Core competences for the foundation programme
The core competences of the foundation programme were designed not only as a way to measure progress throughout training but also to help breed a generation of excellent doctors. Each competence develops key skills inherent in a good doctor and each is vital to securing success in your future career.
Relationships with patients and communication
Negotiation is at the core of a successful clinical relationship. A good doctor listens to patients, guides them in their choices, accepts when they disagree and does not withdraw co-operation unless it’s clear that a patient’s problems cannot be dealt with through a professional relationship. Doctors also need to say a firm ‘no’ if a patient is asking for falsified medical reports or treatment that is unsafe. The doctor and the patient should agree on all aspects of management and treatment. This partnership is a much more satisfactory mode of practice than ‘dictatorial medicine’. It fosters a spirit of mutual respect and a feeling that it is a privilege to practise medicine.
Teamworking and relationships with staff
Medicine is a team activity in which members recognise their own strengths and limits, and gain strength from other team members (including nurses, professionals allied to medicine and managers) in getting the best outcome for patients’ health problems. Respect for one another is at the core of successful teamwork. Both primary and secondary care should operate as one team. Good doctors devolve work to other team members. The alternative, which is decision making by decree from the top, leads to indefensible and rash decisions, lack of initiative by team members and poor team morale.
Teaching and training
Education encourages active searching for new information and the development of a fresh approach to problem solving. Training involves being taught specific skills for specific tasks (eg how to examine a patient systematically). Good doctors use the educational approach to learn to think ‘outside the box’, to keep up to date and to retain a sense of challenge. Failure to keep up to date causes a vicious circle of reduced interest and knowledge leading to impaired clinical skills, which in turn further reduces interest and knowledge. The best learning is self-motivated and interactive, involving looking up information while problem solving. Medical internet search engines are invaluable for this.
Good clinical care
The desire to improve your own performance and that of your team is at the core of ‘professionalism’ and can be learned. It involves training yourself in good practice habits, knowing exactly what’s required of you, checking your work and others’ work and accepting your work being checked by others. Although some clinical care standards are agreed nationally, improving the quality of care is less about meeting externally imposed targets and more about helping yourself to feel professional, accepting control over what you do, and having the satisfaction of meeting standards and avoiding complaints.
Acute care
A good doctor needs the ability to recognise a patient who is ill, to recognise the patient’s stage of illness and be able to initiate treatment. These abilities give you, as a doctor, credibility and give the patient and co-workers confidence. Both are essential for clinical leadership. Doctors also need to recognise the wide variety of ways in which common illnesses show themselves. The ability to provide acute care underpins competence in anaesthetics, all branches of acute medicine, obstetrics and surgery. Many foundation programmes are designed to provide acute care experience over a short time period for doctors who wish to train in acute specialties.
Maintaining good medical practice
Doctors have to prove that they have acquired skills and knowledge (‘competences’) relevant to their specialty. ‘Appraisal’ is the negotiation between you and your trainer to agree goals that you wish to achieve and they think you should achieve. ‘Assessment’ establishes whether you have achieved the goals. Examinations are the common form of knowledge assessment, while directly observed practice methods, which can sometimes form part of an examination, are used for clinical competence assessments. Assessment should place more emphasis on the demonstration of skills and knowledge required to undertake specific tasks, and less on ‘general book knowledge’. Throughout your career you should be motivated to actively seek new information and devise new approaches to problem solving.
Professional behaviour and probity
Professionalism involves having a sense of vocation, using knowledge and skills to do good, and acting with regard to the truth rather than for short-term interest. It is demonstrated through showing responsibility in thought and action and engaging in the disinterested pursuit of knowledge. Professional doctors have a willingness to accept responsibility and keep their patients’ interests to the fore without compromising truthfulness or breaking the law. The challenge for any doctor in acting as the patient’s advocate is to meet their wishes without breaching the boundaries of probity and professional responsibility.
In practice, medical professionalism includes keeping confidences, acting without prejudice to patients or colleagues, treating patients’ beliefs with respect, knowing the limits of your expertise, approaching relevant authorities if you or a colleague is unfit to practise, and also showing financial probity. It is developed when you are immersed in the ‘cultural milieu’ of professional practice and the team environment and through learning by example from those around you. Professionalism is easy to recognise when it is present or absent, but it’s difficult to quantify or test.
Anthony Bradlow MD FRCP is a consultant physician and rheumatologist, and past director of training and education, at the Royal Berkshire NHS Foundation Trust.
