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training should not be planned under the single approach of diagnosis and treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">5</span></a> For this reason&#44; access to faculty&#44; university training&#44; selection in the healthcare institutions&#44; and performance and professional career assessment need a significant review and update of their methodology&#46; We need to determine the competency framework of medical professionals to redesign a training system and have an efficient assessment in keeping with the type and context of the competencies to be assessed&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Only Canada and the USA have state competency frameworks for all medical specialties&#46; In Canada&#44; the Royal College of Physicians and Surgeons has 7 competency frameworks known as CanMEDS&#58; medical expert&#44; communicator&#44; collaborator&#44; leader&#44; health advocate&#44; scholar and professional&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">6</span></a> In the USA&#44; the Accreditation Council for Graduate Medical Education proposes 6 frameworks&#58; patient care&#44; medical knowledge&#44; practice-based learning&#44; interpersonal and communication skills&#44; professionalism&#44; and systems-based practice&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">7</span></a> Both share the redefinition of the physician role and the objective of results-based certification &#40;competency achieved&#41;&#44; rather than training time or completed rotations&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">8</span></a> The United Kingdom &#40;Good Medical Practice&#41; and the Netherlands &#40;inspired by the Canadian model&#41; are adopting similar competency management systems&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Efficiently implementing such frameworks requires reliable and valid competency assessments to detect shortcomings and change or improve the full training curriculum&#44; professional selection&#44; certification and recertification and the professional incentive and promotion systems&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">9</span></a> The aim of this study is to describe the most widely used tools for competency assessment in medicine&#44; analyze the frequency of their use&#44; their main advantages and disadvantages and propose an appropriate assessment model for our context&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Method</span><p id="par0020" class="elsevierStylePara elsevierViewall">We used the MEDLINE database to conduct a review of published articles on competency assessment in medicine under the PRISM protocol&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">10</span></a> The search combined the terms &#8220;competency&#8221;&#44; &#8220;competencies&#8221;&#44; &#8220;360 feedback&#8221;&#44; &#8220;360 degrees&#8221;&#44; &#8220;multisource assessment&#8221;&#44; and &#8220;Objective Structured Clinical Assessment&#8221; &#40;OSCE&#41;&#46; We considered original articles in Spanish or English published between 2000 and 2010&#46; We obtained 93&#37; agreement between the 2 evaluators in the selection of articles&#46; Of a total of 4566 initial articles&#44; we selected those written for the health sciences &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>826&#41; and&#44; specifically&#44; medicine &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>620&#41;&#46; We subsequently excluded 112 studies regarding competencies related to consent in pediatric diseases&#44; patient autonomy and legal aspects&#46; Ultimately&#44; we selected 62 of the 508 remaining studies&#44; which were focused on the assessment of specific competencies &#40;technical&#41; or of those related to nontechnical aspects &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; For each article&#44; we analyzed its target population&#44; the type of competency chosen and the methodology or assessment tools employed&#46; In terms of the target population&#44; the studies were classified according to their setting&#58; academic&#44; undergraduate student &#40;basic university training&#41;&#44; graduate &#40;specialization such as resident and graduate training&#41; and practicing professionals&#46; With regard to the type of competency&#44; we differentiated&#58; 1&#41; core&#44; transversal or general competencies&#44; present regardless of category&#44; position or function and related to nontechnical aspects of the profession and 2&#41; specific competencies&#44; required for the performance of the position&#39;s technical functions and formulated in a language close to the practitioner and to their field of practice&#46; Finally&#44; we analyzed the assessment method or tool employed&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Competency assessment tools and frequency of use</span><p id="par0025" class="elsevierStylePara elsevierViewall">The literature describes various tools for competency assessment in the healthcare setting&#44; with the most relevant being questionnaires and knowledge tests&#44; &#40;360&#176; technique or multisource&#41;&#44; case analysis&#44; interview and analysis of an incident&#44; direct observation tests&#44; situational&#44; simulations&#44; OSCE and portfolio&#46; The tool selection depends on the type of competency to assess &#40;core or specific&#41;&#44; its reliability and validity&#44; its appropriateness for the subject&#39;s activity stage &#40;undergraduate&#44; graduate or practicing&#41; and the purpose for the assessment&#44; which can be training &#40;because it acts during the learning process&#41; or summative &#40;which focuses on the outcome of the process&#41;&#46; Several of the tools involve subjective judgment&#44; which affects their reliability and validity&#46;<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">11&#8211;13</span></a> Combining different instruments for medical competency assessment is therefore advisable&#46; These instruments are described below&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">OSCE was introduced into medical education by Ronald Harden in 1975&#44; using actual or simulated patients in a format of multiple workstations&#44; through which a variety of skills and approaches were analyzed&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">14</span></a> The purpose of OSCE is to simulate the reality experienced by practitioners in their field of clinical practice to assess their responses&#46; Currently&#44; the participants rotate through a circuit of sequential workstations that require the participants to show various skills&#46; Each workstation is constructed to assess one or several specific skills on anamnesis&#44; physical examination&#44; diagnostic identification&#44; decision making&#44; patient education and the implementation of a technical procedure&#46; OSCE uses standardized patients&#44; simulation with mannequins&#44; creation of clinical reports&#44; interpretation of additional tests&#44; resolution of short case-related questions and the implementation of knowledge tests&#44; among others&#46; Valuation judgment is established by comparison with a reference standard or a detailed pre-established verification list&#44; which has been developed by expert clinicians&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">15</span></a> The review shows that most studies on competency assessment in medicine use OSCE&#44; mainly for undergraduate and graduate students&#46; Thus&#44; for undergraduate students&#44; the OSCE assesses specific&#44;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">16&#8211;25</span></a> core<a class="elsevierStyleCrossRefs" href="#bib0565"><span class="elsevierStyleSup">26&#8211;30</span></a> or both competencies&#46;<a class="elsevierStyleCrossRefs" href="#bib0590"><span class="elsevierStyleSup">31&#8211;36</span></a> For graduate students&#44; the specific competencies are assessed through tests that are usually present in the OSCE&#44; such as simulators&#44;<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">37</span></a> standardized patients<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">38</span></a> and the OSCE itself&#46;<a class="elsevierStyleCrossRefs" href="#bib0630"><span class="elsevierStyleSup">39&#8211;42</span></a> We also turn to the OSCE to analyze core competencies<a class="elsevierStyleCrossRefs" href="#bib0650"><span class="elsevierStyleSup">43&#8211;45</span></a> and for joint assessments&#46;<a class="elsevierStyleCrossRefs" href="#bib0665"><span class="elsevierStyleSup">46&#8211;50</span></a> With regard to practicing professionals&#44; the use of the OSCE and&#44; as a consequence&#44; the published studies are scarce and are focused on core competencies&#46;<a class="elsevierStyleCrossRefs" href="#bib0690"><span class="elsevierStyleSup">51&#8211;53</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In light of the reviewed studies and following the recommendations for applying the tool&#44;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">15&#44;54&#44;55</span></a> a reliable and valid OSCE should last 3&#8211;4<span class="elsevierStyleHsp" style=""></span>h&#44; include 15&#8211;20 workstations&#44; with 10-min sessions per workstation&#44; without exceeding 30 assessment items per case or more than 20 candidates per session&#44; preferably using 2 evaluators per workstation and combining several assessment instruments&#46; The OSCE has the ability to detect deficient practices and is therefore usually employed as a certifying element&#46; OSCE is not usually recommended for assessing core competencies&#44; detecting excellence or assessing veteran practitioners&#46; For this group of active professionals&#44; the use of the <span class="elsevierStyleItalic">portfolio</span> is suggested&#44; as a recertifying procedure&#44; when the assessments should be performed on a large scale&#46; This involves a process of evidence collection&#44; which&#44; with a certain purpose&#44; is performed to demonstrate the training and&#47;or competency level reached by a practitioner&#46; The portfolio contains a variety of instruments such as critical incidents&#44; practice indicators and video recordings&#46;<a class="elsevierStyleCrossRefs" href="#bib0615"><span class="elsevierStyleSup">36&#44;54</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">One of the most widely used tools is the 360&#176; assessment &#40;360&#176; feedback or multisource assessment&#41;&#44; which consists of assessing a practitioner according to their observable components&#44; using several different sources&#46; Although this tool can be seen as a collection of subjective assessments&#44; the literature indicates that the subjective methods can be as reliable as the objective&#44; provided that the number of evaluators and the judgment conditions are appropriate&#46;<a class="elsevierStyleCrossRef" href="#bib0715"><span class="elsevierStyleSup">56</span></a> Canada introduced this tool near the end of the 20th century to facilitate the efforts of regulatory agencies in monitoring medical practice and patient safety&#46;<a class="elsevierStyleCrossRef" href="#bib0720"><span class="elsevierStyleSup">57</span></a> The technique uses the perception of work behaviors provided by those who know the role of the person assessed in order to provide alternative approaches&#44; generally through questionnaires&#46; The assessment typically includes a self-assessment of the individual being evaluated&#44; and an assessment by their supervisor&#40;s&#41;&#44; colleagues&#44; colleagues from other categories&#44; subordinates and patients&#44; who are compared to find a consensus&#46; The technique is mainly used in healthcare organizations to analyze quality and improve the service offered and is therefore usually targeted toward practicing professionals and analyzes core competencies&#46;<a class="elsevierStyleCrossRefs" href="#bib0725"><span class="elsevierStyleSup">58&#8211;66</span></a> The technique has also been used&#44; although less often&#44; for graduate students to assess core competencies<a class="elsevierStyleCrossRefs" href="#bib0770"><span class="elsevierStyleSup">67&#8211;69</span></a>&#59; however&#44; the technique has rarely been applied to undergraduate students&#46;<a class="elsevierStyleCrossRef" href="#bib0785"><span class="elsevierStyleSup">70</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The overall objective of the 360&#176; technique is to guide professional development based on the feedback provided by various information sources on observable &#40;and&#44; as such&#44; modifiable&#41; behaviors&#46; However&#44; its implementation differs with respect to the number of evaluators and source that provide feedback&#46; At least 8 medical colleagues&#44; 8 work mates and 25 patients are therefore recommended for the technique to be valid and reliable&#46;<a class="elsevierStyleCrossRef" href="#bib0720"><span class="elsevierStyleSup">57</span></a> Nevertheless&#44; patient scores are usually significantly higher than those from other sources<a class="elsevierStyleCrossRef" href="#bib0790"><span class="elsevierStyleSup">71</span></a> and are usually biased by the patients&#8217; health condition&#44; the amount of time the physician spends caring for them and the physician&#39;s sex&#46;<a class="elsevierStyleCrossRef" href="#bib0795"><span class="elsevierStyleSup">72</span></a> Therefore&#44; despite the fact that the patients&#8217; opinions appear to have a greater effect and acceptance than those of colleagues&#44;<a class="elsevierStyleCrossRef" href="#bib0740"><span class="elsevierStyleSup">61</span></a> a number of authors question its validity due to the lack of ability &#40;or courage&#41; to report poor performance by the assessed physician&#46;<a class="elsevierStyleCrossRef" href="#bib0790"><span class="elsevierStyleSup">71</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">This technique is usually constructed with both questionnaires and considered sources&#44; to ensure the comparability of assessments&#46; Each questionnaire requires approximately 6<span class="elsevierStyleHsp" style=""></span>min to fill out&#46;<a class="elsevierStyleCrossRef" href="#bib0795"><span class="elsevierStyleSup">72</span></a> A characteristic element of this technique is that practitioners participate voluntarily&#44; while those who play the role of evaluator are chosen in advance by those who will be evaluated&#46; Although the evaluated individuals need to perceive their evaluators as credible sources of information&#44;<a class="elsevierStyleCrossRef" href="#bib0800"><span class="elsevierStyleSup">73</span></a> in the sense of being familiar with the work conducted&#44; the act of choosing these evaluators beforehand could bias the assessments&#46; A number of studies have shown that the qualifications granted by evaluators who were not chosen were significantly lower &#40;in other words&#44; they were more demanding&#41; than those granted by previously selected evaluators&#46;<a class="elsevierStyleCrossRef" href="#bib0790"><span class="elsevierStyleSup">71</span></a> It is therefore advisable to mainly select those evaluators who truly know the work of the individual under assessment&#44; beyond their possible likes and dislikes&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The tool&#39;s strengths include its ability to delimit and understand the complexity of the work content&#44; increased reliability and validity of the process due to the use of multiple sources of assessment&#44; and its potential contribution to improving competencies&#44; provided there is a proper selection of the sources&#44; consistency between the scores of the sources&#44; support offered by a mentor and preservation of the evaluators&#8217; anonymity&#46; The tool also helps obtain professional performance data regarding the improvement in healthcare quality&#44; which is of interest from the point of view of both summative<a class="elsevierStyleCrossRefs" href="#bib0720"><span class="elsevierStyleSup">57&#44;72</span></a> and formative assessments&#46;<a class="elsevierStyleCrossRef" href="#bib0795"><span class="elsevierStyleSup">72</span></a> In contrast&#44; the tool&#39;s main limitation is its cost to implement&#44; perform and maintain&#46; More classical or generic tools&#44; such as questionnaires&#44; are therefore occasionally employed&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The questionnaires are constructed based on standard dictionaries or catalogs of competencies&#46; The questionnaires cover a series of competencies and their behavioral evidence&#44; which are considered necessary to carry out a job position&#46; Questionnaires have also been created on the technical aspects of the profession and are in the form of what we know as classical knowledge tests&#46;<a class="elsevierStyleCrossRefs" href="#bib0805"><span class="elsevierStyleSup">74&#44;75</span></a> The questionnaires are completed by a single assessment source&#44; by either the evaluator or a supervisor&#46; The medical literature has a fair number of studies that have used questionnaires&#44; generally with undergraduate students&#44; which have assessed specific&#44;<a class="elsevierStyleCrossRefs" href="#bib0815"><span class="elsevierStyleSup">76&#44;77</span></a> core<a class="elsevierStyleCrossRef" href="#bib0825"><span class="elsevierStyleSup">78</span></a> or both competencies&#44;<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">4&#44;79&#8211;81</span></a> and graduate students&#44; which have mainly assessed core<a class="elsevierStyleCrossRefs" href="#bib0845"><span class="elsevierStyleSup">82&#44;83</span></a> or both competencies&#46;<a class="elsevierStyleCrossRef" href="#bib0855"><span class="elsevierStyleSup">84</span></a> The main advantage is that the questionnaires help standardize the data at a reduced cost and provide significant information on a considerable number of individuals with a short period&#44; with a particular focus on assessing technical competencies&#46; The disadvantages include the reliability of the responses when assessing core competencies &#40;influence of biases such as social desirability&#44; halo effect&#44; memory gaps&#44; etc&#46;&#41; and the inability to learn more about the meanings behind the responses &#40;objective or prescriptive answer format&#44; test type&#41;&#46; To offset these disadvantages&#44; in cost-time terms&#44; the questionnaire &#40;in its multisource psychometric&#47;clinimetric-based format&#41; can be considered one of the most appropriate methods&#46;<a class="elsevierStyleCrossRefs" href="#bib0720"><span class="elsevierStyleSup">57&#44;72&#44;73</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Once the main tools and procedures have been described&#44; according to the reviewed studies on competency assessment in medicine &#40;see supplementary material&#44; available in the online version&#41;&#44; approximately 45&#37; were directed to undergraduate students&#44; 36&#37; to graduate students and 19&#37; to active professionals&#46; Thirty-one percent of the studies assessed specific competencies&#44; 42&#37; assessed core competencies&#44; and 27&#37; assessed both types&#46; In terms of the tools&#8217; prevalence of use&#44; approximately 60&#37; of the studies used OSCE &#40;only 3 of which were aimed at practicing professionals&#41;&#44; followed by 19&#37; that used the 360&#176; technique &#40;in this case&#44; only 3 studies were aimed at professionals undergoing training&#41;&#44; 16&#37; that used questionnaires &#40;aimed at undergraduate and graduate students&#41; and only 5&#37; that employed other instruments&#44; mainly knowledge tests&#46; It is worth mentioning that the considerable majority of referenced studies applied transversal designs&#46; There was also a notable lack of studies on the cost analysis of the various methodologies and tools&#44;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">15</span></a> a fundamental parameter for implementing a competency management system&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Toward a proposed competency assessment management model</span><p id="par0070" class="elsevierStylePara elsevierViewall">The literature reflects the heterogeneity and disparity in the definition&#44; classification and model of competency management&#46; This study considered the competencies as behaviors related to good or excellent performance and differentiates between core and specific competencies&#46; This perspective presents certain analogies concerning the approaches of Ten Cate and Billett&#44;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">8</span></a> who&#44; with their concept of reliability of the professional activity&#44; sought to define the competencies&#44; translating the abstract constructions that describe the individuals&#8217; capabilities into activities to be undertaken&#59; and concerning the studies of Hawkins et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0860"><span class="elsevierStyleSup">85</span></a> who defined competencies as &#8220;<span class="elsevierStyleItalic">markers of progress or observable behaviors&#8221;</span> more precisely&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Based on the evidence found&#44; there is a tendency to assess the more technical aspects of the medical profession during the training years &#40;undergraduate&#41;&#44; generally using OSCE and questionnaires&#46; During residency &#40;graduate&#41;&#44; attention continues to focus on specific competencies but sharing space with the assessment of core competencies&#44; with greater variability of tools&#44; highlighting OSCE and situational tests&#44; the 360&#176; technique and questionnaires&#46; Lastly&#44; during professional practice&#44; the assessment focuses on core competencies using the 360&#176; technique&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Given that medical practice presents a multidimensional structure&#44; it seems advisable to use various tools to assess the separate domains&#46; It is important to note the lack of sufficient empirical evidence as to what method to used depending on the type of competency to be assessed&#46; This vagueness is a clear symptom that the debate on the ideal assessment method for measuring the various types of competencies in medicine is still open&#46; However&#44; it is no less certain that the evidence found indicates that OSCE &#40;and its variants&#41; and the 360&#176; assessment are the most appropriate tools&#44; although pending comparison from a meta-analytical perspective and through longitudinal designs&#46; In our opinion&#44; the OSCE is more appropriate for assessing specific competencies but is not recommended for core competencies&#46; Studies have pointed out the difficulty of assessing communication ability versus clinical skills using OSCE&#46;<a class="elsevierStyleCrossRef" href="#bib0710"><span class="elsevierStyleSup">55</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Moreover&#44; the evidence indicates that the 360&#176; technique is the most appropriate for assessing core competencies&#46; In this respect&#44; studies have concluded that a multisource assessment is most effective for assessing aspects regarding communication&#44; professionalism&#44; management and interpersonal relationships&#46;<a class="elsevierStyleCrossRefs" href="#bib0720"><span class="elsevierStyleSup">57&#44;72</span></a> There is also evidence of the inadequacy of assessing specific competencies with the 360&#176; technique&#44; mainly due to the inability of colleagues to observe the technical performance of the evaluated individual&#44; as well as the inherent difficulty in embodying technical clinical competency in the form of test items&#46;<a class="elsevierStyleCrossRef" href="#bib0740"><span class="elsevierStyleSup">61</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Although we suggest the 360&#176; assessment for core competencies and OSCE for specific competencies&#44; comparative studies are needed for the various instruments&#44; using the same research design &#40;mainly longitudinal&#41;&#44; under controlled conditions &#40;internal validity&#41;&#44; which help analyze the benefits and disadvantages of each type of competency&#46; In contrast&#44; most reviewed studies are cross-sectional&#44; use a single assessment method and provide a static vision that does not allow for the analysis of sensitivity to change after the intervention or of the factors that influence its effectiveness&#46; There are few longitudinal studies in medicine that have used the 360&#176; technique&#44; such as the Physician Assessment Review process or the Sheffield Peer Review Assessment Tool&#46; An example of a pretest-posttest design is suggested by actual training with patients to analyze the change in competency after the intervention in a multidisciplinary team of health professionals&#46;<a class="elsevierStyleCrossRef" href="#bib0865"><span class="elsevierStyleSup">86</span></a> There are also examples of longitudinal design with OSCE to analyze the effect of the change in competency after a training course&#46;<a class="elsevierStyleCrossRefs" href="#bib0570"><span class="elsevierStyleSup">27&#44;50&#44;51&#44;87</span></a> Moreover&#44; core competencies have been evaluated in medical residents through exposure to various clinical scenarios&#46;<a class="elsevierStyleCrossRef" href="#bib0810"><span class="elsevierStyleSup">75</span></a> Despite the published evidence on competency assessment in medicine&#44; we need a more rigorous empirical contrast using more complex research study designs and the complete involvement of healthcare system managers&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Moreover&#44; assuming a competency approach requires a change in educational objectives and standards&#44; a change in assessment systems and accreditation programs and the planning of the maintenance and monitoring of acquired competencies&#46; We need a change in mindset by professors&#44; students&#44; tutors&#44; residents&#44; managers&#44; practitioners and the other agents involved&#44; given that this approach does not establish &#8220;times&#8221; but rather &#8220;results&#8221;&#46; Although it is assumed that academic institutions and managers of health professionals worldwide speak the same competency language&#44; generally technical&#44; the evidence found by this study shows the presence of a vacuum between the educational setting&#44; with a greater prevalence of competency assessment&#44; and the professional&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In our context&#44; we also talk of clinical competency&#44; professional competency&#44; competency-based education&#44; evaluation by competency&#44; accreditation instruments and rewarding professional competency&#46; However&#44; this concern is still not reflected in terms of scientific output&#46; Faced with this deficiency&#44; we should reflect&#44; discuss and attempt to build an assessment model that considers the continuum from access to the faculty to professional practice&#44; taking into account the competency framework that we need to acquire &#40;and maintain&#41; in each stage&#44; as well as checking the suitability of the tools to be employed&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">After discussing the evidence found&#44; we proposed a comprehensive competency assessment model&#44; awaiting evaluation&#44; which contemplates the &#8220;undergraduate&#47;graduate&#47;active professional&#8221; continuum &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The diagram involves determining first the medical competencies to acquire&#44; applicable both in the academic and professional settings&#46; The process should be started by establishing a system of access to faculty that assumes the principles of competency assessment&#44; detecting talent&#44; expertise and technical skills &#40;precursors&#41; and the core competencies of communication&#44; empathy and teamwork&#44; among others&#46; Thus&#44; the selection of future professionals will not be based on just their memory capacity&#46; The current lack of definition regarding the specific tests of access to universities could represent a good opportunity to reflect on the access and selection of students&#46; Once access has been established&#44; we should test the most appropriate assessment methods for use in undergraduate training&#46; We propose the progressive inclusion of the OSCE in the competency assessment of undergraduates&#44; along with other tools&#44; always taking into account the volume of students and the feasibility of implementing the tools&#46; In the graduate training stage&#44; we propose using OSCE annually at the start of the residence &#40;baseline&#41; and upon completion of the rotations&#46; From the third year&#44; we propose inserting the 360&#176; assessment&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">Once the training stage has concluded&#44; we introduce the actual assessment of competencies&#44; which considers the healthcare activity and quality&#58; the &#8220;what&#8221; is performed using key indicators and syntheses of activity and quality&#44; and the &#8220;how&#8221; is performed generally with the 360&#176; technique&#46; It is important to note that the OSCE is not recommended as an instrument to assess veteran professionals&#46; The portfolio also makes no sense in a performance assessment system&#46; Although performance assessment is certainly recommended in the private setting&#44; it has been mandatory for the public setting since the coming into force of Law 7&#47;2007 of April 12 <span class="elsevierStyleItalic">Basic Statute for Public Employees</span>&#44; which requires the implementation of instruments that enable the assessment of professional conduct and performance and the achievement of results&#46; In this framework&#44; if performance assessments are established annually&#44; collecting competency results in 5-year periods&#44; along with those related to training&#44; teaching&#44; research and commitment&#44; the requirements established in the professional career could be met&#46; As healthcare organizations start using the same instruments&#44; benchmarking could be implemented for healthcare competencies&#46; This approach would facilitate the accreditation programs and help establish more efficient human resource policies &#40;professional career&#44; productivity&#44; continuing education&#44; etc&#46;&#41; according to unified criteria that are comparable among institutions&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In conclusion&#44; the reviewed literature paints a highly heterogeneous picture&#46; Systematic reviews in the 2010s have explored whether there has been a change in trends on this subject&#46; More specifically&#44; we must pay special attention to the nonclinical aspects of the medical profession&#44; which are contemplated and evaluated before access to the faculty&#46; Likewise&#44; the assessment instruments need to be compared using similar research study designs and under controlled conditions to ensure the methods&#8217; internal validity and their results&#46; It is essential to promote longitudinal designs that help reach conclusions about the tools&#8217; suitability&#44; based on the quality of the measure and the sensitivity to behavioral changes in those being evaluated&#46;<a class="elsevierStyleCrossRef" href="#bib0800"><span class="elsevierStyleSup">73</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">This study sought to analyze the essentials of competency assessment in medicine&#44; through the main evidence of published empirical&#44; academic and professional studies and to propose a comprehensive model for career development&#46; We hope to contribute to the generation of relevant scientific knowledge in the optimization of competency assessment&#44; with the ultimate goal of not only improving the training&#44; and hence the professional practice&#44; but also promoting better quality of patient care&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interests</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To describe the most widely used tools in the assessment of medical competencies&#44; analyze their prevalence of use&#44; their advantages and disadvantages and propose an appropriate model for our context&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We conducted a narrative review of articles from MEDLINE&#44; following the PRISM protocol&#44; and analyzed a total of 62 articles&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The assessment of competencies is heterogeneous&#44; especially in the educational and professional settings&#46; The specific and technical competencies acquired during university education are mainly assessed using the objective structured clinical assessment&#46; In the professional setting&#44; core competencies are assessed using the 360&#176; technique&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">We need a rigorous empiric comparison of the efficiency of the tools according to the type of competency&#46; We propose a competency management model for the &#8220;undergraduate&#47;graduate&#47;active professional&#8221; continuum&#44; whose goal is to improve training and professional practice and thereby increase the quality of patient care&#46;</p></span>"
        "secciones" => array:4 [
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      "es" => array:3 [
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Describir las herramientas m&#225;s utilizadas en la evaluaci&#243;n competencial en Medicina&#44; analizar su prevalencia de uso&#44; sus ventajas e inconvenientes y proponer un modelo apropiado para nuestro contexto&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Revisi&#243;n narrativa de art&#237;culos de MEDLINE&#44; siguiendo el protocolo PRISMA&#46; Se analizaron un total de 62 art&#237;culos&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La evaluaci&#243;n competencial es heterog&#233;nea&#44; especialmente en el &#225;mbito educativo y profesional&#46; Las competencias espec&#237;ficas o t&#233;cnicas durante la formaci&#243;n universitaria se eval&#250;an fundamentalmente mediante evaluaci&#243;n cl&#237;nica objetiva estructurada&#44; mientras que en el ejercicio profesional se valoran competencias nucleares utilizando la t&#233;cnica 360&#176;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se necesita un contraste emp&#237;rico riguroso de la eficiencia de las herramientas en funci&#243;n del tipo de competencia&#46; Se propone un modelo de gesti&#243;n competencial sobre el continuo &#171;pregrado&#47;posgrado&#47;profesionales en activo&#187;&#46; Su finalidad es contribuir a la mejora de la formaci&#243;n y de la pr&#225;ctica profesional y&#44; por ende&#44; incrementar la calidad de la atenci&#243;n al paciente&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Sureda-Demeulemeester E&#44; Ramis-Palmer C&#44; Ses&#233;-Abad A&#46; La evaluaci&#243;n de competencias en Medicina&#46; Rev Clin Esp&#46; 2017&#59;217&#58;534&#8211;542&#46;</p>"
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            "apendice" => "<p id="par0135" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0035"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Flow diagram for the selection process of studies on competency assessment in medicine&#46; We excluded 112 studies regarding competencies related to consent in pediatric diseases&#44; patient autonomy and legal aspects&#44; 620 articles identified in the field of Medicine&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Integrated model for competency assessment in the healthcare setting &#40;&#8220;undergraduate&#44; graduate&#44; practicing professionals&#8221;&#41;&#46;</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; ANECA&#44; National Agency for Assessment of Quality and Accreditation&#59; OSCE&#44; objective structured clinical assessment&#59; 360 assess&#44; 360&#176; assessment technique&#59; HR&#44; human resources&#46;</p>"
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Review
The assessment of medical competencies
La evaluación de competencias en Medicina
E. Sureda-Demeulemeestera,b, C. Ramis-Palmerb, A. Sesé-Abadb,
Corresponding author
albert.sese@uib.es

Corresponding author.
a Departamento de Desarrollo Organizacional, Hospital Universitario Son Espases, Palma, Mallorca, Islas Baleares, Spain
b Departamento de Psicología, Universitat de les Illes Balears, Palma, Mallorca, Islas Baleares, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">The 21th century is becoming the century for competency management in medical training&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">1</span></a> Although there is no one definition for &#8220;competency&#8221;&#44; in general&#44; the term is considered as &#8220;observable and habitual behaviors that lead to success in a function or task&#46;&#8221;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">2</span></a> Healthcare requires a professional competency framework that contains not only technical knowledge and skills but also competencies related to values&#44; communication&#44; collaboration and the search for efficiency in interventions&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">3</span></a> Even medical students have indicated that training a physician involves much more than just providing theoretical&#8211;clinical knowledge&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">4</span></a> Therefore&#44; training should not be planned under the single approach of diagnosis and treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">5</span></a> For this reason&#44; access to faculty&#44; university training&#44; selection in the healthcare institutions&#44; and performance and professional career assessment need a significant review and update of their methodology&#46; We need to determine the competency framework of medical professionals to redesign a training system and have an efficient assessment in keeping with the type and context of the competencies to be assessed&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Only Canada and the USA have state competency frameworks for all medical specialties&#46; In Canada&#44; the Royal College of Physicians and Surgeons has 7 competency frameworks known as CanMEDS&#58; medical expert&#44; communicator&#44; collaborator&#44; leader&#44; health advocate&#44; scholar and professional&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">6</span></a> In the USA&#44; the Accreditation Council for Graduate Medical Education proposes 6 frameworks&#58; patient care&#44; medical knowledge&#44; practice-based learning&#44; interpersonal and communication skills&#44; professionalism&#44; and systems-based practice&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">7</span></a> Both share the redefinition of the physician role and the objective of results-based certification &#40;competency achieved&#41;&#44; rather than training time or completed rotations&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">8</span></a> The United Kingdom &#40;Good Medical Practice&#41; and the Netherlands &#40;inspired by the Canadian model&#41; are adopting similar competency management systems&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Efficiently implementing such frameworks requires reliable and valid competency assessments to detect shortcomings and change or improve the full training curriculum&#44; professional selection&#44; certification and recertification and the professional incentive and promotion systems&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">9</span></a> The aim of this study is to describe the most widely used tools for competency assessment in medicine&#44; analyze the frequency of their use&#44; their main advantages and disadvantages and propose an appropriate assessment model for our context&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Method</span><p id="par0020" class="elsevierStylePara elsevierViewall">We used the MEDLINE database to conduct a review of published articles on competency assessment in medicine under the PRISM protocol&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">10</span></a> The search combined the terms &#8220;competency&#8221;&#44; &#8220;competencies&#8221;&#44; &#8220;360 feedback&#8221;&#44; &#8220;360 degrees&#8221;&#44; &#8220;multisource assessment&#8221;&#44; and &#8220;Objective Structured Clinical Assessment&#8221; &#40;OSCE&#41;&#46; We considered original articles in Spanish or English published between 2000 and 2010&#46; We obtained 93&#37; agreement between the 2 evaluators in the selection of articles&#46; Of a total of 4566 initial articles&#44; we selected those written for the health sciences &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>826&#41; and&#44; specifically&#44; medicine &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>620&#41;&#46; We subsequently excluded 112 studies regarding competencies related to consent in pediatric diseases&#44; patient autonomy and legal aspects&#46; Ultimately&#44; we selected 62 of the 508 remaining studies&#44; which were focused on the assessment of specific competencies &#40;technical&#41; or of those related to nontechnical aspects &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; For each article&#44; we analyzed its target population&#44; the type of competency chosen and the methodology or assessment tools employed&#46; In terms of the target population&#44; the studies were classified according to their setting&#58; academic&#44; undergraduate student &#40;basic university training&#41;&#44; graduate &#40;specialization such as resident and graduate training&#41; and practicing professionals&#46; With regard to the type of competency&#44; we differentiated&#58; 1&#41; core&#44; transversal or general competencies&#44; present regardless of category&#44; position or function and related to nontechnical aspects of the profession and 2&#41; specific competencies&#44; required for the performance of the position&#39;s technical functions and formulated in a language close to the practitioner and to their field of practice&#46; Finally&#44; we analyzed the assessment method or tool employed&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Competency assessment tools and frequency of use</span><p id="par0025" class="elsevierStylePara elsevierViewall">The literature describes various tools for competency assessment in the healthcare setting&#44; with the most relevant being questionnaires and knowledge tests&#44; &#40;360&#176; technique or multisource&#41;&#44; case analysis&#44; interview and analysis of an incident&#44; direct observation tests&#44; situational&#44; simulations&#44; OSCE and portfolio&#46; The tool selection depends on the type of competency to assess &#40;core or specific&#41;&#44; its reliability and validity&#44; its appropriateness for the subject&#39;s activity stage &#40;undergraduate&#44; graduate or practicing&#41; and the purpose for the assessment&#44; which can be training &#40;because it acts during the learning process&#41; or summative &#40;which focuses on the outcome of the process&#41;&#46; Several of the tools involve subjective judgment&#44; which affects their reliability and validity&#46;<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">11&#8211;13</span></a> Combining different instruments for medical competency assessment is therefore advisable&#46; These instruments are described below&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">OSCE was introduced into medical education by Ronald Harden in 1975&#44; using actual or simulated patients in a format of multiple workstations&#44; through which a variety of skills and approaches were analyzed&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">14</span></a> The purpose of OSCE is to simulate the reality experienced by practitioners in their field of clinical practice to assess their responses&#46; Currently&#44; the participants rotate through a circuit of sequential workstations that require the participants to show various skills&#46; Each workstation is constructed to assess one or several specific skills on anamnesis&#44; physical examination&#44; diagnostic identification&#44; decision making&#44; patient education and the implementation of a technical procedure&#46; OSCE uses standardized patients&#44; simulation with mannequins&#44; creation of clinical reports&#44; interpretation of additional tests&#44; resolution of short case-related questions and the implementation of knowledge tests&#44; among others&#46; Valuation judgment is established by comparison with a reference standard or a detailed pre-established verification list&#44; which has been developed by expert clinicians&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">15</span></a> The review shows that most studies on competency assessment in medicine use OSCE&#44; mainly for undergraduate and graduate students&#46; Thus&#44; for undergraduate students&#44; the OSCE assesses specific&#44;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">16&#8211;25</span></a> core<a class="elsevierStyleCrossRefs" href="#bib0565"><span class="elsevierStyleSup">26&#8211;30</span></a> or both competencies&#46;<a class="elsevierStyleCrossRefs" href="#bib0590"><span class="elsevierStyleSup">31&#8211;36</span></a> For graduate students&#44; the specific competencies are assessed through tests that are usually present in the OSCE&#44; such as simulators&#44;<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">37</span></a> standardized patients<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">38</span></a> and the OSCE itself&#46;<a class="elsevierStyleCrossRefs" href="#bib0630"><span class="elsevierStyleSup">39&#8211;42</span></a> We also turn to the OSCE to analyze core competencies<a class="elsevierStyleCrossRefs" href="#bib0650"><span class="elsevierStyleSup">43&#8211;45</span></a> and for joint assessments&#46;<a class="elsevierStyleCrossRefs" href="#bib0665"><span class="elsevierStyleSup">46&#8211;50</span></a> With regard to practicing professionals&#44; the use of the OSCE and&#44; as a consequence&#44; the published studies are scarce and are focused on core competencies&#46;<a class="elsevierStyleCrossRefs" href="#bib0690"><span class="elsevierStyleSup">51&#8211;53</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In light of the reviewed studies and following the recommendations for applying the tool&#44;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">15&#44;54&#44;55</span></a> a reliable and valid OSCE should last 3&#8211;4<span class="elsevierStyleHsp" style=""></span>h&#44; include 15&#8211;20 workstations&#44; with 10-min sessions per workstation&#44; without exceeding 30 assessment items per case or more than 20 candidates per session&#44; preferably using 2 evaluators per workstation and combining several assessment instruments&#46; The OSCE has the ability to detect deficient practices and is therefore usually employed as a certifying element&#46; OSCE is not usually recommended for assessing core competencies&#44; detecting excellence or assessing veteran practitioners&#46; For this group of active professionals&#44; the use of the <span class="elsevierStyleItalic">portfolio</span> is suggested&#44; as a recertifying procedure&#44; when the assessments should be performed on a large scale&#46; This involves a process of evidence collection&#44; which&#44; with a certain purpose&#44; is performed to demonstrate the training and&#47;or competency level reached by a practitioner&#46; The portfolio contains a variety of instruments such as critical incidents&#44; practice indicators and video recordings&#46;<a class="elsevierStyleCrossRefs" href="#bib0615"><span class="elsevierStyleSup">36&#44;54</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">One of the most widely used tools is the 360&#176; assessment &#40;360&#176; feedback or multisource assessment&#41;&#44; which consists of assessing a practitioner according to their observable components&#44; using several different sources&#46; Although this tool can be seen as a collection of subjective assessments&#44; the literature indicates that the subjective methods can be as reliable as the objective&#44; provided that the number of evaluators and the judgment conditions are appropriate&#46;<a class="elsevierStyleCrossRef" href="#bib0715"><span class="elsevierStyleSup">56</span></a> Canada introduced this tool near the end of the 20th century to facilitate the efforts of regulatory agencies in monitoring medical practice and patient safety&#46;<a class="elsevierStyleCrossRef" href="#bib0720"><span class="elsevierStyleSup">57</span></a> The technique uses the perception of work behaviors provided by those who know the role of the person assessed in order to provide alternative approaches&#44; generally through questionnaires&#46; The assessment typically includes a self-assessment of the individual being evaluated&#44; and an assessment by their supervisor&#40;s&#41;&#44; colleagues&#44; colleagues from other categories&#44; subordinates and patients&#44; who are compared to find a consensus&#46; The technique is mainly used in healthcare organizations to analyze quality and improve the service offered and is therefore usually targeted toward practicing professionals and analyzes core competencies&#46;<a class="elsevierStyleCrossRefs" href="#bib0725"><span class="elsevierStyleSup">58&#8211;66</span></a> The technique has also been used&#44; although less often&#44; for graduate students to assess core competencies<a class="elsevierStyleCrossRefs" href="#bib0770"><span class="elsevierStyleSup">67&#8211;69</span></a>&#59; however&#44; the technique has rarely been applied to undergraduate students&#46;<a class="elsevierStyleCrossRef" href="#bib0785"><span class="elsevierStyleSup">70</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The overall objective of the 360&#176; technique is to guide professional development based on the feedback provided by various information sources on observable &#40;and&#44; as such&#44; modifiable&#41; behaviors&#46; However&#44; its implementation differs with respect to the number of evaluators and source that provide feedback&#46; At least 8 medical colleagues&#44; 8 work mates and 25 patients are therefore recommended for the technique to be valid and reliable&#46;<a class="elsevierStyleCrossRef" href="#bib0720"><span class="elsevierStyleSup">57</span></a> Nevertheless&#44; patient scores are usually significantly higher than those from other sources<a class="elsevierStyleCrossRef" href="#bib0790"><span class="elsevierStyleSup">71</span></a> and are usually biased by the patients&#8217; health condition&#44; the amount of time the physician spends caring for them and the physician&#39;s sex&#46;<a class="elsevierStyleCrossRef" href="#bib0795"><span class="elsevierStyleSup">72</span></a> Therefore&#44; despite the fact that the patients&#8217; opinions appear to have a greater effect and acceptance than those of colleagues&#44;<a class="elsevierStyleCrossRef" href="#bib0740"><span class="elsevierStyleSup">61</span></a> a number of authors question its validity due to the lack of ability &#40;or courage&#41; to report poor performance by the assessed physician&#46;<a class="elsevierStyleCrossRef" href="#bib0790"><span class="elsevierStyleSup">71</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">This technique is usually constructed with both questionnaires and considered sources&#44; to ensure the comparability of assessments&#46; Each questionnaire requires approximately 6<span class="elsevierStyleHsp" style=""></span>min to fill out&#46;<a class="elsevierStyleCrossRef" href="#bib0795"><span class="elsevierStyleSup">72</span></a> A characteristic element of this technique is that practitioners participate voluntarily&#44; while those who play the role of evaluator are chosen in advance by those who will be evaluated&#46; Although the evaluated individuals need to perceive their evaluators as credible sources of information&#44;<a class="elsevierStyleCrossRef" href="#bib0800"><span class="elsevierStyleSup">73</span></a> in the sense of being familiar with the work conducted&#44; the act of choosing these evaluators beforehand could bias the assessments&#46; A number of studies have shown that the qualifications granted by evaluators who were not chosen were significantly lower &#40;in other words&#44; they were more demanding&#41; than those granted by previously selected evaluators&#46;<a class="elsevierStyleCrossRef" href="#bib0790"><span class="elsevierStyleSup">71</span></a> It is therefore advisable to mainly select those evaluators who truly know the work of the individual under assessment&#44; beyond their possible likes and dislikes&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The tool&#39;s strengths include its ability to delimit and understand the complexity of the work content&#44; increased reliability and validity of the process due to the use of multiple sources of assessment&#44; and its potential contribution to improving competencies&#44; provided there is a proper selection of the sources&#44; consistency between the scores of the sources&#44; support offered by a mentor and preservation of the evaluators&#8217; anonymity&#46; The tool also helps obtain professional performance data regarding the improvement in healthcare quality&#44; which is of interest from the point of view of both summative<a class="elsevierStyleCrossRefs" href="#bib0720"><span class="elsevierStyleSup">57&#44;72</span></a> and formative assessments&#46;<a class="elsevierStyleCrossRef" href="#bib0795"><span class="elsevierStyleSup">72</span></a> In contrast&#44; the tool&#39;s main limitation is its cost to implement&#44; perform and maintain&#46; More classical or generic tools&#44; such as questionnaires&#44; are therefore occasionally employed&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The questionnaires are constructed based on standard dictionaries or catalogs of competencies&#46; The questionnaires cover a series of competencies and their behavioral evidence&#44; which are considered necessary to carry out a job position&#46; Questionnaires have also been created on the technical aspects of the profession and are in the form of what we know as classical knowledge tests&#46;<a class="elsevierStyleCrossRefs" href="#bib0805"><span class="elsevierStyleSup">74&#44;75</span></a> The questionnaires are completed by a single assessment source&#44; by either the evaluator or a supervisor&#46; The medical literature has a fair number of studies that have used questionnaires&#44; generally with undergraduate students&#44; which have assessed specific&#44;<a class="elsevierStyleCrossRefs" href="#bib0815"><span class="elsevierStyleSup">76&#44;77</span></a> core<a class="elsevierStyleCrossRef" href="#bib0825"><span class="elsevierStyleSup">78</span></a> or both competencies&#44;<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">4&#44;79&#8211;81</span></a> and graduate students&#44; which have mainly assessed core<a class="elsevierStyleCrossRefs" href="#bib0845"><span class="elsevierStyleSup">82&#44;83</span></a> or both competencies&#46;<a class="elsevierStyleCrossRef" href="#bib0855"><span class="elsevierStyleSup">84</span></a> The main advantage is that the questionnaires help standardize the data at a reduced cost and provide significant information on a considerable number of individuals with a short period&#44; with a particular focus on assessing technical competencies&#46; The disadvantages include the reliability of the responses when assessing core competencies &#40;influence of biases such as social desirability&#44; halo effect&#44; memory gaps&#44; etc&#46;&#41; and the inability to learn more about the meanings behind the responses &#40;objective or prescriptive answer format&#44; test type&#41;&#46; To offset these disadvantages&#44; in cost-time terms&#44; the questionnaire &#40;in its multisource psychometric&#47;clinimetric-based format&#41; can be considered one of the most appropriate methods&#46;<a class="elsevierStyleCrossRefs" href="#bib0720"><span class="elsevierStyleSup">57&#44;72&#44;73</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Once the main tools and procedures have been described&#44; according to the reviewed studies on competency assessment in medicine &#40;see supplementary material&#44; available in the online version&#41;&#44; approximately 45&#37; were directed to undergraduate students&#44; 36&#37; to graduate students and 19&#37; to active professionals&#46; Thirty-one percent of the studies assessed specific competencies&#44; 42&#37; assessed core competencies&#44; and 27&#37; assessed both types&#46; In terms of the tools&#8217; prevalence of use&#44; approximately 60&#37; of the studies used OSCE &#40;only 3 of which were aimed at practicing professionals&#41;&#44; followed by 19&#37; that used the 360&#176; technique &#40;in this case&#44; only 3 studies were aimed at professionals undergoing training&#41;&#44; 16&#37; that used questionnaires &#40;aimed at undergraduate and graduate students&#41; and only 5&#37; that employed other instruments&#44; mainly knowledge tests&#46; It is worth mentioning that the considerable majority of referenced studies applied transversal designs&#46; There was also a notable lack of studies on the cost analysis of the various methodologies and tools&#44;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">15</span></a> a fundamental parameter for implementing a competency management system&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Toward a proposed competency assessment management model</span><p id="par0070" class="elsevierStylePara elsevierViewall">The literature reflects the heterogeneity and disparity in the definition&#44; classification and model of competency management&#46; This study considered the competencies as behaviors related to good or excellent performance and differentiates between core and specific competencies&#46; This perspective presents certain analogies concerning the approaches of Ten Cate and Billett&#44;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">8</span></a> who&#44; with their concept of reliability of the professional activity&#44; sought to define the competencies&#44; translating the abstract constructions that describe the individuals&#8217; capabilities into activities to be undertaken&#59; and concerning the studies of Hawkins et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0860"><span class="elsevierStyleSup">85</span></a> who defined competencies as &#8220;<span class="elsevierStyleItalic">markers of progress or observable behaviors&#8221;</span> more precisely&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Based on the evidence found&#44; there is a tendency to assess the more technical aspects of the medical profession during the training years &#40;undergraduate&#41;&#44; generally using OSCE and questionnaires&#46; During residency &#40;graduate&#41;&#44; attention continues to focus on specific competencies but sharing space with the assessment of core competencies&#44; with greater variability of tools&#44; highlighting OSCE and situational tests&#44; the 360&#176; technique and questionnaires&#46; Lastly&#44; during professional practice&#44; the assessment focuses on core competencies using the 360&#176; technique&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Given that medical practice presents a multidimensional structure&#44; it seems advisable to use various tools to assess the separate domains&#46; It is important to note the lack of sufficient empirical evidence as to what method to used depending on the type of competency to be assessed&#46; This vagueness is a clear symptom that the debate on the ideal assessment method for measuring the various types of competencies in medicine is still open&#46; However&#44; it is no less certain that the evidence found indicates that OSCE &#40;and its variants&#41; and the 360&#176; assessment are the most appropriate tools&#44; although pending comparison from a meta-analytical perspective and through longitudinal designs&#46; In our opinion&#44; the OSCE is more appropriate for assessing specific competencies but is not recommended for core competencies&#46; Studies have pointed out the difficulty of assessing communication ability versus clinical skills using OSCE&#46;<a class="elsevierStyleCrossRef" href="#bib0710"><span class="elsevierStyleSup">55</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Moreover&#44; the evidence indicates that the 360&#176; technique is the most appropriate for assessing core competencies&#46; In this respect&#44; studies have concluded that a multisource assessment is most effective for assessing aspects regarding communication&#44; professionalism&#44; management and interpersonal relationships&#46;<a class="elsevierStyleCrossRefs" href="#bib0720"><span class="elsevierStyleSup">57&#44;72</span></a> There is also evidence of the inadequacy of assessing specific competencies with the 360&#176; technique&#44; mainly due to the inability of colleagues to observe the technical performance of the evaluated individual&#44; as well as the inherent difficulty in embodying technical clinical competency in the form of test items&#46;<a class="elsevierStyleCrossRef" href="#bib0740"><span class="elsevierStyleSup">61</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Although we suggest the 360&#176; assessment for core competencies and OSCE for specific competencies&#44; comparative studies are needed for the various instruments&#44; using the same research design &#40;mainly longitudinal&#41;&#44; under controlled conditions &#40;internal validity&#41;&#44; which help analyze the benefits and disadvantages of each type of competency&#46; In contrast&#44; most reviewed studies are cross-sectional&#44; use a single assessment method and provide a static vision that does not allow for the analysis of sensitivity to change after the intervention or of the factors that influence its effectiveness&#46; There are few longitudinal studies in medicine that have used the 360&#176; technique&#44; such as the Physician Assessment Review process or the Sheffield Peer Review Assessment Tool&#46; An example of a pretest-posttest design is suggested by actual training with patients to analyze the change in competency after the intervention in a multidisciplinary team of health professionals&#46;<a class="elsevierStyleCrossRef" href="#bib0865"><span class="elsevierStyleSup">86</span></a> There are also examples of longitudinal design with OSCE to analyze the effect of the change in competency after a training course&#46;<a class="elsevierStyleCrossRefs" href="#bib0570"><span class="elsevierStyleSup">27&#44;50&#44;51&#44;87</span></a> Moreover&#44; core competencies have been evaluated in medical residents through exposure to various clinical scenarios&#46;<a class="elsevierStyleCrossRef" href="#bib0810"><span class="elsevierStyleSup">75</span></a> Despite the published evidence on competency assessment in medicine&#44; we need a more rigorous empirical contrast using more complex research study designs and the complete involvement of healthcare system managers&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Moreover&#44; assuming a competency approach requires a change in educational objectives and standards&#44; a change in assessment systems and accreditation programs and the planning of the maintenance and monitoring of acquired competencies&#46; We need a change in mindset by professors&#44; students&#44; tutors&#44; residents&#44; managers&#44; practitioners and the other agents involved&#44; given that this approach does not establish &#8220;times&#8221; but rather &#8220;results&#8221;&#46; Although it is assumed that academic institutions and managers of health professionals worldwide speak the same competency language&#44; generally technical&#44; the evidence found by this study shows the presence of a vacuum between the educational setting&#44; with a greater prevalence of competency assessment&#44; and the professional&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In our context&#44; we also talk of clinical competency&#44; professional competency&#44; competency-based education&#44; evaluation by competency&#44; accreditation instruments and rewarding professional competency&#46; However&#44; this concern is still not reflected in terms of scientific output&#46; Faced with this deficiency&#44; we should reflect&#44; discuss and attempt to build an assessment model that considers the continuum from access to the faculty to professional practice&#44; taking into account the competency framework that we need to acquire &#40;and maintain&#41; in each stage&#44; as well as checking the suitability of the tools to be employed&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">After discussing the evidence found&#44; we proposed a comprehensive competency assessment model&#44; awaiting evaluation&#44; which contemplates the &#8220;undergraduate&#47;graduate&#47;active professional&#8221; continuum &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The diagram involves determining first the medical competencies to acquire&#44; applicable both in the academic and professional settings&#46; The process should be started by establishing a system of access to faculty that assumes the principles of competency assessment&#44; detecting talent&#44; expertise and technical skills &#40;precursors&#41; and the core competencies of communication&#44; empathy and teamwork&#44; among others&#46; Thus&#44; the selection of future professionals will not be based on just their memory capacity&#46; The current lack of definition regarding the specific tests of access to universities could represent a good opportunity to reflect on the access and selection of students&#46; Once access has been established&#44; we should test the most appropriate assessment methods for use in undergraduate training&#46; We propose the progressive inclusion of the OSCE in the competency assessment of undergraduates&#44; along with other tools&#44; always taking into account the volume of students and the feasibility of implementing the tools&#46; In the graduate training stage&#44; we propose using OSCE annually at the start of the residence &#40;baseline&#41; and upon completion of the rotations&#46; From the third year&#44; we propose inserting the 360&#176; assessment&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">Once the training stage has concluded&#44; we introduce the actual assessment of competencies&#44; which considers the healthcare activity and quality&#58; the &#8220;what&#8221; is performed using key indicators and syntheses of activity and quality&#44; and the &#8220;how&#8221; is performed generally with the 360&#176; technique&#46; It is important to note that the OSCE is not recommended as an instrument to assess veteran professionals&#46; The portfolio also makes no sense in a performance assessment system&#46; Although performance assessment is certainly recommended in the private setting&#44; it has been mandatory for the public setting since the coming into force of Law 7&#47;2007 of April 12 <span class="elsevierStyleItalic">Basic Statute for Public Employees</span>&#44; which requires the implementation of instruments that enable the assessment of professional conduct and performance and the achievement of results&#46; In this framework&#44; if performance assessments are established annually&#44; collecting competency results in 5-year periods&#44; along with those related to training&#44; teaching&#44; research and commitment&#44; the requirements established in the professional career could be met&#46; As healthcare organizations start using the same instruments&#44; benchmarking could be implemented for healthcare competencies&#46; This approach would facilitate the accreditation programs and help establish more efficient human resource policies &#40;professional career&#44; productivity&#44; continuing education&#44; etc&#46;&#41; according to unified criteria that are comparable among institutions&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In conclusion&#44; the reviewed literature paints a highly heterogeneous picture&#46; Systematic reviews in the 2010s have explored whether there has been a change in trends on this subject&#46; More specifically&#44; we must pay special attention to the nonclinical aspects of the medical profession&#44; which are contemplated and evaluated before access to the faculty&#46; Likewise&#44; the assessment instruments need to be compared using similar research study designs and under controlled conditions to ensure the methods&#8217; internal validity and their results&#46; It is essential to promote longitudinal designs that help reach conclusions about the tools&#8217; suitability&#44; based on the quality of the measure and the sensitivity to behavioral changes in those being evaluated&#46;<a class="elsevierStyleCrossRef" href="#bib0800"><span class="elsevierStyleSup">73</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">This study sought to analyze the essentials of competency assessment in medicine&#44; through the main evidence of published empirical&#44; academic and professional studies and to propose a comprehensive model for career development&#46; We hope to contribute to the generation of relevant scientific knowledge in the optimization of competency assessment&#44; with the ultimate goal of not only improving the training&#44; and hence the professional practice&#44; but also promoting better quality of patient care&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interests</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Palabras clave"
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            0 => "Gesti&#243;n por competencias"
            1 => "Evaluaci&#243;n competencial"
            2 => "Competencias profesionales"
            3 => "Instrumentos de evaluaci&#243;n"
            4 => "Evaluaci&#243;n cl&#237;nica objetiva estructurada"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To describe the most widely used tools in the assessment of medical competencies&#44; analyze their prevalence of use&#44; their advantages and disadvantages and propose an appropriate model for our context&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We conducted a narrative review of articles from MEDLINE&#44; following the PRISM protocol&#44; and analyzed a total of 62 articles&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The assessment of competencies is heterogeneous&#44; especially in the educational and professional settings&#46; The specific and technical competencies acquired during university education are mainly assessed using the objective structured clinical assessment&#46; In the professional setting&#44; core competencies are assessed using the 360&#176; technique&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">We need a rigorous empiric comparison of the efficiency of the tools according to the type of competency&#46; We propose a competency management model for the &#8220;undergraduate&#47;graduate&#47;active professional&#8221; continuum&#44; whose goal is to improve training and professional practice and thereby increase the quality of patient care&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Describir las herramientas m&#225;s utilizadas en la evaluaci&#243;n competencial en Medicina&#44; analizar su prevalencia de uso&#44; sus ventajas e inconvenientes y proponer un modelo apropiado para nuestro contexto&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Revisi&#243;n narrativa de art&#237;culos de MEDLINE&#44; siguiendo el protocolo PRISMA&#46; Se analizaron un total de 62 art&#237;culos&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La evaluaci&#243;n competencial es heterog&#233;nea&#44; especialmente en el &#225;mbito educativo y profesional&#46; Las competencias espec&#237;ficas o t&#233;cnicas durante la formaci&#243;n universitaria se eval&#250;an fundamentalmente mediante evaluaci&#243;n cl&#237;nica objetiva estructurada&#44; mientras que en el ejercicio profesional se valoran competencias nucleares utilizando la t&#233;cnica 360&#176;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se necesita un contraste emp&#237;rico riguroso de la eficiencia de las herramientas en funci&#243;n del tipo de competencia&#46; Se propone un modelo de gesti&#243;n competencial sobre el continuo &#171;pregrado&#47;posgrado&#47;profesionales en activo&#187;&#46; Su finalidad es contribuir a la mejora de la formaci&#243;n y de la pr&#225;ctica profesional y&#44; por ende&#44; incrementar la calidad de la atenci&#243;n al paciente&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Sureda-Demeulemeester E&#44; Ramis-Palmer C&#44; Ses&#233;-Abad A&#46; La evaluaci&#243;n de competencias en Medicina&#46; Rev Clin Esp&#46; 2017&#59;217&#58;534&#8211;542&#46;</p>"
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            "titulo" => "Supplementary data"
            "identificador" => "sec0035"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Flow diagram for the selection process of studies on competency assessment in medicine&#46; We excluded 112 studies regarding competencies related to consent in pediatric diseases&#44; patient autonomy and legal aspects&#44; 620 articles identified in the field of Medicine&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Integrated model for competency assessment in the healthcare setting &#40;&#8220;undergraduate&#44; graduate&#44; practicing professionals&#8221;&#41;&#46;</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; ANECA&#44; National Agency for Assessment of Quality and Accreditation&#59; OSCE&#44; objective structured clinical assessment&#59; 360 assess&#44; 360&#176; assessment technique&#59; HR&#44; human resources&#46;</p>"
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Article information
ISSN: 22548874
Original language: English
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