varying conceptions of competence: an analysis of how health sciences educators define competence

Varying conceptions of competence: an analysis ofhow health sciences educators define competenceNicolas Fernandez,1 Valerie Dory,2,3 Louis-Georges Ste-Marie,1 Monique Chaput,1 Bernard Charlin1 &Andree Boucher1

CONTEXT Current debate in medical educationfocuses on the nature of ‘competency-based medicaleducation’ (CBME) and whether or not it should beadopted. Many medical schools claim to run ‘com-petency-based’ curricula, but the structure of theirprogrammes can differ radically. A review of theexisting CBME literature reveals that little attentionhas been paid to defining the concept of compe-tence. A straightforward examination of what ismeant by the term ‘competence’ is noticeably miss-ing from the literature, despite its impact onmedical training.

OBJECTIVES This paper aims to illustrate thevarying conceptions of ‘competence’ by comparingand contrasting definitions provided in the healthsciences education literature and discussing theirrespective impacts on medical education.

METHODS A systematic review of recentpublications in medical education journals pub-lished in English and French was conducted toextract definitions of competence or, if definitionswere not explicitly stated, to derive the authors’implicit conception of competence. A sample of14 definitions from articles in the health sciences

education field was studied using thematicanalysis.

RESULTS There is agreement that competence iscomposed of knowledge, skills and other compo-nents. Although agreement about the nature ofthese other components is lacking, attitudes andvalues are suggested to be essential ingredients ofcompetence. Furthermore, a clear divergence inconceptions of how a competent person utilisesthese components is apparent. One view specifiesthat competence involves selecting componentsaccording to specific situations, as required. A sec-ond view places greater emphasis on the synergythat results from the use of a combination ofcomponents in a given situation.

CONCLUSIONS These conceptual distinctionshave many implications for the way CBME isimplemented. A conception of competence as theselection of components may lead to a greateremphasis, in a training setting, on the mastery ofeach component separately. A conception of com-petence as the use of a combination of componentsleads to greater emphasis on the synergy that resultsas they are deployed in clinical situations.

medical education in review

Medical Education 2012: 46: 357–365doi:10.1111/j.1365-2923.2011.04183.x

Read this article online at www.mededuc.com ‘read’Discuss ideas arising from this article at www.mededuc.com ‘discuss’

1Centre for Pedagogy Applied to Health Sciences, Faculty ofMedicine, University of Montreal, Montreal, Quebec, Canada2Fonds de la Recherche Scientifique-FNRS, Brussels, Belgium3Universite catholique de Louvain, Institute of Health and Society(IRSS), Brussels, Belgium

Correspondence: Nicolas Fernandez, Centre de Pedagogie Appliqueeaux Sciences de la Sante (CPASS), Faculte de Medecine, Universitede Montreal, CP 6128, Succursale Centre-Ville, Montreal, QuebecH3C 3J7, Canada. Tel: 00 1 514 343 6111 ⁄ 1683;Fax: 00 1 514 343 7864; E-mail: [email protected]

ª Blackwell Publishing Ltd 2012. MEDICAL EDUCATION 2012; 46: 357–365 357

INTRODUCTION

The trend towards competency-based medical edu-cation (CBME) in doctor training is growing.Recently, a number of national training frameworksidentifying the competencies required of doctorshave been developed (e.g. CanMEDS,1 the Accredi-tation Council for Graduate Medical Education[ACGME] framework2 and the Dundee OutcomesModel3). These frameworks, which are generallylinked to national accreditation standards, set out-come expectations and criteria for medical schools interms of competencies. Yet, the implementation ofCBME presents both possibilities and challenges thathave led to extensive debate in the literature.4–6

There is still much resistance to its implementationand much confusion as to what exactly CBME entails.

Competency-based medical education has been crit-icised for being steeped in reductionist behaviourism,which limits the development of professional exper-tise to the acquisition of discrete, easily measurablepractical skills.7–10 Advocates of CBME have arguedthat these criticisms reflect narrow conceptualisationsof CBME rather than pertaining to the conceptitself.11 In the current context, when the viability ofCBME is debated,12 it is important to clarify theconcept at the heart of the debate and, indeed, at theheart of national accreditation frameworks. Exami-nation of the various conceptions behind widely usedterminology, such as ‘competency’, can lead to betterunderstanding of the issues and the potential benefitsand pitfalls of CBME.12,13 This paper presents asystematic review of definitions of competence citedin the health sciences education literature with theaim of identifying both areas of common ground andthe differences between them.

METHODS

Literature search

We conducted a systematic review of the healthsciences education literature addressing the definitionof competence or competency. The MEDLINE data-base (OVID interface, period: 1948 to February 2011[week 5]) was queried on 16 February 2011 using thekeywords ‘competenc* AND terminology as topic’;this yielded 248 hits. The EMBASE database (period:1996–2011, week 5) was queried on the same day withthe key words ‘competenc* AND definition’, yielding188 hits. Two members of the research team inde-pendently scanned the resulting records (titles and

abstracts) in order to select those that included anoriginal definition of competence. PubMed was notconsulted because it is considered to be equivalent toOVID ⁄ MEDLINE and differs only by being a few weeksmore up-to-date; given the nature of this review, it wasnot deemed necessary to consult a third database.

Inclusion and exclusion criteria

Records were considered potentially relevant if theyincluded a definition of competence, a notion ofcompetence or a concept of competence. Recordswere excluded if the reference addressed definitionsof competence relating to patients, dealt with theregulation of health sciences practice at a macro levelor were published in languages other than English orFrench. The full texts of all potentially relevantrecords were retrieved and screened independentlyby two authors for final inclusion.

Data extraction and analysis

A total of seven records were selected from EMBASEand a total of 12 records were selected fromOVID ⁄ MEDLINE. Two articles were cited in bothdatabases and thus 17 records were found to satisfy allinclusion criteria. These form the basis of ouranalysis. Of these, one was published in French andthe remainder were published in English.

Competence definitions, when given by the authors,were extracted directly from the original text.Passages in which the concept or notion of compe-tence was not defined directly but was discussed inbroader terms were also extracted from the originaltext; only the relevant sections were included. In allcases, care was taken to respect the vocabulary andphrasing used in the original texts. Three articleswere excluded because the research team was unableto isolate a sufficiently clear definition of the concept.The resulting 14 passages (Table 1) constituted thedataset used for analysis.

A thematic analysis14 approach was adopted. Thisconsisted of multiple stages of data exploration and aconstant comparison of data with the emergingcategories, leading to a refinement of the categoriesin which data are coded.15 To limit the effect ofpersonal bias, two members of the research teamexamined all definitions independently. Differenceswere outlined and discussed in order to achieveresolutions acceptable to all authors.

Broad themes were identified from each recordin the dataset and used as initial categorisation.

358 ª Blackwell Publishing Ltd 2012. MEDICAL EDUCATION 2012; 46: 357–365

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These were: the components of competence; whatcompetence allows a competent person to do, andthe purpose of competence. Hence, each of thedefinitions was broken down into discrete clauses thatwere categorised appropriately. The data, thussegregated, were subsequently subcategorisedaccording to the semantic value of the terms used tomake up the clause. Discrete sets of meaning wereidentified, allowing the authors to draw inferencesabout the data. Table 1 presents the final datasetused to carry out the analysis.

RESULTS

The results are presented according to the broadcategories: the components of competence; what

competence allows a competent person to do, andthe purpose of competence.

The components of competence

Twelve of the definitions in the 14 papers3,16–22,24–28

identified specify what a competence is composed of.For the most part, the definitions indicate thatcompetence is composed of knowledge (mentionedin eight definitions16–20,24,26,28) and skills (mentionedin six definitions16,18–20,24,28). The Oxford EnglishReference Dictionary defines competence (or com-petency) in terms of ability and in terms of skill as ‘(i)ability; the state of being competent, (ii) an area inwhich a person is competent; a skill’.29 Although thedictionary does not link competence and knowledge,the study sample indicates agreement that compe-

Table 1 Definitions of competence extracted from the health sciences literature

Definition of competence

1 ‘…habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values and

reflection in daily practice for the benefit of the individual and community being served’16

2 ‘…competence […] is the integration of several domains of knowledge, and the use of experience and judgement’17

3 ‘…competence in radiography is the ability to link technical knowledge with appropriate values in judgement making. A

competent health practitioner is one who can demonstrate the knowledge and skills defined in a profession’s occupational

standards’18

4 ‘…definitions of competence abound and most refer to adequacy of qualification, ability, skill, and knowledge. The word

‘‘perform’’ is often seen in ‘‘competence’’ definitions’19

5 ‘…competency involves the ability to combine knowledge, attitudes, and motor skills appropriate to the delivery of

professional service’20

6 ‘…the ability to do something successfully. Competence and competency – both words may be used with the same

meaning – are a quality or state of being’21

7 ‘…this notion of competence incorporates professional judgement, is relational and involves complex structuring, bringing

together disparate attributes and tasks required for intelligent performance in specific situations’22

8 ‘...competence can be simply defined as the ability to operate to an adequate, safe standard’23

9 ‘…competency […] is an effective application of available knowledge, skills, attitudes, and values in complex situations’24

10 ‘…competence refers to what needs to be learned during training and also how trainees learn. For this, we need to know

what we are assessing – we need criteria of competence. Can we find ways of evaluating whether the practice of our

trainees is more or less competent that go beyond intuitive judgements from a group of elders? In my view, competence

and how it is integrated is likely to be dependent in good part on character attributes’25

11 ‘…individual characteristics (knowledge, abilities and attitudes) that allow a person to practise an activity in an autonomous

fashion, to continuously improve practice and to adapt to a rapidly mutating environment’26

12 ‘…professional competence has three components: psychomotor and intellectual problem-solving skills, professional

socialisation and judgement’27

13 ‘…a complex set of behaviours built on the components of knowledge, skills, attitudes, and ‘‘competence’’ as personal

ability’28

14 ‘…the ability to manage ambiguous problems, tolerate uncertainty and make decisions with limited information’3


Conceptions of competence

tence includes a minimum of two components:knowledge and skills. However, these are not the onlycomponents mentioned. Definitions include furthercomponents of competence that constitute a rathereclectic list, as presented in Table 2.

The components of competence presented inTable 2 can be broadly summarised as attitudes,abilities, judgement, values, and personal orcharacter attributes. Epstein and Hundert,16 forexample, conceive of competence as the judiciousdeployment of such things as emotions and values.The heterogeneous nature of the componentsmentioned is awkward; how can values be placed onthe same level as abilities? The definitions indicate ageneral acceptance that knowledge and skills are notthe only components of competence, but there seemsto be little agreement on the nature of the othercomponents.

Many authors in the realm of education research haveincluded ability as one of the three broad compo-nents of competence, namely, knowledge, skills andabilities.30 Others, such as industrial and organisa-tional psychologists, characterise competence as acomplex entity composed of four broad components,namely, knowledge, skills, abilities and ‘other’ attri-butes (denoted ‘KSAOs’).31 In the health sciences, asper the study sample of definitions, two distinctcategories emerge, of which one converges on abilityand the other on attitudes, based on values andjudgement.

The word ‘ability’ is mentioned five distinct times inthe 14 definitions, indicating that, for these authors,

ability does not equate to competence, but is acomponent of it. Ability is generally composedof abstract reasoning, memory and the cognitiveprocesses associated with solving novel questions.31

Thus, clinical reasoning, professional socialisation,communication and reflection in daily practicecan be thought of as abilities that constitute a part ofcompetence.

The second category to emerge is related to attitudesand values, which are distinct from knowledge andskills. These components belie a possible conceptionof competence as consisting of personal characteris-tics or values, none of which can be formally taught ina training curriculum, but belong, instead, to therealm of experience and personal growth fosteredby appropriate role models in a training setting. Yet, asLeung notes, it is this component, beyond knowledgeand skills, that may account in large part for the ‘abilityto manage ambiguous problems, tolerate uncertaintyand make decisions with limited information’.3

Thus, competence, as it might be interpreted fromthis sample of definitions, describes more thanknowledge and skills. It also involves an intangiblecomponent related to the individual’s personalcharacteristics, attitudes and values as they manifestin professional judgement. Much of the difficulty indefining these components of competence reflectsthe fact that they are comparatively difficult toobserve and assess.

What competence allows a competent person to do

All definitions conceive of competence as enablingsomeone to do something adequately or successfully.Two records equate competence with the respect ofoccupational18 or adequate and safe23 standards. Tworecords define competence exclusively by what itenables a competent person to do as, respectively, theability ‘to operate to an adequate, safe standard’23

and the ability ‘to manage ambiguous problems,tolerate uncertainty and make decisions with limitedinformation’.3

The idea most frequently included, appearing in fourof the definitions, is that competence can ‘bringtogether disparate attributes and tasks’.22 For exam-ple, writing from a radiography perspective, Wrightet al.18 equate competence with the ‘ability to linktechnical knowledge with appropriate values injudgement making’. The various verbs used in thedefinitions to express this idea are ‘linking’,‘integrating’, ‘combining’ and ‘bringing together’and they refer to the ‘integration’25 of various

Table 2 Components of competence other than knowledgeand skills

Definition

no. Components

1 Reflection in daily practice

3 Appropriate values in judgement making

4 Adequacy of qualification, ability

5 Attitudes

6 Quality or state of being

7 Professional judgement

9 Attitudes and values

10 Character attributes

12 Professional socialisation and judgement

13 Attitudes and ‘competence’ as personal ability


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components of competence. Thus, competence canbe conceived of as the bringing together of differentcomponents to perform, do something successfully ormanage complex situations.

However, not all definitions adopt the same tack todefine competence. Whereas some define a compe-tent doctor by focusing on how he or she leveragessound interpersonal skills and judgement to providebetter care for patients, others focus on the compe-tent doctor’s ready access to appropriate resourcesand behaviours in complex situations. For example,Calhoun et al.24 define competence as the ‘effectiveapplication’, rather than the bringing together, of‘available’ components in complex situations.Carraccio et al.’s28 definition of ‘a complex set ofbehaviours built on the components of knowledge,skills, attitudes, and ‘‘competence’’ as personal ability’also belies a view of competence as a set of behavioursto be selected in accordance with a given situation.

This second conception, that competence is the act ofselecting components, echoes the characteristics ofeducational competencies suggested by Albaneseet al.32 in that competence is viewed as a series ofdiscrete and measurable behaviours selected deliber-ately in accordance with the specific contexts ofprofessional practice. The underlying idea is that thecompetent doctor is able to select, rather thancombine, the appropriate behaviours or componentsin complex situations.

Thus, the study of the definitions reveals an under-lying dichotomy in how the components of compe-tence are to be used. In one view, in which thecompetent professional combines components as afunction of a complex situation, the emphasis is onthe ‘bringing together’ of components and includesthe notion that synergy will enable an outcome that ismore than the sum of all parts. By contrast, someauthors consider that the competent professional iscompetent because he or she can select from avail-able components those that are most appropriate forthe complex situation with which he or she isconfronted. In this second view, the notion ofcombining or synergy is not as prevalent as in thefirst.

The purpose of competence

Three definitions specify what competence is for. Forexample, Epstein and Hundert16 indicate that com-petence is for the ‘benefit of the individual and thecommunity being served’. In this instance, service tothe community is viewed as a sort of benchmark

against which to assess the ‘habitual and judicioususe’ of different components of competence.16 Bhattiand Cummings refer to competence as the ability tocombine different components for the ‘delivery ofprofessional service’.20 Cowan et al. specify that com-petence brings together different attributes and tasksfor ‘intelligent performance in specific situations’.22

The purpose of competence, as expressed in thesedefinitions, is linked to the idea that socially relevantservice33,34 requires that practitioners demonstratethey are qualified to deliver it. Competence, equatedhere with qualification, is thus conceived of as ameans of exchange between society and profession-als: in exchange for status and exclusivity of practice,doctors develop competence in order to deliverquality health care services.

Beyond the idea of qualification and quality ofservice, the definitions of competence that allude toits purpose extend the concept to include the specificcontext in which it is meant to be deployed. The factthat competence plays a role in the social pactbetween doctors and society indicates that the con-text in which competence exists also defines it.Competence is not conceived of only as a sum ofcomponents to be combined or selected; it isconceived of as having a socially relevant purpose.Hence, competence cannot exist without specificcontexts in which it is deployed.

The notion that competence is closely linked to acomplex situation is widely accepted in the literatureon competence in the health sciences and otherfields. For example, the three components men-tioned by Clifford and Plumridge27 in their definitionof competence as the presence of psychomotor andintellectual problem-solving skills, professional soci-alisation and professional judgement, make directreference to contexts in which competence isrequired.

To summarise, the review of this sample of definitionsreveals that, according to prevailing perceptions,competence: (i) is composed of knowledge, skills anda series of components related to personal abilitiesand attributes; (ii) allows the professional to select orcombine components in order to maintain standardsof performance, and (iii) constitutes a guarantee forthe community or society that the possessor will beable to perform to acceptable standards.

From this, we observe, firstly, that a clear consensuson the nature of the components is lacking; some,such as technical knowledge, clinical skills, and so



forth, are clearly teachable, but others describeoutcomes of personal growth processes that span aperson’s lifetime. Clarification and agreement on thenature of this third group of components must beachieved in light of the specificity of health scienceseducation.

Secondly, two verbs are used to define what compe-tence allows one to do: these refer to selecting orcombining components. Four definitions explicitlystate that competence is demonstrated by the very actof combining components of various types, be theytechnical knowledge and skills or personal values andjudgement, in order to produce professional action.Two definitions, by contrast, clearly equate compe-tence with sets of components or complex behavioursto be selected and applied in complex situations.

This distinction, albeit subtle, points to differentconceptions of competence, one of which views it asthe accumulation of components that are to beappropriately selected in complex situations. Com-petence, in this view, hinges on the availability ofcomponents and the ability to select the right ones.

Govaerts,35 commenting on the paper by Albaneseet al.,32 warns of the possible ‘anatomisation’ ofcompetence, of limiting the concept to the sole sumof its parts, thus submitting to the pressures of the‘traditional dominance of disciplinary educationalapproaches’. Leung3 recognises that deconstructingmedical practice into small discrete behaviours is notstraightforward or necessarily useful. There must bean intermediate level of description, which takes intoaccount the cultural and social contexts in whichcompetence is defined.

This intermediate level of description of competence,the second conception emerging from the sample,places greater emphasis on the combination ofcomponents as a function of the complex situationitself. This means that the components cannot bereadily dissociated from the complexity of the situa-tions with which health professionals are confronted.These situations will have an influence on the natureof the competencies a practitioner will develop. Theemphasis in this second view of competence, as itemerges from the sample data, is on the interplay ofthe components and the resulting synergy for inter-vention in complex professional situations.

Thus, a dichotomy emerges in the way competence isconceptualised: competence constitutes the sum ofvarying components and discrete behaviours3,20 to beeither selected or combined for socially responsible

medical practice. Describing competence as made upof components to be selected emphasises the discreteand isolated nature of each component. Describingcompetence as the combination of componentsemphasises the resulting synergy, in which the effectof the whole is greater than the sum of the effects ofeach part.

DISCUSSION

This dichotomy in the way competence is conceived isnot new. Noam Chomsky36, cited by Allal,37 used theterm ‘competence’ in an academic setting in refer-ring to the human being’s biological potential toacquire linguistic competence. Chomsky drew a cleardistinction between knowledge about a language (e.g.grammar rules, vocabulary, etc.) and proficiency inusing this knowledge to express complex ideas andconcepts.36

Gonczi33 also underscored the conceptual dichotomybetween the task-specific approach (competence isconceived of in terms of discrete behaviours associ-ated with the completion of atomised tasks) and thegeneral attributes approach (competencies thoughtof as general attributes, regardless of the context inwhich they might be applied).

Inspired by the Royal College of General Practitio-ners, Leung3 makes a distinction between clinicalcompetence (what doctors can do) and clinicalperformance (what doctors do do), indicating apotential divide in the perspective of competence as apotential to act, reminiscent of the distinctionbetween the ‘shows how’ and ‘does’ levels in Miller’spyramid,38 and competence as the performance itself.

Some literature emphasises the meaning of compe-tence as a combination of components and defines itas ‘know-how in action’.39 LeBoterf,40 Perrenoud41

and Rey42 use the term ‘competence’ to describe themobilisation of resources to accomplish a taskbelonging to a specific cluster of professional situa-tions. Tardif defines competence as a ‘complex abilityto act supported by the mobilisation and the efficientcombination of a variety of internal and externalresources within a specific family of situations’.43

This view places a greater emphasis on the actualisa-tion of the doctor’s potential in the resolution ofmedical problems and on the integrative property ofwhat is defined as ‘competence’. The focus is clearlyon the quality of the professional act, in which thedifferent resources (both internal, such as


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knowledge, skills and attitudes, and external, such asthe medical literature and members of the healthcare team) available to the doctor are put intocombined action. The impact of each individualresource becomes meshed into the integrated act.43

In summary, authors espousing this view of compe-tence agree on three principles: (i) competence is anintegration and a combination of various types ofinternal and external resources that can be deployedinto action; (ii) competence is closely associated witha specific set of problems or situations, and (iii) themobilisation of competence in order to resolve aproblem or to execute a task within a specificsituation is the ultimate proof of its existence.Competence is therefore only apparent when it is inaction, when it is used to attain a desired andexpected performance42 and when its constituentparts are combined in such a way that they areindistinguishable.

Implications for teaching and learning

Although the distinctions among the varying viewson competence might appear at first glance aca-demic, the way competence is conceptualised,implicitly or explicitly, has profound and far-reach-ing implications on the way curricula are structured,the way teaching and learning are carried out andthe way learning is assessed. Furthermore, this canlead to misunderstandings and difficulties in imple-menting CBME and can, if it is not addressedrationally, be a disruptive factor for those who pushto implement it.

The view of competence as the selection of compo-nents implies that the quality of the action is afunction of the ready availability of components(knowledge, skills, attitudes, etc.). Assessments ofcompetence are likely to focus on the demonstratedmastery of each component separately. Hence, astudent who has demonstrated that he or shepossesses the correct knowledge, proper skills andappropriate personal attitudes is deemed to becompetent. This student’s training will place greateremphasis on the acquisition of the widest possiblearray of internal resources than it will on fostering theability to combine these in specific situations. Thisview fits well with Flexner’s model of medical educa-tion, which draws a clear distinction between theinitial 2 years of basic science education and the final2 years of clinical education.44 In the first 2 years,the student acquires basic scientific knowledge; thefinal 2 years afford the student the possibility of usingthis knowledge in various clinical settings.

By contrast, competence as a combination of com-ponents defines the desired outcome of training, theoutcome driving the education process,28 as profes-sionally meaningful actions. This view emphasises thenotion that the successful completion of these actionsrequires the mobilisation of an integrated andundifferentiated whole composed of internal andexternal resources. This implies that, in trainingcurricula, students are simultaneously exposed to andmust acquire the required resources, internal andexternal, as they mobilise them in authentic clinicalsettings. Competence is likely to be assessed withinthe clinical setting and such assessment will focus onthe way resources are combined. The significantdifference, therefore, is that as competence is linkedto performance, it follows that its acquisition anddevelopment should be conducted in a contextua-lised and active setting.

Strengths and limitations

The conclusions of this paper can only be as robust asour literature search. Because competence is such avast topic, it was important to narrow the search topapers that would provide a formal definition or anapproximation of a definition of competence in thecontext of education and training in the healthprofessions. Using the queries ‘competenc* ANDterminology’ and ‘competenc* AND definition’ wasthought to be the most efficient way to narrow thescope of the search. This resulted in the identificationof 14 papers, which we considered an adequate andrepresentative sample of how authors in healthprofessions education conceive of competence.

This implies that many papers addressing the widerissue of CBME were not within the scope of theliterature search and hence not included in theanalysis, although they may have provided somedefinition of competence. An article by Frank et al.45

on the definition of CBME was consulted, but noindication as to how the authors defined competencewas found. To attenuate this limitation, knownreferences both within and outside the health sci-ences education field, which provide clear definitionsof competence, were consulted and used to interpretthe present findings.

CONCLUSIONS

The overarching questions in medical educationconcern the ways medical training curricula impartinternal and external resources or, as Swing46

describes them, basic unitary skills, and how they



facilitate the development of unified medical compe-tence. It is easy to conceive of teaching and acquiringknowledge and skills in an academic setting, but is itpossible to acquire or teach such things as emotions,values and character attributes? If it is agreed thatcompetence is made up of more than knowledge andskills, shouldn’t there be clear agreement on thenature of the other components included in theconcept? These are important issues as they have adirect impact on teaching and learning in CBME.

The concept of competence plays a key role indefining the outcomes of medical curricula, what isto be assessed, the nature of the internal andexternal resources and the way that these will beused to deliver appropriate health services. Thus,this paper has attempted to underscore some of thefault lines that exist between diverging conceptionsof competence, as they are expressed in the litera-ture. The paper was not intended to propose aunified concept of competence, but, rather, toattempt to describe the differences among currentconcepts. The task of further identifying a unitaryconcept of competence is daunting and beyond thescope of this paper.

Certainly, the first task in that endeavour will be toexplore, define more precisely and agree on thenature of the components of competence, especiallythose other than knowledge and skill. As noted, thiscauses difficulty in academic settings because not allof the components described in the literature can betaught. Hence, it would be appropriate to definethese components with reference to both theirteachability and their assessability.

The second task is to investigate the link betweencompetence and the socially relevant practice ofmedicine. It will be necessary to determine the extentto which the impact of society’s expectations on howdoctors practise is important in shaping the compe-tency frameworks adopted and to subsequently agreeon the appropriate concept of competence.

Contributors: NF designed the study, conducted theliterature review, extracted and analysed all data, draftedthe manuscript and coordinated the revision process. VDsupplemented the literature review and contributed to theinterpretation of findings. L-GS-M contributed to the studydesign and to the development of its intellectual content.MC conceived of the intellectual premise for the paper,selected and analysed records in the literature review, andcontributed significantly to the data extraction and analysis.BC contributed significantly to the interpretation offindings and provided invaluable guidance in the writing

process. AB contributed to the development of theintellectual premise for the paper. All authors contributedto the critical revision of the paper and approved the finalmanuscript for publication.Acknowledgements: we wish to acknowledge Dr JeanJouquan, Bureau de pedagogie medicale, Faculte demedecine, Universite de Bretagne occidentale (Brest),France, for his invaluable advice on the writing of thispaper.Funding: none.

Conflicts of interest: none.

Ethical approval: not applicable.

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Received 12 April 2011; editorial comments to authors 9 June2011, 12 October 2011; accepted for publication 20 October 2011



varying conceptions of competence: an analysis of how health sciences educators define competence

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