Zubin Austin BScPhm, MBA, MISc, PhDProfessor

University of TorontoCanada

What keeps you awake at night?

High-profile cases of “breach of duty of care” amongst professionals

Growing calls for accountability – and “action” - from politicians and the public

Tension between professional expertise and an increasingly well-educated public with unfettered access to information

Declining public esteem for professionals

Shifting self-identity of professionals from “vocation” to “job”

Squeaky wheels getting oiled within an environment of austerity and scarcity

General narrative of “decline” and “self-reliance” vs “common goods” and “trust”

In a world where some patients know more about their health care than practitioners do…what does it mean to be a professional?

Who actually still believes that “professionals” solve problems and make society better?

Does anyone believe that another Mid-Staffs (or HSC or Royal Winnipeg Hospital) really won’t happen again?

A nurse has been badgering a physician for a prescription for a patient. Finally, at 9:00pm, the prescription is written, and the nurse sends it off to the pharmacy…which closed at 9:00pm.

A physiotherapist is trying to assess a patient’s mobility and joint status and needs an x-ray ordered to do so properly. He approaches a medical resident from the team, and is informed that the patient in question “…isn’t mine”.

“The quality of being adequately or well-qualified, physically or intellectually”

The basis for evaluating success, and defining readiness for practice, in education, regulation, and employment

In reality, means different things to different people at different times in different contexts, yet….

What do patients want from health care professionals?

- Accessibility

- Affability

- Acknowledgement

Complaints about practitioners are rarely due to “an honest mistake”

Impoliteness is the most frequent cause of complaint

<2% of practitioners are generally complained about within most professions and even fewer end up before a disciplinary or fitness to practice committee

Competency = interpersonal savvy

Day-to-day professional practice is tough…and getting tougher

Decreasing autonomy, increasing demands, burnout, and fatigue

Legalism dominates clinical judgment

In the context of error, “…there but for the grace of God go I…”

Competency = good luck and NOT being in the wrong place at the wrong time

Safety: of the public

Transparency: for members

Accountability: to multiple stakeholders

Consistency: like cases being judged similarly

Adversarial: follows principles of administrative law

Competency = a contested and contestable (political?) construct

Tension between developmental and psychometric dimensions…and increasingly financial constraints

Idealistic desire to prepare individuals for a life time of practice, not simply to pass tomorrow’s test at odds with financial reality and league-table mentality

Certification function trumps most others –commodification of personal/professional development

Competency = “our name is on this product”

Operational efficiency and economies of scale drive “production model” of care delivery

SOPs dominate practice to facilitate standardization, predictability, efficiency

Data, workload measurement dominate resource allocation and decision making

Competency = fitness for purpose/context

Most frequently used tool currently available to address multiple stakeholder needs/wants

Built upon competency frameworks which purport to define “the good practitioner”

Significant allocation of time, resource and energy…

….yet has this actually PREVENTED problems from occurring? And has our focus on competency assessment blinded us to other ways of “seeing” professional practice?

Attendance at CE does not translate into change Completion of CE does not predict whether

individuals will meet objectively defined competency standards

Individuals at greatest risk for competency drift are: i) older (>25 years post-graduation); ii) work in sole proprietorships; and iii) internationally educated

Only a very small number of practitioners are ever found to be incompetent and sanctioned for it

We have no idea how many are at some stage of competency drift

Self-reporting: concerns regarding veracity, value, effort and outcomes

Complaints-driven: subjectivity/bias issues Mandatory CE: no evidence of impact Peer review: lack of standardisation, “n-of-1 problem” Patient satisfaction: “Dr. Shipman problem” Standardised test of knowledge: translate into

performance? Standardised test of performance: “trained monkey

problem” Revalidation: reinforces previous validation problems Secret shopper methods: ethics, culture of surveillance Outcomes measurement: too many confounders

“It’s not my job”

“If I answer this question, everyone is going to come to me”

“If I stay late this time, the nurses will never learn that we close at 9:00 pm”

“It’s just a job”

What if we were to define competency not as “the quality of being adequately or well-qualified physically or intellectually” but instead defined it as “demonstration that you are firing on all pistons, giving it your all?”

Identified as a “root cause” of error in many health care systems

Traditionally used interchangeably with “satisfaction”: focus is on creating organisations that “satisfy” workers –frequently results in system-wide “bottom-up decision making”, or “collaborative practice” models

Psychologically, engagement refers to the balance point between personal skills/interests and environmental challenges, and is characterized by timelessness, productivity, purposefulness, subjective connection between individuals (“synchronicity” or “chemistry”)

Do macro-level interventions produce micro-level psychological changes?

Within a regimented, legalistic, bureaucratised system….“(w)e cannot become attached to higher aims and submit to a rule if we see nothing above us to which we belong.”

E.D. ‘97

Anomie: condition in which (society) provides little socio-ethical guidance to individuals; the breakdown of social bonds between individuals and the community results in fragmentation of social identity and rejection of self-regulatory values.

Educators: emphasis on technical/procedural mastery through hoop-jumping…in the name of competency

Regulators: legalistic constraint/replacement for professional ethos…in the name of competency

Employers: mass-regimentation of professional practice…in the name of competency

The problem of “do something…anything!” and the need to be seen to act with certainty

To think – apply complex and adaptive cognitive skills to address ambiguous problems

To observe – and not ignore cues and signals To care – about what they do and who they do it

to To connect – with their profession, their practice,

and their patient To try – to the best of one’s ability To understand – right answers vs “least worst

alternatives” To fire on all pistons – to bring the best of

themselves to their work and not simply think of it as “a job”

No one-size-fits all pattern or model seems to apply; desire to proceduralise synchronicity is itself a barrier to engagement

Emotional intelligence emerging as a critical –and under-examined – form of competence, particularly in an interprofessional context

Flexible, adaptive, authentic repertoire of behaviours/responses best describe synchronicity – defying attempts to formalise, codify, or regulate

Strong individual relationships with peers/team may be associated with clinical success and improved patient outcomes

“To a hammer, everything looks like a nail”

Complex issues defy simplistic bureaucratised solutions

Multiple factors require multiple stakeholders to work in tandem with one another

Rush to act following high-profile crises may be politically satisfactory but ineffective

There may not be a “right answer”, only “least worst alternatives”

Psychological needs of health and care professionals for engagement, synchronicity, interpersonal chemistry, and feeling of belonging have not been adequately examined

While patient-focus is necessary, is it sufficient to drive professional practice?

While competency assessment is necessary, it is probably not sufficient to ensure quality, safety, and efficacy

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