Capabilities – evidence

I was asked, on Twitter by Jacqui Wheatcroft: “I wondered about the references to support the inclusion of each area in the mind map?” (shown here) Replying in a Tweet was a challenge! I will explain here that: capabilities are high-level abilities that are simply chosen or agreed as indicative or representative of a person’s overall ability; the behaviours used are equally indicative or representative; the knowledge suggested is again not definitive, and one can be competent without some of it, or one could be incompetent despite all of it; and the same applies to skills. (Or am I just copping out from answering a difficult but fair question?)

The context

This original question, “I wondered about the references to support the inclusion of each area in the mind map?“, must be placed in its context. The problem facing professionalism – the professional person, their educators and trainers, and those responsible for setting and maintaining standards – is, how can we assess a person’s professional quality? How can one distinguish a poor, low quality professional who may harm patients (or customers)? How can the regulatory body (the General Medical Council for doctors) know that the doctor who they are registering as a specialist in XXXX is actually specialist or even safe in the practice of XXXX?

The General Medical Council, after considerable discussion and research, moved recently to identify six high level generic capabilities that were indicative of being a good doctor, and asked each speciality to identify 6-8 capabilities that would indicate being good at the speciality. The generic capabilities covered matters where problems were commonly seen in poor doctors, on the grounds that making them better would reduce the probability of being found below standard.

For each speciality, it was left to the speciality to identify the six to eight capabilities that characterised their speciality. The Rehabilitation Medicine capabilities largely originated from my own experience, but they were consulted on widely and agreed (with minor changes) to be reasonably indicative of being expert in Rehabilitation. There was no research base, nor could there be.

Capability itself is a judgement made by practicing clinicians in the field, from their knowledge of the individual, supported by evidence in an electronic portfolio – quite extensive evidence accumulated over years (four years for rehabilitation). The person needs to be safe and independent at the capability. It is known as entrustability. The Rough Guide to the curriculum, which will soon (by June 2021 I hope) be available on the training website, (here) give more background to this.

A solution

In order to help both the trainee and the trainer understand what the capability actually meant “on the ground”, a list of behaviours that one would expect a capable person to show were required. They are indicative, they are compatible with being capable or, more importantly, if they are not seen then one has reason to be concerned.

Thus, just as there are 12-14 capabilities that generally will imply that the doctor (or other professional) is a safe and effective doctor (or other profession), so a range of behaviours will suggest that the person has that capability. But it does not prove it; nor does the absence of one behaviour prove that a person is not capable.

Exactly the same considerations apply to knowledge and skills, which are not explicitly considered in the curriculum.

This whole edifice is built upon a combination of expert opinion, experience, logical analysis, and consensus. Over time the capabilities may evolve as weaknesses and strengths become apparent. I have modified them significantly since 2017 when first put forward, and the rehabilitation ones on this site have been modified as a close analysis will reveal.

Despite all these apparent weaknesses, the system is much better than in the past, when one person just said “He (and, for doctors, it was usually he) is a good man.” The system has made more explicit what is required and how it will be judged. It can also evolve and improve.

So, to answer the question, there is no evidence. There is an explicit method and framework, which can be evaluated, criticised and improved. It is not unlike the development of scientific theories. At present this is the best there is, but a scientific approach will lead to better systems of determining and confirming professional quality.

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