AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. February 2002, Volume 4, Number 2.

Journal Discussion

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Competence and Professionalism

An article from a 2002 issue of JAMA discusses competence as a form of professionalism, and suggests that a commitment to competence and excellence is a way of ensuring ethical behavior and improving the physician-patient relationship.

Sam Huber

Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA. 2002;287(2):226-235.

Quality assessment and competency-based training are hot topics in medical education. Defining competence and validating performance measures are the major sticking points thus far in developing a systematic approach to evaluation. In a review of the relevant literature and their own experience in developing novel medical curricula, Drs. Ronald Epstein and Edward Hundert synthesize a prescriptive definition of professional competence and present their own views on assessment in a recent JAMA article, "Defining and Assessing Professional Competence" [1]. Integrating current thinking about medical education and professional assessment, the authors set the stage for the next round of medical culture and curriculum design.

Competency-based assessment is a common idea in business and management circles. There are even companies with validated competency measures for certain industries [2]. The Accreditation Council for Graduate Medical Education (ACGME) has led the way in identifying and requiring certain competencies in residency training. It is anticipated that future licensing requirements at all levels of medical education will require some sort of competency-based assessment, rather than just coursework and time-based standards. In the rush to embrace a popular new idea, few have taken the time to consider substantively and systematically the skills, attitudes, levels of knowledge, and behaviors of a competent physician, and how these standards may be measured. Epstein and Hundert recognize the need to use evidence-based critiques for assessment standards in medical practice just as they would be used on any scientific innovation.

Epstein and Hundert pose the following definition of professional competence: "the 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." They describe dimensions of competence in cognitive, technical, integrative, context, relationship, affective/moral, and habits of mind categories. They add that, "professional competence is developmental, impermanent, and context-dependent."

A definition of professional competence is only as useful as it is measurable. In the manner of a review article, the authors have identified the relevant medical literature on assessment, with specific inclusion criteria and search strategies, and then synthesized the data around trends in performance measurement. Not surprisingly, multiple-choice examination, subjective supervisor assessment, and standardized patient encounters were found to be the most commonly used methods for professional evaluation. The authors found disagreement about the validity of such methods in certain situations and about the relationship between test scores and success as a physician. Defining criteria for evaluation is a complex endeavor, and test reliability has been challenged by many authors. From their literature survey, Epstein and Hundert meditate on the normative purposes of assessment and offer some suggestions for creative improvement in assessment technique, some of which have been validated already. Assessment is addressed as formative rather than evaluative, with benefits to the trainee, the curriculum, the institution, and as a trust-building mechanism for the public.

The relationship of the authors to medical education adds weight to the article's findings and conclusions. Hundert is dean at the University of Rochester School of Medicine and Dentistry and the main designer of the integrative curriculum used there. Epstein is involved in a student assessment program at Rochester that models many of the innovations proposed in their article. Given the authors' proximity to assessment and interest in competency development, both their definitions and suggestions appear practical as well as aspirational.

Epstein and Hundert speak to competence as a form of professionalism. While ethics is explicitly addressed only briefly, the undertone of the entire article suggests that a commitment to competence and excellence is a way of ensuring a culture of ethical behavior. Since many of their competencies are based in communication skills and the patient-physician relationship, success in the Epstein-Hundert paradigm serves as a kind of ethics dilemma prophylaxis. Although such an approach may sound like virtue theory, it serves their model of defining and assessing competence on a continuing basis and in a context-dependent manner.

Questions for Discussion:

  1. Ethics and moral reasoning are mentioned briefly, and only in passing in this article, but are undoubtedly important to competence as well as to the authors. Do "ethics competencies" comprise what amount to a virtue-ethic, and if so, does this alter the importance of codes or moral reasoning in clinical practice?
  2. Is the role of competencies aspirational, normative, or descriptive?


  1. Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA. 2002;287(2):226-235.
  2. Lombardo MM, Eichinger RW. The big five personality factors. Lominger Limited, Inc.

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