JAMA ( IF 45.540 ) Pub Date : 2019-12-26 , DOI: 10.1001/jama.2019.21081 Sally A Santen,Robin R Hemphill,Martin Pusic
Physician education during residency and fellowship has shifted from a model based on how long a physician trains to one that emphasizes assessing and encouraging measurable competence.1 There needs to be a similar shift to ensuring competency for physicians who have completed their training, with an emphasis on maintaining knowledge and clinical skills to ensure patient safety. This leads to several questions. Who must be competent in what? Who decides? Does experience count? How does aging affect competence? In medicine, an expansive range of competencies are considered important, and not every physician maintains every competency. Achieving, assuring, and maintaining competency across medicine requires time and effort and involves perseverance for individual physicians and the health care system. In this Viewpoint, we discuss 2 forces that can lead to diminishing competence over time: deterioration in ability with age and decrease in opportunities for maintenance and self-improvement.
Deliberate practice, as described by Ericsson2 and demonstrated in many fields, including music, chess, and surgery, is the sequential, mindful repetition of a training task with feedback that leads to effective improvement in performance. Early in training, there is a rapid learning trajectory in which large gains in performance occur through intentional learning activities. However, for some individuals, when formal training ceases performance can eventually degrade and can be documented by a forgetting curve,3 in which the rate of decay depends on a number of factors, including the complexity of the skill in question, opportunities for practice, and support from the health system. For example, in many specialties, residents are intensively trained in procedural skills, such as intubation and central line placement; however, these skills decay without continued practice and repeated training.4 It is important to recognize that there is a threshold for competency that must be maintained. This skill decay over time may be compounded by the aging of the physician population, which has made maintenance of competency an important issue in medicine in the United States and around the world.5 The literature on aging and its effects on professional performance is mixed with evidence of cognitive and physical decline of abilities in some individuals. However, there is evidence that competency in medicine can be successfully maintained through intentional deliberate practice and mastery learning with procedural simulation training.2,4,6
Advances in medicine and clinical procedures continue to change practice, and some physicians may not have the opportunity to keep up with new diseases, diagnostics, and therapies or may not be able to achieve sufficient mastery of technical skills required for performance of new procedures.7 While physicians may retain the expertise from years of experience, in some areas (especially in procedurally oriented disciplines), some physicians may be subject to the trajectory of skill decay. Yet, their identity as physicians is an important self-concept and supports their professional credibility. As some physicians mature in their careers, they may choose to decrease their clinical time as they move toward retirement; spending more time with their family; or increasing professional administrative, research, or teaching activities. Even though these physicians have accumulated comprehensive expertise from thousands of patient encounters and a complementary understanding of the health care system, teamwork, and patient-centered care, physicians who decrease their clinical time must maintain a certain equipoise, balancing their nonclinical time against the important need to maintain skills in procedures they may be called on to perform, even if only rarely. For example, emergency physicians might need to refresh their skills in intubation, cricothyrotomy, central line placement, thoracotomy, or focused ultrasonography if they have not performed these procedures recently.