The Building Blocks of Clinical Competency

Competency standards communicate the benchmarks for effective clinical performance and best practices. Therefore, competence should be evaluated and guided by effectiveness and safety, including the integration of the best research evidence. This must, of course, take into account the patients' values and clinical circumstances.

The clinical decision-making process ensures that beneficial outcomes are anticipated and achievable. However, there continues to be a significant gap between clinical decision-making using evidence from published literature and the knowledge, attitudes, skills, practice behaviour and clinical outcomes observed in some chiropractic practices. Ideological differences notwithstanding, chiropractic clinical guidelines are now entrenched in chiropractic education, research and practice. Government and funding concerns drive it. But there seems to be a lot of confusion in understanding the very real differences between clinical practice guidelines, standards of care and clinical competence.

Clinical guidelines are meant to be flexible extensions of investigative experiments in the evolution of optimal patient care. Guidelines begin as relevant questions, not anecdotal conclusions. Evidence must be collected in an honest, open-minded way from the best available sources and then appraised consistently and correctly. Recommendations should not be made as to practice options until effectiveness, efficiency and safety issues are resolved through rigorous outcome evaluations in the form of clinical trials or reviews. In the patient's best interest, we must be able to trust the evidence before we can recommend the intervention. Therefore, clinical guidelines should be developed by academics and then filtered through continuing education, symposia and finally the peer-reviewed literature.

Standards of care, on the other hand, represent the profession's core knowledge and minimum requirements; these standards are legislated, controlled and monitored. Ideally, clinical practice guidelines predict the future standards of care. By implication, a truly rigorous guideline process minimizes contamination and bias. Special interests, deceptive claims and financial incentives retard the successful implementation of new guidelines, improved standards of care and patient safety.

So, what then is competence? How do we get competence, and how can we maintain it? Competence is most often associated with models of learning and may extend back in time to the early stages, as evidenced by the following anonymous proverb:

He who knows not, and knows not that he knows not, is a fool (unconscious incompetent);
he who knows not, and knows that he knows not is ignorant (conscious incompetent);
he who knows, and knows not that he knows, is mindless (unconscious competent);
but he who knows, and knows that he knows, is a wise person (conscious competent).

Gordon Training International developed a learning matrix based on this ancient model to explain how people learn and why learning is best accomplished in stages. You should note that it is not possible to jump stages, nor is the order fixed. Different models may use a different hierarchical progression. All models, however, take into account the need to establish the ongoing awareness of deficiencies in competence, because competency standards change. Additionally, the teaching of complex learning skills is important since many people will regress to previous stages. We may commonly know this attitude as "staying in the comfort zone" or "taking the path of least resistance."

The first principle is that people must acknowledge they are incompetent and are willing to escape from the "ignorance is bliss" stage. Moving from unconscious incompetence to conscious incompetence is where we begin as chiropractic students. This is the state of "beginner's mind," and it is both stimulating and most insecure. We should return to this state often if we challenge ourselves with continuing education and evidence-based practice.

The acquisition of advanced skills that are performed reliably and effectively without supervision moves us into the unconscious competent stage. If you have driven over a distance of highway, but cannot remember driving it, then you have experienced this stage of unconscious competence.

This is also known as "condition white." You are actively performing a skill, but are oblivious of your surroundings or your conscious part in them. For obvious reasons, this is when most accidents and misadventures happen. You are just not paying attention to what you are doing. You should appreciate the clinical significance of this if you also treat patients in this state of mindlessness.

There are daily reports of medical mistakes and instances of overuse, underuse and misuse. Modern society is gripped in a "culture of fear" mindset that keeps the public informed but is increasingly focused on the negative news and perceptions. Given declining health care revenues, competition and the growing complexity of care, some health care professionals take shortcuts and gradually default to the provision of a lower standard of both care and competence.

The social anthropologist Ashley Montagu wrote, "Freedom is not so much the liberty to do what one likes, as the right to be able to do what one ought." As professionals and lifelong learners, we must stay alert and work toward recognizing and correcting our deficiencies. In this way, we will establish a desire for change rather than an acceptance of leaving things as they are. High-quality standards of practice that are framed in evidence-based practice and positive patient outcomes will advance the modern practice of chiropractic and more effectively integrate us into mainstream health care.