Clinical Courage

It takes both competence and confidence

Monica Newton, DO

When I went to medical school and residency, competency-based education looked like someone giving you a thumbs up in the hallway. You know if you ever had to go to someone’s office to talk about your progress, you were about to receive bad news. Unfortunately for me, my faculty did not have the end in mind (creating family physicians with the skills that meet American needs). So, by default, the goal became to get people through the process and pass their boards. Though I am a fan of structure, and I must remind my folks to trust the process, it should not be based solely on time.

Back then, my teachers were so pleased – I made it through the process! Four years of medical school and three years of residency.

Of course, there were lots of tests along the way, but there was no one who watched me take a history and said, “you know what, when you asked the patient about that sensitive subject, I might have phrased it a little different.” Who knows what I could have avoided from the school of hard knocks or what fears would have been relieved if I had competency-based education then?

Everyone believes they have a sense of what they are good at and what they are not. Research has shown, to the contrary. Medical student self-assessments have little correlation to what they know and don’t know (Tousignant and DesMarchais, 2002).

What I think we all are actually pretty good at is stuffing our fears and playing confident – and that is a huge problem.

It is imperative that residents have competence and confidence. Competence comes with evidence-based assessments that are frequent and happen longitudinally. Confidence comes from the feedback we get from assessments- they go hand in hand. Without assessment, you can have self-confidence, but you can’t be sure you are competent (or are doing something right).

My advice to our residents – buckle up. There are lots of assessments ahead. These assessments are not punitive, they are formative in that they form and shape your skill set. Assessments are nothing but a snapshot that begin to tell a story over three years of your well rounded, full scope capabilities. These capabilities are what America desperately needs.

This is how we do it

We have a system of assessment. It is based on well-timed progressive experiences so that your skills grow. It is multi-modal with a variety of input types and from a 360-degree perspective. If we are assessing medical knowledge, we may use a test to do that. If we are assessing nonverbal communication, we may use a video recorded encounter or a patient simulation. If we are assessing a skill, we may use a checklist or framework. No matter how you look at it, its all to get you to your desired end: competence and confidence.

In March 2023, I was the recipient of a GME Excellence in CBME award to do a one-week course at ACGME in Chicago that was sponsored by ABFM. My colleagues and I honed our skills and planned to share our learnings with the Southeast through an ACGME Faculty Development Hub. We are planning our first conference for September 2024 and I can’t wait. 

We owe it to our residents to be “experts” in assessment and we owe it our patients to create competent and confident family physicians who have progressed to mastery. When this happens, residents will have the courage to practice their full scope training. They won’t be passing off patients to specialists for procedures they were trained to do. That is clinical courage. That is our desired end.