The Quest for Competence

     If you are anything like me, I'll bet you were on cloud nine when you received your certification card and first EMS patch. A feeling of great pride, nervous anticipation and general feeling of accomplishment was like a bubble of superpower created when you passed your class and certification test. It was also the bubble that burst when you encountered the first patient in the field you didn't know how to treat. After returning from my first failed call, I remember staring at my patch and feeling like I didn't deserve to wear it. Are you a competent EMS provider? Do you have satisfactory skills? Knowledge? Work habits? Can you point to specific actions, attributes, or events that prove your competency? If you are an instructor or supervisor who routinely evaluates others, are you confident in your tools to identify who is competent?

     "Competency" has long been a buzzword in the world of EMS quality improvement and education. The meaning of this word and scope of its concept vary greatly. One state agency might use the term "competencies" for psychomotor skills on a certification exam (like splinting and oxygen administration), while an EMS service might use it to determine if a new employee is ready to work on the street. Adding to the confusion of a definition, there is little research to support any of the standards we seem to hold as critical in our business.^1–4 Does a 90% success rate at intravenous cannulation⁵ and endotracheal intubation make you a "good" clinician?^6–8 If a patient complains about your attitude, does that suggest you are incompetent? How many assessments should you perform in clinical training with an instructor before you graduate?⁹ Does it matter if an EMT knows cardiac anatomy?¹⁰

     For the purposes of this article, let's agree that a competent EMS clinician is one who has the physical skills, mental ability and emotional attributes necessary to properly care for a patient in the prehospital environment. From this perspective, competency is a comprehensive term that represents the sum of all knowledge, attitudes and abilities needed to be a successful EMS clinician.

     Let's also agree that competency is not a state that is achieved or bestowed upon a clinician by some higher power, person or agency.¹¹ In EMS, we often seek out the evaluation of others as proof that we are meeting a standard and complain that tests only measure a small part of our skills and knowledge. In fact, no state EMS agency, instructor or supervisor can simply declare us competent.

     Sure, you may have aced a test, performed a skill exactly to specification or received a commendation for handling a difficult case, but let's face it: What "looked good" may be an illusion. You may have guessed at some questions, or your perfectly performed skill may have failed, and your commendation may have been because you simply kept your cool even though you had no idea what to do. In other words, just because things looked right and turned out in your favor, it doesn't really reflect your abilities. This is why, if you're honest with yourself, you are the best person to assess your own competence. Your self-reflection, self-evaluation and self-directed acquisition of new knowledge to correct your own deficiencies are perhaps the most important processes in the quest for competency.

     State agencies and work supervisors are important safeguards to grant you entry-level permissions to practice, but remember that you need to do just that: practice the art of prehospital medicine.^12,13 Deliberate practice will lead to experiences you can both test your abilities on and learn from. The more you perfect your practice, the more your work quality will improve. The Greek philosopher Plato is quoted as saying, "Experience develops our best flute players. And also our worst." You (the clinician) are ultimately responsible for honestly appraising your performance, learning from your experiences and improving.^14–17