A measure of competence. The first Mushin lecture

The process by which an individual is finally recognised as a physician and licensed to practice medicine is long and complicated. The physician who chooses to specialise pursues additional study and after successfully completing both written and oral examinations may be certified by a 'specialty board'. Such certification is looked upon as evidence that the physician is competent to practice at the consultant level. The competent clinician possesses the intellectual capacity to make valid medical judgments and the technical expertise in his own special field to implement or to direct the implementation of such judgments. The written examination measures the pool of information essential for the individual to make valid medical judgments in the area tested. The oral examination examines attributes difficult to evaluate by other techniques since attributes demand both observation of the candidate and interaction with him. The oral exam is probably a better way to evaluate a candidate's ability to make clinical judgments, to synthesize information, to relate specific basis information to clinical problems presented and, to some extent, to test the ability of the candidate to react in stressful situations. Inadequacies of the oral examination continue to include a lack of objectivity and the potential for bias. Some specialty boards require certificates of clinical competence issued by the faculty of the training programme on behalf of applicants who seek certification in their specialty. In addition to such judgments of clinical competence, the concepts of peer review, licensure, recertification and continuing education all play a role in the elusive objective of assessing clinical competence.