Posted by: Witch Doctor | May 27, 2007

Ribeiro – a crack in the competency mantra?



In healthcare in the UK at the present time, the elephant in the room is the “Competency Mantra”

Competencies are, always have been, and always will be implicit in the training of any individual for most purposes. However, relying solely on competency based training is only useful when a small, easily defined, number of competencies are necessary to acheive the required outcome. If the required outcome is to nail a linen canvas on to a wooden frame ready for an artist to paint, then a competency system of training is all that is required. However, an individual can be trained in all the available competencies necessary to paint a picture but the chances that a work of art will result is remote. Indeed, it is possible that sometimes focusing too much on competencies may constrain the artist from producing a masterpiece.

This is true in all the arts and the sciences too. Einstein did not acheive what he did because of his competencies. Competencies played an important part but there was “Something Else”.


“Everything that is really great and inspiring is created by the individual who can labor in freedom.”

Albert Einstein, ‘Out of My Later Years,’ 1950

US (German-born) physicist (1879 – 1955)


The “Something Else” is evasive and poorly understood. It resides deeply within the human brain. It is probably unique for the individual. It is probably closely related to tenacity, judgement and creativity. And probably involves many more attributes. The challenge of education is not only to facilitate the acquisition of competencies but to nurture the individual by allowing enough freedon to allow the “Something Else” to develop and mature. The “Competency plus Something Else Approach” gives excellence a chance. Relying on competency alone to deal with complex issues is likely at best to result in mediocrity. At worst it is dangerous.

Modernising Medical Careers and a “flattened” competency based, protocol driven, healthcare system is attempting to elevate the status of the basic joinery skills necessary to prepare a canvas, to the level of of an artist capable of producing a work of art. Modernising Medical Careers is being designed by basic joiners who grasp their basic competencies. These basic MMC joiners may never have experienced the “Something Else.” Ignorance is bliss. Mediocrity perpetuating mediocrity.

It will not succeed. Mediocrity can only survive for so long. Sooner or later patients need excellence. Patients will die because of lack of excellence and the protocol driven NHS will be found wanting. And when this happens it will be medical heads that will roll. Not the Secretary of State for Health. Not the DOH. Not the CMO. Not the shady “Health Care Professionals”. Medical heads. The government of the day will say they were “following the advice of the medical establishment.” Yes, “the colleges, the deaneries, the BMA, have all been involved – all along the way” Does this smack of MTAS perhaps?

Mr Bernard Ribeiro, CBE, President of the Royal College of Surgeons of England on 25 May 2007 wrote a letter to Professor Neil Douglas, President of the Royal College of Physicians of Edinburgh.

In his letter, Mr Ribeiro states that he is withdrawing from current and ongoing discussion about the selection and appointment arrangements for junior doctors in training.

He had been highlighting to Patricia Hewitt difficulties that would arise with the system since 2005 and offered her solutions. This was acknowledged but ignored.

He states: (the bold italics are my emphasis)

“There has been in my view a scandalous failure of duty to address this issue. We have all, as taxpayers, rightly invested in training this talented generation of young surgeons. It is my duty to ensure that this is not squandered.”

Strong words.

In the final paragraph of the letter, the word competency is not mentioned, however the failings of a system of training based mainly on competencies is adressed:

“My second concern relates to the arrangements for selection of junior doctors into run- through surgical training programmes. Surgery has unique requirements in terms of recruitment – the criteria for selection include diagnostic skills, clinical judgement and manual dexterity. It is neither practical, nor indeed safe, to select junior doctors with a view to a career in surgery without the opportunity of assessing whether they have the full mix of professional skills required. The view within surgery, amongst consultants and trainees and across all specialties, is that selection must take place at ST3 level when trainees have had two years to acquire basic skills under supervision in the operating theatre. This is essential to ensure that the next generation of specialist trainees will be able to provide a safe service for patients. I am dismayed that DH has sought clinical engagement on this issue of selection and again failed to accept unequivocal professional advice.”

Yes. The Witch Doctor thinks this may herald an attack on the competency based training system (ie MMC).

The Witch Doctor hopes the other college presidents will follow.


“To punish me for my contempt for authority, fate made me an authority myself.”

Albert Einstein

US (German-born) physicist (1879 – 1955)


P.S. And by the way, Professor Fiona Patterson, all the psychologists in the world cannot measure the “Something Else”. This is because the “Something Else” is a myriad of tangled neurones making multiple super-efficient synapses well hidden in the depths of the human brain. Areas of the brain yet to be explored.Areas well out of the reach of psychological tests that cannot be validated.

The Witch Doctor – Link to a random page






  1. […] Yes, the elephant in the room is the competency mantra. […]


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