Thirty years ago, an attachment that became known as the “Capability Manifesto” was published in the Royal Society for the Encouragement of Arts, Manufactures and Commerce Journal This crystalized a philosophy, the Capability Movement, that proved to be a long lived branching in how higher education viewed itself and its role. Now, somewhat late to the party, health care is “discovering” the same concept. Why is this important?

In the late 1990’s and early 2000’s, a major change swept across the medical education scene in the United States on the heels of similar changes in British/Australian/New Zealand medical education: competency. Up until then, medical education was primarily defined by a “structural” and “process” approach. Students would spend a set amount of time studying the various elements of the medical curriculum, take a test, and then proceed on to the next course.

Over a period of years, beginning early in this century, the Accreditation Council for Graduate Medical Education (ACGME) phased in a competency-based assessment, to be matched by a competency-based curriculum. Students are now taught and assessed according to the “general competencies” of: Patient Care; Medical Knowledge; Practice-Based Learning and Improvement; Interpersonal and Communication Skills; Professionalism; Systems-Based Practice The same competencies are also used in assessing a physician for appointment and reappointment to the staffs of hospitals and clinics. Although most educators understand Patient Care and Medical Knowledge, there is a varying amount of understanding concerning the teaching and assessment of the others.

Many laud this move to “competency-based” education as a significant improvement over the old structure and process-based system. However, there are problems with this approach. Authors, such as John Stephenson, Susan Weil Stewart Hase, Chris Kenyon Reva Brown and others have made the distinction between “competence” and “capability”. Competence is a static, backward looking concept that tells what a person has done. Capability is a forward looking concept that tells what a person can do in a novel situation.

It is not enough for us to insure “medical competence”–we need to foster capability as well! In fact, this plea was incorporated in a new term, “capatance” put forward by Reva Brown and Sean McCartney in an article in Eduction and Training in 2003. There is not a small amount of congruence here with Mark Quirk’s concept of “metacognition and intuition” discussed in an earlier blog post. Capability, much like intuition, is primarily an “emergent” property. It can be learned, but it is difficult to teach. It can be fostered with an attractor. It is complex!

At this point it is important to look at the recommendations of Stewart Hase and Chris Kenyon. In “Heutagogy: A Child of Complexity Theory”, (Complicity: An International Journal of Complexity and Education, 2007;4(1):111-118), they state:

Thus far there appears, potentially to be a number of ways in which heutagogical thinking might be applied to designing learning processes:

·Recognition of the emergent nature of learning and hence the need for a ‘living’ curriculum that is flexible and open to change as the learner learns;
·Related to this is the involvement of the learner in this ‘living’ cur- riculum as the key driver.
·Recognising that knowledge and skill acquisition, and learning are separate processes and need different approaches;
·Identification of learning activities/processes by the learner not just the teacher.
·Using action research and action learning as meta-methodologies in the learning experience.
·Involvement of the learner in the design of assessment, self-diagnosis and application of knowledge in real life contexts.
·Collaborative learning;
·Coaching for individual learning needs and application.

Is there a way to embrace these goals in the way medical students are taught? There have been experiments in and variable adoption of alternative methods. In 1979 the University of New Mexico adopted a model of Problem-Based Learning following its pioneering development at McMaster University in Toronto a decade earlier In its purest form, Problem-Based Learning integrates the learning of both basic and clinical science through a student-directed study of illustrative cases. Faculty act as facilitators, tutors and guides. Although many medical schools utilize at least some aspects of Problem Based Learning, most include it as a fusion with more traditional lectures.

At least in some institutions, PBL has proven to be successful: The challenge for the future will be to continue the development of “capability” throughout a health care professional’s life. Capability can not become just another competence! It’s complex!

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