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Psychological Fitness Foundations, Part 8 - Competence

This week, we conclude our series of the three foundational ingredients that support physicians’ psychological health. We camped out on Autonomy for five weeks, then covered Relatedness last week. This week we focus on Competence.


(I hope no one is disappointed that I will NOT be taking on the demonstration of competencies to specialty boards, governmental stakeholders, hospital organizations, patients, and other external entities. That controversial topic is beyond the issue of mental fitness foundations, though certainly an important factor psychologically. I am focusing on the individual’s proficiency in medicine.)


I’d like to differentiate between competence and confidence. As I explored in the confidence blog series, the two do not always align.   So, caution here not to confuse lack of confidence with lack of competence. When we are clear-minded about our true skills, abilities, and knowledge, we can accurately assess which areas to focus our growth.


Before we delve a little further, I invite you to pause and take inventory of your strongest areas of proficiency along with areas that afford opportunities for growth to enhance your enjoyment in your career. Make a note of those for later.


The ABFM has defined family physicians’ core competencies by combining ACGME’s universal milestones and its own general sub-competencies.

As a way of review, those are

  1. Medical Knowledge, including critical thinking and decision-making skills.
  2. Patient care – essentially the clinical application of that knowledge in various types of disease (acute, chronic, uncertain), procedural interventions, and wellness promotion. 
  3. Systems-Based Practiced – understanding, navigating, and leading healthcare systems/teams for safety, quality, patient-centered care, and advocacy.
  4. Practice-Based Learning and Improvement includes knowing, discerning, and utilizing solid evidence-based medicine, self-motivation, and reflection for personal growth.
  5. Professionalism – includes behavior, ethics, conscientiousness, self-awareness, and help-seeking behaviors.
  6. Interpersonal and Communication Skills with patients, colleagues, staff, and healthcare systems.


Most of us go into medicine to learn the first two domains, underestimating the importance of the last four. Eventually, we all gain respect for the importance of the last four competencies’ ability to equip us to deliver excellent patient care.


Others have also advocated for highlighting skills not explicitly named above but likely fit in one area or another. These include better utilization of informatics, intentional leadership training, conflict management, patient experience enhancement, emotional intelligence, time management, population health management, healthcare disparities, resource management, medical economics, and health policy. Some of these additions can naturally be (and in many programs already are) incorporated into training. However, unless we extend the training period, there is a limit to the depth, breadth, and number of topics that can be part of formal training. I’d also like to point out the balance at the top of the bell curve for trainees – enough clinical experiences but not so much work that detracts from the education process. This is a delicate balancing act. Also consider, some of the additional skills could begin in undergrad.


Learning the remaining topics and expanding, updating, and deepening the initial competency areas become part of the lifelong learning that most of us anticipated. Again, I offer that this should be viewed as a shared responsibility between the organization and the individual. Of course, if the individual is in private practice, they discover and engage in learning in these other domains on their own.


Many facilities offer grand rounds, leadership courses, EMR training, healthcare disparities training, and patient safety and satisfaction skills. Most academic programs do pretty well, providing faculty members learning opportunities in many domains. Most organizations support competence by providing access to training programs and giving resources (time and money) for CME. I propose an additional way that organizations can show support. They can adjust the physician schedule structure to add in admin time. Doing so would provide time to catch up on notes, inbox messages, and point-of-care reading.


Point-of-care is an effective way of ongoing learning. Access to solid peer-reviewed publications with bite-size answers is a necessity. All organizations should provide and/or all physicians should get access to resources. Personally, my top ones are Up To Date, Sandford Guide app, ASCCP app, ASCVD app, and Prescriber’s Letter. I also appreciate my faculty appointment’s benefit of accessing the free online Care Provider Toolkit containing numerous resources.



An example of organizational investment in learning practice management, medical economics, and improving patient satisfaction: The large organization I worked for in Florida provided me access to a clinical business expert to learn the skill of evaluating my patient-panel size and distribution along with schedule optimization and best billing practices. For instance, I learned to assess my “third-next open” appointment for each type (new, regular, physical, same-day) and increase the number of same-day appointments during cold and flu season and the number of physical slots during school physical season. I learned when to address the need to decrease new patient slots and modify the ratios of regular appointments, same-days, and physicals so my patients had access when they needed it most.



Individually, accurate self-reflecting of what skills need to be developed, strengthened, or updated periodically is important to fill the gaps. Remaining curious, humble, and committed to lifelong learning is crucial. Most of us are naturally built this way.


However, when we have long periods of being overwhelmed with responsibilities, it’s natural for learning to get deprioritized. And, for any of us practicing for any length of time, we know that knowledge and technology are expanding and shifting exponentially. Combined, those present challenges.


Just in the last couple of years, my understanding of oxygen in COPD patients has shifted and I learned of the Haldane effect. My understanding of third-spacing has shifted to understanding the glycocalyx lining of endothelial cells and how over fluid-resuscitating past the J-point was the cause of our patients’ edema – not capillary leak.


It can feel daunting and even defeating to try to keep up. To grow our competence, we must be intentional.  Building in a regular review period is helpful. Consider taking stock of the top 3 things you’d like to grow toward mastery once a year, design a plan, and put it on the calendar. Remember the list I asked you about before – review it considering the other competencies I’ve mentioned and decide your top 3 for the rest of 2022. What’s your plan of attack? Will you put it on the calendar and commit?


Regular reading needs to be part of our typical day/week. How many piles of articles have I stacked up over the years with good intentions to one day read through them? It has been estimated that physicians have at least 8 knowledge gaps each clinical day. Time, Flexibility, and Resources (provided by the organization), Humility, Dedication to learning, and Curiosity (the individuals’ commitments), combine to allow learning at or near the point of care. This affords regular, small forward progress. That consistency helps us grow in our abilities regularly, improving our competence and translating into positive outcomes for our patients.  In turn, that instills and/or reinforces our fulfillment through the love of work and impact on our patient relationships (two of the five items a recent article identified for flourishing as a primary care physician - Thriving in Primary Care)


As an individual, what is your appreciation for and ask from the organization in supporting competence? What are your commitment and actions? After all, this is a fundamental building block of mental fitness. It’s worth the effort.


In review, this 7-week series of building a solid foundation for mental fitness for physicians (like all humans) include Autonomy, Relatedness, and Competence. Autonomy is critical in supporting the other two because a lack of it creates disengagement. Shared responsibility and shared opportunity exist in each of the three domains for healthcare organizations to partner with the individual physicians to create a meaningful gain. 

Have a joy-filled week! Tonya

Do you know a resident or faculty member who is struggling? Our 6-week reset program intensive may be just the thing they need.  


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