professional habit.
tent. Somehow, feeling bad about mistakes and good about
correct decisions provides the needed intimacy with context
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244 JAMA, January 9, 2002—Vol 287, No. 2 (Reprinted) ©2002 American Medical Association. All rights reserved.

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