4.3.5.4 Competency

At the turn of the century, medical education, inspired by a renewed emphasis on the essential abilities physicians need for optimal patient outcomes and on preparing students for clinical practice, switched from problem-based learning to an outcomes or competencies based approach. The CanMEDS competency framework which was developed in the nineties, is probably the best known example of this approach [Frank 2005]. Nowadays, all Dutch medical specialist curricula are based on this competency framework [Scheele 2008]. The CanMEDS framework comprises numerous competencies organized thematically around seven "meta-competencies" or roles that a physician should master. At the heart of the framework lies the physician's role of Medical Expert completed by six generic roles such as Communicator, Collaborator and Manager. As medical experts physicians integrate all areas of expertise defined by the CanMEDS framework. Thus, expertise which is defined as the superior and stable ability to handle challenging situations [Ericsson 2008], is the benchmark for the assessment of physicians' ability to handle clinical situations. Challenging patient education issues which are mentioned in the CanMEDS framework, are obtaining informed consent, delivering bad news, addressing anger, confusion and misunderstanding and dealing with non-adherence.

The introduction of the CanMEDS framework in undergraduate and postgraduate curricula influenced the teaching of communication skills in several ways. Firstly, since the key competencies of the communicator role explicitly refer to patient education competencies, the teaching of patient education skills was gradually implemented in undergraduate curricula [Von Fragstein 2008, Gillard 2009] and in postgraduate courses [Jones 2011]. However, during their clerkships students still focus their attention to history taking and time-management, and are still not supposed to educate their patients [Small 2008]. Secondly, the concept of patient- centredness was criticized and regarded to be unsuitable as leading concept for communication programmes [De Haes 2009, Veldhuijzen 2011]. Today, a functional approach is advocated in which the physicians' communication tasks and matching skills are derived from the goals and desired outcomes of the consultation [Carlson 2005, De Haes 2009, Hulsman 2009, Street 2013, Wouda 2013]. Thirdly, workplace based learning came into focus. Workplace based learning means that students and residents improve their competencies by applying their knowledge and practising their skills in supervised clinical situations followed by constructive feedback and reflection. New assessment methods matching workplace based learning, were also developed such as the mini clinical evaluation exercise (mini-CEX), the direct observation of procedural skills (DOPS) and multisource feedback [Norcini 2007, Davis 2009]. All the assessments, feedback and reflections which a learner has collected, are documented in the learner's portfolio. As mentioned before, communication assessment and feedback based on videoed consultations, already existed in primary care and general practice vocational training. In undergraduate education several initiatives have been developed using videoed consultations for self assessment, feedback and reflection [Hammound 2012]. However, we found no study which used videoed consultations for communication assessment and feedback in medical specialist training.