REFLECTIONS

A critical time for medical education: the perilsof competence-based reform of the curriculum

Karen Malone • Salinder Supri

Received: 30 July 2010 / Accepted: 30 August 2010 / Published online: 14 September 2010� Springer Science+Business Media B.V. 2010

Abstract Rapid expansion in scientific knowledge, changes in medical practice, and

greater demands from patients and society necessitate reform of the medical curriculum. In

recognition of this, medical educators across the world have recommended the adoption of

competence-based education. This is intended to increase the rigour and relevance of the

curriculum, move students beyond a focus on the memorisation and regurgitation of sci-

entific facts, and better enable them to understand scientific principles and apply them to

the practice of medicine. Experience from 40 years’ use of competence-based curricula

across the world suggests that the uncritical application of this approach to the medical

curriculum may not achieve its intended aims. There are valuable lessons to be learnt from

the history of competence-based education. By taking on board these lessons, confronting

the pitfalls of this approach, and devising new and creative solutions to the problems

inherent in this methodology, medical educators can better achieve their aim of providing a

strong foundation for the practice of medicine in the twenty-first century. It is only through

such a strategy—rather than the uncritical adoption of this educational approach—that we

will have real movement and progress both in competence-based education in general, and

in its applications to medicine in particular.

Keywords Canada � Competence-based education � Curriculum change � Curriculum

development � Curriculum reform � Medical education � Scotland � United Kingdom �United States

Driven by rapid expansion in scientific knowledge, changes in medical practice, and higher

demands made of physicians by patients and society, medical education is in the throes of a

revolution (Norman 2006). Medical educators across major industrialised countries,

K. Malone (&)University of Medicine and Dentistry of New Jersey, 65 Bergen St., Rm. 160,Newark, NJ 07107-1709, USAe-mail: karen_m_malone@yahoo.com

S. SupriAnderung Consulting, New York, NY, USA

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Adv in Health Sci Educ (2012) 17:241–246DOI 10.1007/s10459-010-9247-2

including the United States, Canada, and the United Kingdom, are advocating the adoption

of a competence-based approach to the medical curriculum. This seeks to steer the cur-

riculum away from an emphasis on the teaching of prescribed courses, towards a focus on

the specific scientific, social and behavioural competencies that students need for the

practice of medicine (Royal College of Physicians and Surgeons of Canada 2000; General

Medical Council 2002, 2009; Scottish Medical Deans Curriculum Group 2002; Association

of American Medical Colleges 2009). This methodological shift aims to increase the rigour

and relevance of the medical curriculum, move students beyond a focus on the memori-

sation and regurgitation of scientific facts, and better enable them to understand scientific

principles and apply them in practice.

However, it is debatable whether a competence-based approach to the medical curric-

ulum will fulfill these intended aims. For nearly 40 years, competence-based curricula

have formed the basis of national vocational education and training across the world, most

notably in the United Kingdom, Australia, New Zealand, Asia, Latin America and main-

land Europe (Arguelles and Gonczi 2000). Competence-based curricula were first intro-

duced for the manual trades, primarily to increase the vocational relevance of courses by

providing greater coherence between training outcomes and the skill needs of employers

(West 2004). The competence-based approach was thus essentially a system of assessment

designed to evaluate training in the manual trades; it was not developed as a compre-

hensive pedagogical approach encompassing the whole of the teaching and learning pro-

cess (West 2004). For this, and other reasons, ever since their implementation,

competence-based curricula have been heavily criticised by educationalists on both

philosophical and practical grounds (Elliott 1991; Hyland 1993, 1994; Hodkinson and Issitt

1995; Winter 1995; Wolf 1995; Arguelles and Gonczi 2000; Grundy 2001; West 2004;

Cox 2007). Medical educators too, have expressed misgivings about this approach as

applied to medicine (Barber 1997; Leung 2002; Talbot 2004; Norman 2006; Huddle and

Heudebert 2007). While a spectrum of concerns have been leveled, we focus on five

criticisms of particular relevance to teaching and learning in the medical curriculum.

Competence is complex and cannot be reduced into isolated elements,since the whole is more than the sum of the parts

The first criticism relates to the underlying philosophical foundations of the competence-

based approach to learning. At issue is the question of whether overall competence in a

particular area can be attained by mastering a set of narrower, discrete competencies. It is

argued that real world competence is a complex, multi-faceted phenomenon which cannot

be reduced to a series of simpler measurable tasks or steps (Hyland 1993; Halsall 1995;

West 2004). Put another way, mastery of individual elements of competence do not nec-

essarily add up to produce overall competence in relation to a particular task or skill

(Ashworth and Saxton 1990; Erridge and Perry 1994). To take photography as an analogy,

one may be able correctly to learn each of the sequence of tasks involved in taking a

photograph, but this does not mean that one will necessarily produce a beautiful picture.

Similarly, in medical education, deconstructing complex scientific and clinical knowledge

into smaller, discrete competencies is also a flawed and questionable strategy (Leung

2002). Atomising clinical performance into isolated elements of procedural knowledge and

skill cannot be added back together to create competence in the clinical context (Huddle

and Heudebert 2007). Hence, the validity of the concept of competence as applied to the

complex process of learning is philosophically questionable.

242 K. Malone, S. Supri

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Competence-based approaches are not suitable for highly skilled professions

A second philosophical criticism relates to the nature of professionalism. It has long been

argued that competence-based education is better suited to lower-level occupations that

involve relatively routine tasks and simple testable skills (Erridge and Perry 1994; Hod-

kinson and Issitt 1995). It is therefore not appropriate to higher-level professions, such as

medicine, which require far more than the satisfactory completion of routine and stand-

ardised tasks. Instead medicine necessitates higher-order cognitive skills, including anal-

ysis, judgment, reflection on previous experience, and ‘‘reading the situation,’’ in order to

understand a clinical problem and undertake differential diagnosis (Huddle and Heudebert

2007). Such higher-order skills do not easily lend themselves to a competence-based

approach (Cave and McKeown 1993; Winter 1995; Grundy 2001; Cox 2007). Perhaps not

surprisingly then, in the United Kingdom 90% of national competence-based qualifications

are awarded for lower-level occupations, and only 4% are awarded for higher professional

education (Department for Education and Skills 2003). In the health care arena, the use of

competencies has been largely confined to the lower-level occupations (Grundy 2001).

While competence-based curricula in medicine may be suited for training in areas

involving lower-level and specific objective tasks, or where protocols exist, such as

hygiene procedures and history taking, the development of robust and reliable higher-order

competencies in medicine has remained elusive (Leung 2002).

Competence-based approaches limit the content of the curriculum

A third criticism concerns the educational rigour of the competence-based approach. In

particular, it has been said to narrow and limit the content of the curriculum in two

significant ways. First, it reduces traditional broad curricula, by narrowing their focus

towards the knowledge and skills required to complete a specific range of tasks in a

particular set of contexts. Second, it limits the curriculum to what is amenable to definition,

that is, to what is concrete and directly measurable (Winter 1995). This narrowing and

limiting imposed by the competence-based approach is inimical to the development of the

broad knowledge, understanding and skills fostered by traditional and more comprehensive

curricula (Hyland 1993). Patients often present with complex multi-faceted health prob-

lems, such as heart failure for example. Teaching how to treat such medical conditions is

problematic using a competence-based approach, because it does not provide students with

the depth of understanding needed to be able to deal with the complexity of such medical

needs in practice. As a result, students may flounder when confronted with the large

universe of possible clinical situations (Huddle and Heudebert 2007).

Competence-based approaches result in ‘‘teaching to the test’’

The fourth major criticism of the competence-based approach relates to how the already

narrowed curriculum becomes yet more attenuated when implemented. When applied in

practice, competence-based approaches result in what has been termed ‘‘teaching to the

test’’ (Grundy 2001). In other words, educators tend to limit teaching to what is specified in

the list of competencies, because it is only those aspects of the curriculum that are tested.

Students in turn largely restrict their studies to what is assessed. Thus, teaching and

learning can become narrow and superficial, tempting students to focus on learning ‘‘the

A critical time for medical education 243

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minimum needed to pass,’’ rather than to think critically and gain a fuller understanding of

the material. In this way, competence-based education further undermines the acquisition

of the broad-based knowledge, understanding and skills needed for professions such as

medicine.

Competence-based approaches are bureaucratic and burdensome

The final major criticism is that competence-based approaches lead to the emergence of

large and complex bureaucracies (Smithers 1993). A significant quantity of written

guidance needs to be produced to ensure the operation and reliability of the system

(Grundy 2001). Educationalists thus may spend more time in administering the system than

on the content and quality of students’ education. The competence-based curriculum can

become dominated by the need to complete forms and check-boxes, ultimately reducing

education to a paper chase, and devaluing the role of educators into that of form-filling

bureaucrats (West 2004). Indeed, published outcome data from evaluative studies of this

approach has revealed an increase in administrative burden, coupled with no clear evidence

of beneficial educational effects (Bates 1999).

In summary, evidence from 40 years’ use of competence-based curricula across the

world reveals that this educational approach is philosophically questionable, methodo-

logically complex and highly controversial. Concerns raised about the rigour, validity and

effectiveness of competence-based approaches, and the consequent loss of important

higher-order learning outcomes for students, mean that there are serious matters to be

addressed if this approach is to be successfully applied to the medical curriculum.

The need for a critical and creative approach to competence-basedmedical education

In light of the lessons from the past, it is important for medical educationalists carefully to

reconsider the use of competence-based curricula. The evidence suggests that the uncritical

application of this approach to the medical curriculum will not achieve its intended aims.

The starting point for medical educators should be to think through the basic philosophical

and methodological underpinnings of this educational approach, and carefully evaluate its

validity and relevance to the medical curriculum. It should be recognised that adopting a

competence-based approach in practice is not easy. The competence-based curriculum

presents new methodological challenges in terms of how best to develop, teach and assess

competencies, so that students are provided with strong foundations in the knowledge and

skills needed to perform at the required academic and professional levels. Moreover,

educators also need to ensure that, if implementing a competence-based approach, they do

not lose sight of the considerable strengths of the current curriculum. They must not

‘‘throw out the baby with the bathwater.’’ Instead of a wholesale swing to competence-

based education, they should consider how to blend the best of traditional with compe-

tence-based approaches.

In the final analysis, we would urge that any reform of the medical curriculum—

whether based on traditional approaches, competencies, or some combination of the two—

be thoroughly informed by the evidence. Only then will medical education reform achieve

its aim to provide a strong foundation for the practice of medicine in the twenty-first

century. In this endeavour, there are many valuable lessons to be learnt from the history of

244 K. Malone, S. Supri

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the implementation of competence-based education. Medical educators need to confront

the pitfalls of this approach and find new and creative solutions to the problems inherent in

this methodology. In this way we will have real movement and progress both in compe-

tence-based education in general, and in its applications to medicine in particular.

No funding was received for this work.

The authors declare that they have no conflict of interest—financial, personal, or

other—which may affect the information, research, analysis, or interpretations presented in

this manuscript.

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