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Sureda-Demeulemeester, C. Ramis-Palmer, A. Sesé-Abad" "autores" => array:3 [ 0 => array:3 [ "nombre" => "E." "apellidos" => "Sureda-Demeulemeester" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 1 => array:3 [ "nombre" => "C." "apellidos" => "Ramis-Palmer" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:4 [ "nombre" => "A." "apellidos" => "Sesé-Abad" "email" => array:1 [ 0 => "albert.sese@uib.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Departamento de Desarrollo Organizacional, Hospital Universitario Son Espases, Palma, Mallorca, Islas Baleares, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Psicología, Universitat de les Illes Balears, Palma, Mallorca, Islas Baleares, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La evaluación de competencias en Medicina" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2649 "Ancho" => 2333 "Tamanyo" => 348165 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Flow diagram for the selection process of studies on competency assessment in medicine. We excluded 112 studies regarding competencies related to consent in pediatric diseases, patient autonomy and legal aspects, 620 articles identified in the field of Medicine.</p>" ] ] ] "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.<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">1</span></a> Although there is no one definition for “competency”, in general, the term is considered as “observable and habitual behaviors that lead to success in a function or task.”<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, communication, collaboration and the search for efficiency in interventions.<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–clinical knowledge.<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">4</span></a> Therefore, training should not be planned under the single approach of diagnosis and treatment.<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">5</span></a> For this reason, access to faculty, university training, selection in the healthcare institutions, and performance and professional career assessment need a significant review and update of their methodology. 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.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Only Canada and the USA have state competency frameworks for all medical specialties. In Canada, the Royal College of Physicians and Surgeons has 7 competency frameworks known as CanMEDS: medical expert, communicator, collaborator, leader, health advocate, scholar and professional.<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">6</span></a> In the USA, the Accreditation Council for Graduate Medical Education proposes 6 frameworks: patient care, medical knowledge, practice-based learning, interpersonal and communication skills, professionalism, and systems-based practice.<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 (competency achieved), rather than training time or completed rotations.<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">8</span></a> The United Kingdom (Good Medical Practice) and the Netherlands (inspired by the Canadian model) are adopting similar competency management systems.</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, professional selection, certification and recertification and the professional incentive and promotion systems.<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, analyze the frequency of their use, their main advantages and disadvantages and propose an appropriate assessment model for our context.</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.<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">10</span></a> The search combined the terms “competency”, “competencies”, “360 feedback”, “360 degrees”, “multisource assessment”, and “Objective Structured Clinical Assessment” (OSCE). We considered original articles in Spanish or English published between 2000 and 2010. We obtained 93% agreement between the 2 evaluators in the selection of articles. Of a total of 4566 initial articles, we selected those written for the health sciences (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>826) and, specifically, medicine (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>620). We subsequently excluded 112 studies regarding competencies related to consent in pediatric diseases, patient autonomy and legal aspects. Ultimately, we selected 62 of the 508 remaining studies, which were focused on the assessment of specific competencies (technical) or of those related to nontechnical aspects (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). For each article, we analyzed its target population, the type of competency chosen and the methodology or assessment tools employed. In terms of the target population, the studies were classified according to their setting: academic, undergraduate student (basic university training), graduate (specialization such as resident and graduate training) and practicing professionals. With regard to the type of competency, we differentiated: 1) core, transversal or general competencies, present regardless of category, position or function and related to nontechnical aspects of the profession and 2) specific competencies, required for the performance of the position's technical functions and formulated in a language close to the practitioner and to their field of practice. Finally, we analyzed the assessment method or tool employed.</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, with the most relevant being questionnaires and knowledge tests, (360° technique or multisource), case analysis, interview and analysis of an incident, direct observation tests, situational, simulations, OSCE and portfolio. The tool selection depends on the type of competency to assess (core or specific), its reliability and validity, its appropriateness for the subject's activity stage (undergraduate, graduate or practicing) and the purpose for the assessment, which can be training (because it acts during the learning process) or summative (which focuses on the outcome of the process). Several of the tools involve subjective judgment, which affects their reliability and validity.<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">11–13</span></a> Combining different instruments for medical competency assessment is therefore advisable. These instruments are described below.</p><p id="par0030" class="elsevierStylePara elsevierViewall">OSCE was introduced into medical education by Ronald Harden in 1975, using actual or simulated patients in a format of multiple workstations, through which a variety of skills and approaches were analyzed.<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. Currently, the participants rotate through a circuit of sequential workstations that require the participants to show various skills. Each workstation is constructed to assess one or several specific skills on anamnesis, physical examination, diagnostic identification, decision making, patient education and the implementation of a technical procedure. OSCE uses standardized patients, simulation with mannequins, creation of clinical reports, interpretation of additional tests, resolution of short case-related questions and the implementation of knowledge tests, among others. Valuation judgment is established by comparison with a reference standard or a detailed pre-established verification list, which has been developed by expert clinicians.<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">15</span></a> The review shows that most studies on competency assessment in medicine use OSCE, mainly for undergraduate and graduate students. Thus, for undergraduate students, the OSCE assesses specific,<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">16–25</span></a> core<a class="elsevierStyleCrossRefs" href="#bib0565"><span class="elsevierStyleSup">26–30</span></a> or both competencies.<a class="elsevierStyleCrossRefs" href="#bib0590"><span class="elsevierStyleSup">31–36</span></a> For graduate students, the specific competencies are assessed through tests that are usually present in the OSCE, such as simulators,<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.<a class="elsevierStyleCrossRefs" href="#bib0630"><span class="elsevierStyleSup">39–42</span></a> We also turn to the OSCE to analyze core competencies<a class="elsevierStyleCrossRefs" href="#bib0650"><span class="elsevierStyleSup">43–45</span></a> and for joint assessments.<a class="elsevierStyleCrossRefs" href="#bib0665"><span class="elsevierStyleSup">46–50</span></a> With regard to practicing professionals, the use of the OSCE and, as a consequence, the published studies are scarce and are focused on core competencies.<a class="elsevierStyleCrossRefs" href="#bib0690"><span class="elsevierStyleSup">51–53</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In light of the reviewed studies and following the recommendations for applying the tool,<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">15,54,55</span></a> a reliable and valid OSCE should last 3–4<span class="elsevierStyleHsp" style=""></span>h, include 15–20 workstations, with 10-min sessions per workstation, without exceeding 30 assessment items per case or more than 20 candidates per session, preferably using 2 evaluators per workstation and combining several assessment instruments. The OSCE has the ability to detect deficient practices and is therefore usually employed as a certifying element. OSCE is not usually recommended for assessing core competencies, detecting excellence or assessing veteran practitioners. For this group of active professionals, the use of the <span class="elsevierStyleItalic">portfolio</span> is suggested, as a recertifying procedure, when the assessments should be performed on a large scale. This involves a process of evidence collection, which, with a certain purpose, is performed to demonstrate the training and/or competency level reached by a practitioner. The portfolio contains a variety of instruments such as critical incidents, practice indicators and video recordings.<a class="elsevierStyleCrossRefs" href="#bib0615"><span class="elsevierStyleSup">36,54</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">One of the most widely used tools is the 360° assessment (360° feedback or multisource assessment), which consists of assessing a practitioner according to their observable components, using several different sources. Although this tool can be seen as a collection of subjective assessments, the literature indicates that the subjective methods can be as reliable as the objective, provided that the number of evaluators and the judgment conditions are appropriate.<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.<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, generally through questionnaires. The assessment typically includes a self-assessment of the individual being evaluated, and an assessment by their supervisor(s), colleagues, colleagues from other categories, subordinates and patients, who are compared to find a consensus. 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.<a class="elsevierStyleCrossRefs" href="#bib0725"><span class="elsevierStyleSup">58–66</span></a> The technique has also been used, although less often, for graduate students to assess core competencies<a class="elsevierStyleCrossRefs" href="#bib0770"><span class="elsevierStyleSup">67–69</span></a>; however, the technique has rarely been applied to undergraduate students.<a class="elsevierStyleCrossRef" href="#bib0785"><span class="elsevierStyleSup">70</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The overall objective of the 360° technique is to guide professional development based on the feedback provided by various information sources on observable (and, as such, modifiable) behaviors. However, its implementation differs with respect to the number of evaluators and source that provide feedback. At least 8 medical colleagues, 8 work mates and 25 patients are therefore recommended for the technique to be valid and reliable.<a class="elsevierStyleCrossRef" href="#bib0720"><span class="elsevierStyleSup">57</span></a> Nevertheless, 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’ health condition, the amount of time the physician spends caring for them and the physician's sex.<a class="elsevierStyleCrossRef" href="#bib0795"><span class="elsevierStyleSup">72</span></a> Therefore, despite the fact that the patients’ opinions appear to have a greater effect and acceptance than those of colleagues,<a class="elsevierStyleCrossRef" href="#bib0740"><span class="elsevierStyleSup">61</span></a> a number of authors question its validity due to the lack of ability (or courage) to report poor performance by the assessed physician.<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, to ensure the comparability of assessments. Each questionnaire requires approximately 6<span class="elsevierStyleHsp" style=""></span>min to fill out.<a class="elsevierStyleCrossRef" href="#bib0795"><span class="elsevierStyleSup">72</span></a> A characteristic element of this technique is that practitioners participate voluntarily, while those who play the role of evaluator are chosen in advance by those who will be evaluated. Although the evaluated individuals need to perceive their evaluators as credible sources of information,<a class="elsevierStyleCrossRef" href="#bib0800"><span class="elsevierStyleSup">73</span></a> in the sense of being familiar with the work conducted, the act of choosing these evaluators beforehand could bias the assessments. A number of studies have shown that the qualifications granted by evaluators who were not chosen were significantly lower (in other words, they were more demanding) than those granted by previously selected evaluators.<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, beyond their possible likes and dislikes.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The tool's strengths include its ability to delimit and understand the complexity of the work content, increased reliability and validity of the process due to the use of multiple sources of assessment, and its potential contribution to improving competencies, provided there is a proper selection of the sources, consistency between the scores of the sources, support offered by a mentor and preservation of the evaluators’ anonymity. The tool also helps obtain professional performance data regarding the improvement in healthcare quality, which is of interest from the point of view of both summative<a class="elsevierStyleCrossRefs" href="#bib0720"><span class="elsevierStyleSup">57,72</span></a> and formative assessments.<a class="elsevierStyleCrossRef" href="#bib0795"><span class="elsevierStyleSup">72</span></a> In contrast, the tool's main limitation is its cost to implement, perform and maintain. More classical or generic tools, such as questionnaires, are therefore occasionally employed.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The questionnaires are constructed based on standard dictionaries or catalogs of competencies. The questionnaires cover a series of competencies and their behavioral evidence, which are considered necessary to carry out a job position. 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.<a class="elsevierStyleCrossRefs" href="#bib0805"><span class="elsevierStyleSup">74,75</span></a> The questionnaires are completed by a single assessment source, by either the evaluator or a supervisor. The medical literature has a fair number of studies that have used questionnaires, generally with undergraduate students, which have assessed specific,<a class="elsevierStyleCrossRefs" href="#bib0815"><span class="elsevierStyleSup">76,77</span></a> core<a class="elsevierStyleCrossRef" href="#bib0825"><span class="elsevierStyleSup">78</span></a> or both competencies,<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">4,79–81</span></a> and graduate students, which have mainly assessed core<a class="elsevierStyleCrossRefs" href="#bib0845"><span class="elsevierStyleSup">82,83</span></a> or both competencies.<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, with a particular focus on assessing technical competencies. The disadvantages include the reliability of the responses when assessing core competencies (influence of biases such as social desirability, halo effect, memory gaps, etc.) and the inability to learn more about the meanings behind the responses (objective or prescriptive answer format, test type). To offset these disadvantages, in cost-time terms, the questionnaire (in its multisource psychometric/clinimetric-based format) can be considered one of the most appropriate methods.<a class="elsevierStyleCrossRefs" href="#bib0720"><span class="elsevierStyleSup">57,72,73</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Once the main tools and procedures have been described, according to the reviewed studies on competency assessment in medicine (see supplementary material, available in the online version), approximately 45% were directed to undergraduate students, 36% to graduate students and 19% to active professionals. Thirty-one percent of the studies assessed specific competencies, 42% assessed core competencies, and 27% assessed both types. In terms of the tools’ prevalence of use, approximately 60% of the studies used OSCE (only 3 of which were aimed at practicing professionals), followed by 19% that used the 360° technique (in this case, only 3 studies were aimed at professionals undergoing training), 16% that used questionnaires (aimed at undergraduate and graduate students) and only 5% that employed other instruments, mainly knowledge tests. It is worth mentioning that the considerable majority of referenced studies applied transversal designs. There was also a notable lack of studies on the cost analysis of the various methodologies and tools,<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">15</span></a> a fundamental parameter for implementing a competency management system.</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, classification and model of competency management. This study considered the competencies as behaviors related to good or excellent performance and differentiates between core and specific competencies. This perspective presents certain analogies concerning the approaches of Ten Cate and Billett,<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">8</span></a> who, with their concept of reliability of the professional activity, sought to define the competencies, translating the abstract constructions that describe the individuals’ capabilities into activities to be undertaken; and concerning the studies of Hawkins et al.,<a class="elsevierStyleCrossRef" href="#bib0860"><span class="elsevierStyleSup">85</span></a> who defined competencies as “<span class="elsevierStyleItalic">markers of progress or observable behaviors”</span> more precisely.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Based on the evidence found, there is a tendency to assess the more technical aspects of the medical profession during the training years (undergraduate), generally using OSCE and questionnaires. During residency (graduate), attention continues to focus on specific competencies but sharing space with the assessment of core competencies, with greater variability of tools, highlighting OSCE and situational tests, the 360° technique and questionnaires. Lastly, during professional practice, the assessment focuses on core competencies using the 360° technique.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Given that medical practice presents a multidimensional structure, it seems advisable to use various tools to assess the separate domains. 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. 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. However, it is no less certain that the evidence found indicates that OSCE (and its variants) and the 360° assessment are the most appropriate tools, although pending comparison from a meta-analytical perspective and through longitudinal designs. In our opinion, the OSCE is more appropriate for assessing specific competencies but is not recommended for core competencies. Studies have pointed out the difficulty of assessing communication ability versus clinical skills using OSCE.<a class="elsevierStyleCrossRef" href="#bib0710"><span class="elsevierStyleSup">55</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Moreover, the evidence indicates that the 360° technique is the most appropriate for assessing core competencies. In this respect, studies have concluded that a multisource assessment is most effective for assessing aspects regarding communication, professionalism, management and interpersonal relationships.<a class="elsevierStyleCrossRefs" href="#bib0720"><span class="elsevierStyleSup">57,72</span></a> There is also evidence of the inadequacy of assessing specific competencies with the 360° technique, mainly due to the inability of colleagues to observe the technical performance of the evaluated individual, as well as the inherent difficulty in embodying technical clinical competency in the form of test items.<a class="elsevierStyleCrossRef" href="#bib0740"><span class="elsevierStyleSup">61</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Although we suggest the 360° assessment for core competencies and OSCE for specific competencies, comparative studies are needed for the various instruments, using the same research design (mainly longitudinal), under controlled conditions (internal validity), which help analyze the benefits and disadvantages of each type of competency. In contrast, most reviewed studies are cross-sectional, 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. There are few longitudinal studies in medicine that have used the 360° technique, such as the Physician Assessment Review process or the Sheffield Peer Review Assessment Tool. 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.<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.<a class="elsevierStyleCrossRefs" href="#bib0570"><span class="elsevierStyleSup">27,50,51,87</span></a> Moreover, core competencies have been evaluated in medical residents through exposure to various clinical scenarios.<a class="elsevierStyleCrossRef" href="#bib0810"><span class="elsevierStyleSup">75</span></a> Despite the published evidence on competency assessment in medicine, we need a more rigorous empirical contrast using more complex research study designs and the complete involvement of healthcare system managers.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Moreover, assuming a competency approach requires a change in educational objectives and standards, a change in assessment systems and accreditation programs and the planning of the maintenance and monitoring of acquired competencies. We need a change in mindset by professors, students, tutors, residents, managers, practitioners and the other agents involved, given that this approach does not establish “times” but rather “results”. Although it is assumed that academic institutions and managers of health professionals worldwide speak the same competency language, generally technical, the evidence found by this study shows the presence of a vacuum between the educational setting, with a greater prevalence of competency assessment, and the professional.</p><p id="par0100" class="elsevierStylePara elsevierViewall">In our context, we also talk of clinical competency, professional competency, competency-based education, evaluation by competency, accreditation instruments and rewarding professional competency. However, this concern is still not reflected in terms of scientific output. Faced with this deficiency, we should reflect, discuss and attempt to build an assessment model that considers the continuum from access to the faculty to professional practice, taking into account the competency framework that we need to acquire (and maintain) in each stage, as well as checking the suitability of the tools to be employed.</p><p id="par0105" class="elsevierStylePara elsevierViewall">After discussing the evidence found, we proposed a comprehensive competency assessment model, awaiting evaluation, which contemplates the “undergraduate/graduate/active professional” continuum (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The diagram involves determining first the medical competencies to acquire, applicable both in the academic and professional settings. The process should be started by establishing a system of access to faculty that assumes the principles of competency assessment, detecting talent, expertise and technical skills (precursors) and the core competencies of communication, empathy and teamwork, among others. Thus, the selection of future professionals will not be based on just their memory capacity. 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. Once access has been established, we should test the most appropriate assessment methods for use in undergraduate training. We propose the progressive inclusion of the OSCE in the competency assessment of undergraduates, along with other tools, always taking into account the volume of students and the feasibility of implementing the tools. In the graduate training stage, we propose using OSCE annually at the start of the residence (baseline) and upon completion of the rotations. From the third year, we propose inserting the 360° assessment.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">Once the training stage has concluded, we introduce the actual assessment of competencies, which considers the healthcare activity and quality: the “what” is performed using key indicators and syntheses of activity and quality, and the “how” is performed generally with the 360° technique. It is important to note that the OSCE is not recommended as an instrument to assess veteran professionals. The portfolio also makes no sense in a performance assessment system. Although performance assessment is certainly recommended in the private setting, it has been mandatory for the public setting since the coming into force of Law 7/2007 of April 12 <span class="elsevierStyleItalic">Basic Statute for Public Employees</span>, which requires the implementation of instruments that enable the assessment of professional conduct and performance and the achievement of results. In this framework, if performance assessments are established annually, collecting competency results in 5-year periods, along with those related to training, teaching, research and commitment, the requirements established in the professional career could be met. As healthcare organizations start using the same instruments, benchmarking could be implemented for healthcare competencies. This approach would facilitate the accreditation programs and help establish more efficient human resource policies (professional career, productivity, continuing education, etc.) according to unified criteria that are comparable among institutions.</p><p id="par0115" class="elsevierStylePara elsevierViewall">In conclusion, the reviewed literature paints a highly heterogeneous picture. Systematic reviews in the 2010s have explored whether there has been a change in trends on this subject. More specifically, we must pay special attention to the nonclinical aspects of the medical profession, which are contemplated and evaluated before access to the faculty. Likewise, the assessment instruments need to be compared using similar research study designs and under controlled conditions to ensure the methods’ internal validity and their results. It is essential to promote longitudinal designs that help reach conclusions about the tools’ suitability, based on the quality of the measure and the sensitivity to behavioral changes in those being evaluated.<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, through the main evidence of published empirical, academic and professional studies and to propose a comprehensive model for career development. We hope to contribute to the generation of relevant scientific knowledge in the optimization of competency assessment, with the ultimate goal of not only improving the training, and hence the professional practice, but also promoting better quality of patient care.</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.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres947405" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec919889" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres947406" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec919888" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Method" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Competency assessment tools and frequency of use" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Toward a proposed competency assessment management model" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-03-27" "fechaAceptado" => "2017-05-28" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec919889" "palabras" => array:6 [ 0 => "Competency management" 1 => "Competency assessment" 2 => "Professionals competencies" 3 => "Assessment instruments" 4 => "Objective structured clinical evaluation" 5 => "360° assessment" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec919888" "palabras" => array:6 [ 0 => "Gestión por competencias" 1 => "Evaluación competencial" 2 => "Competencias profesionales" 3 => "Instrumentos de evaluación" 4 => "Evaluación clínica objetiva estructurada" 5 => "Evaluación 360°" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "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, analyze their prevalence of use, their advantages and disadvantages and propose an appropriate model for our context.</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, following the PRISM protocol, and analyzed a total of 62 articles.</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, especially in the educational and professional settings. The specific and technical competencies acquired during university education are mainly assessed using the objective structured clinical assessment. In the professional setting, core competencies are assessed using the 360° technique.</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. We propose a competency management model for the “undergraduate/graduate/active professional” continuum, whose goal is to improve training and professional practice and thereby increase the quality of patient care.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Describir las herramientas más utilizadas en la evaluación competencial en Medicina, analizar su prevalencia de uso, sus ventajas e inconvenientes y proponer un modelo apropiado para nuestro contexto.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Método</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Revisión narrativa de artículos de MEDLINE, siguiendo el protocolo PRISMA. Se analizaron un total de 62 artículos.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La evaluación competencial es heterogénea, especialmente en el ámbito educativo y profesional. Las competencias específicas o técnicas durante la formación universitaria se evalúan fundamentalmente mediante evaluación clínica objetiva estructurada, mientras que en el ejercicio profesional se valoran competencias nucleares utilizando la técnica 360°.</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 empírico riguroso de la eficiencia de las herramientas en función del tipo de competencia. Se propone un modelo de gestión competencial sobre el continuo «pregrado/posgrado/profesionales en activo». Su finalidad es contribuir a la mejora de la formación y de la práctica profesional y, por ende, incrementar la calidad de la atención al paciente.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Sureda-Demeulemeester E, Ramis-Palmer C, Sesé-Abad A. La evaluación de competencias en Medicina. Rev Clin Esp. 2017;217:534–542.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0135" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0035" ] ] ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2649 "Ancho" => 2333 "Tamanyo" => 348165 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Flow diagram for the selection process of studies on competency assessment in medicine. We excluded 112 studies regarding competencies related to consent in pediatric diseases, patient autonomy and legal aspects, 620 articles identified in the field of Medicine.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2953 "Ancho" => 2500 "Tamanyo" => 534499 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Integrated model for competency assessment in the healthcare setting (“undergraduate, graduate, practicing professionals”).</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>: ANECA, National Agency for Assessment of Quality and Accreditation; OSCE, objective structured clinical assessment; 360 assess, 360° assessment technique; HR, human resources.</p>" ] ] 2 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 84538 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:87 [ 0 => array:3 [ "identificador" => "bib0440" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Entrustability of professional activities and competency-based training" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "O. 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