The nature of a specialty

An essential component of competency-based frameworks within postgraduate medical training programmes is the Clinical Competency Committee (CCC). Enabling more structured, transparent and objective approaches to assessing learner performance, the primary purpose of a CCC is to ensure that programme graduates deliver high-quality and safe patient care.¹ This is accomplished through regular review and interpretation of each trainee's assessment data. Ideally this process leads to recommendations that support an individual trainee's development, outline a level of supervision the trainee requires and clarify the trainee's readiness for progression to the next stage of training or for practice.¹ CCCs are comprised of programme directors, faculty members and clinician educators who review and use assessment data to make prospective entrustment decisions.

Aiming to theorize how these prospective entrustment decisions unfold in real-world CCC settings, Schumacher et al conducted a realist literature synthesis.² The theoretical model that resulted was anchored by the finding that CCC decision making was rarely deliberative and most often occurred by default. Decisions about progression were found to frequently occur automatically, and when a deliberative process was utilized, it was in response to red flags having been identified.

To examine their theoretical model against empirical data, Schumacher et al. recently elaborated on the deliberative process undertaken by CCCs through a realist inquiry of committee structure and function among eight paediatric training programmes.³ The authors found evidence of deliberation during CCC meetings however this was not for the purpose of guiding progression decisions. Rather, deliberation occurred when focus was on the developmental needs of trainees. When making progression decisions, the authors confirmed the predominant use of defaulting. This led to the recommendation that CCCs shift to more deliberate rather than passive processes when making progression decisions. Although the importance of optimizing strategies that improve the deliberative processes of a CCC (e.g., ensuring clarity on both committee terms of reference and shared mental models among a diverse membership) is inarguable, this recommended shift may not be as straightforward.

An important question to consider is why certain programmes may be less likely or less able to integrate deliberative processes into progression decisions. A rarely explored variable in the implementation of competency-based education in general is the underlying nature of a specialty, that is, procedure based, non-procedure based, or relational. The nature of a specialty may have direct implications for several implementation domains, one being the deliberative processes of CCC progression decisions.

Procedural specialties, including surgery, anaesthesiology and gastroenterology, require technical skills, dexterity and procedural efficiency, often under high-stakes conditions. Historically, these comparatively concrete and well-defined skills have been assessed through direct observation, performance metrics and simulation.

Non-procedural or cognitive specialties, for example, internal medicine and paediatrics, are composed of more abstract but just as essential competencies that include clinical reasoning, diagnostic skills and patient management. Practitioners in these fields must excel in clinical decision-making as well as the application of medical knowledge to complex, often multisystem conditions.

Essential competencies for relational specialties like palliative medicine, family medicine and psychiatry tend to be even more abstract. These include abilities to modulate communication skills to efficiently develop therapeutic relationships and build trust and rapport through adaptability.

To date, possible differences in competency-based education among differently natured specialties in general have received limited attention. Two examples of components of CCC deliberations that may differ based on a specialty's nature are addressing assessor variation and clarifying the role for undocumented information.

Assessor variation can be challenging for CCCs given the heavy reliance on the data that assessors formally submit being accurate reflections of learner performances. For specialties largely defined by procedures, variation among assessors may be idiosyncratic and arise out of differences in the medical expertise elements or procedural processes that individual faculty members determine to be important.⁴ Assessor variation for this context may be better addressed by faculty development than be an important consideration for a CCC deliberating about progression decisions. Conversely, for relational specialties that are largely defined by competencies involving interactions, differential salience of different performance elements may lead to legitimate variation among assessors.⁴ Assessor variation for relational specialties may introduce a layer of complexity for CCCs that has direct implications for deliberations on progression decisions.

Undocumented information would include opinions, informal judgements, personal experiences and contextual information from programme directors and other CCC members.⁵ Views on the role in general for undocumented information during CCC deliberations are mixed, with the American Accreditation Council for Graduate Medical Education accepting that some information essential to decision-making may not be captured by assessment tools and the Canadian Royal College of Physicians and Surgeons clear with the view that CCC discussions and decisions should only be informed by formal documentation.^{6, 7}

The use of undocumented information by CCCs was examined by van Enk et al through case studies of two training programmes, one being more procedurally oriented and one being less so.⁵ CCC meetings of the more procedural programme were focused on quantitative data, on ensuring trainees meet procedural competency standards and on making progression decisions. Very few undocumented contributions were made, and narrative data were acknowledged but not heavily interrogated. Red flags were only explored if they prompted significant concerns directly related to procedural competence.

Contrasting this, CCC meetings for the less procedural programme included aspects of both progression and resident development. There was greater engagement with narrative data, and to ensure comprehensive understandings of issues raised, undocumented information was often used to interpret an issue and formulate a plan. A trainee's personal circumstances were often considered and red flags were proactively explored. For CCCs of less procedural programmes, it may be that undocumented information provides essential context, which may make deliberations on progression decisions less straightforward.

Prospective entrustment decisions that reflect a learner's progression through their training are high stakes and consequential. Decisions made by default as opposed to deliberative processes are less defensible and introduce risks for the learner, for the programme and for patients. There are important differences between specialties based on their nature however, and these may warrant consideration when evaluating the quality of deliberative processes used by CCCs to make progression decisions.