A performance-based conception of competence is changing the regulation of physicians' professional behavior

It is the obligation of a profession to articulate the special meaning of competence in its field and to foster the good performance of its practitioners through education and discipline. External societal demands for increased accountability, and internal pressures for greater use of measurements of the processes and outcomes of clinical performance, are forcing the medical profession to reevaluate its view of competence and to change the way the profession "manages" the competence of its members. Traditionally, and predicated on the notion of "once in, good for life," medical education has focused on assuring the competence of trainees as they first enter independent professional life. In parallel, professional regulatory authorities have concentrated on apprehending the "false-positives" of the educational system. But viewed from a performance orientation, competence reflects situational relationships among doctors, their patients, and the systems in which they perform and, thus, is only partly dependent on the attributes of individual actors. This shift in thinking has major implications for the practice of medicine, particularly for the process of maintaining and improving performance. In jurisdictions throughout the world, recognition of the need for systematic and accountable ongoing education for practicing doctors is growing. This educational need should not be seen as a mark of weakness or failure but, rather, as the natural consequence of engagement in challenging practice. "Ars longa, vita breva." The profession must address the complex issues of education-in-practice with the same determination and creativity that it previously applied to education at entry to practice.