Compete or competent?

By: Olle ten Cate (@olletencate)

I like the intricacies and power of language. Choosing the right words can make the difference between being understood or becoming a source of confusion. Compete and competent look alike but mean totally different things. Hm. Somewhere in a very far past they must relate. My library has a Latin dictionary and I found that ‘peto’ or ‘petere’ means ‘reaching out to something’, ‘to strive’, ‘to long for’, ‘to solicit’. ‘Con’ is ‘together’, and becomes ‘com’ if followed by a voiceless bilabial plosive (p or b) (I will remember that funny expression).
Anyway, ‘compete’ and ‘competent’ are linguistically related. They both mean something like “striving together to reach a similar point”. But here is where competence and competition start to diverge. If the “point” reflects scarcity, like a single job opening or residency place, the “compete” may overwhelm the “competence”, while if the target is available in abundance, no competition is needed. Working together with class mates and helping each other to attain the level of competence needed to graduate may result in joyful collaboration, friendship and long-lasting gratitude. But competing for a highly sought after residency spot can replace the benevolence with rivalry.

Why is this all relevant? In competency-based medical education, the aim is to bring as many learners as possible to a similar high level of competence and readiness for practice to serve health care needs, even if the routes to that goal are different for various learners. If we have 100 students, our goal is not to determine the single student who beats all others in speed of learning or in breadth of knowledge and skill. Our goal is to bring all or at least the majority to a high level. The famous, still living educational scientist Lee Shulman wrote in 1970 in the Journal of Medical Education (45:S90-S100) “Consider the analogy of a race. Our purposes in education, especially in medical education, are to see to it that a certain minimal level of competence is established for each learner. Therefore, we should logically set levels of achievement as constants and let time act as a variable. Instead, we do exactly the opposite. We set time as a constant and have students run until their time is up. The grades we give reflect how far they have gotten in the race within the time span we have allotted.” Medical schools and specialty programs have a societal duty to provide a workforce to meet health care needs, not to award Oscars for medicine. Communication and collaboration are values we endorse in a designed curriculum, yet celebrating competition shows the hidden curriculum, the hidden “course of a race” in Latin. Why do we do that? Does competition make happy? Does it provide better doctors? Does this really serve the badly needed diversity in the health care workforce? Or is the epidemic of burn-out and depression among students and residents just collateral damage that we accept to support a few to surpass others?

Maybe it is time to turn to competency-based medical education that serves whole classes and cohorts and to realize that we do not need only cardiothoracic surgeons or neurosurgeons, but also many family physicians, pediatricians, radiologists, pathologists – a whole variety of different, not identical individuals. That message is not easy to express in a few words in a way that will convey. But let’s keep trying.

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