#KeyLIMEPodcast 333: Competence in Context

This week’s article, presented by Jason, takes a look at transitions in Health Professions Education. We all know it can be difficult to adjust to change, but there is also work that suggests experiencing transitions of setting during training can build adaptability and enhance learning. The researchers behind today’s article wanted better insight in to this and thus set out to “understand how trainees entering a new setting develop awareness of specific contextual changes that they need to navigate and learn from”.

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KeyLIME Session 333

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Teunissen et. al., Contextual Competence: How residents develop competent performance in new settings Med Educ 2021 Sep;55(9):1100-1109


Jason R. Frank (@drjfrank)


“A ship in harbour is safe, but that is not what ships are built for.”

-John A Shedd, 1928

If you are a human being reading this (and if you are not, please contact us), then you have likely experienced some kind of disorienting transition from one setting to another in your life. Maybe many times. It might be a move to a new home during childhood, or a new job as an adolescent, a new school, or a new placement during training.

There are a number of implications for health professions education of this disorientation phenomenon. Previous scholarship suggests that big transitions in the careers of health professionals (e.g. From medical student to resident) are stressful, challenging, poorly designed, impair learning, and can harm patients. Our current understanding of the nature of human competence also suggests that competence is quite contextual. In other words, a practitioner who can perform consistently well in one setting may fumble when moved to another setting (e.g. an academic surgeon in a big hospital moved to a rural one, or Jon’s favourite hockey team playing against real teams, but I digress).

On the other hand, there is some work that suggests that experiencing transitions of setting during training can build adaptability and enhance learning.

In HPE, a rotation in a faraway geographic location is a special case, often in a non-urban setting, can be lonely, intimidating, and far from usual supports, resources, peers, and care systems.

So how do we get the good effects of training in a new setting and avoid the negative effects?


Enter an astronomical all-star team of meded researchers, including meded gurus Pim Teunissen, Chris Watling, Rachel Ellaway, and the late Joanna Bates. These authors assembled to “understand how trainees entering a new setting develop awareness of specific contextual changes that they need to navigate and learn from”.

Key Points on the Methods

The authors chose Internal Medicine residents from 3 Canadian programs that have at least 1 rotation geographically distributed far from the home training site. They focused on the “community-based rotation” far from a large academic centre as a prototypical example of a significant training transition, to a site that “differs substantially” from the home site.

The team used constructivist grounded theory to explore this phenomenon of training away via in-depth interviews. They used the usual CGT methods, recording, transcribing, anonymizing, and participant checking. Coding frameworks were created and updated using constant comparison. Themes informed subsequent interviews. They provide an extensive (relatively) reflexivity statement.

The team used several sensitizing concepts to guide this work. A “capability approach” was chosen from the literature, Nussbaum and Sen’s conceptual framework that posits that competence is the result of a dynamic interplay between an individual and a context. (This is in contrast to a cognivist perspective that competence is the result of numerous opportunities to apply knowledge and skills in many settings or cases.) Capability is defined as the interplay between “an individual’s ability and the opportunities and constraints they encounter in using their abilities.” They also used the works of Little et al on a rural Australian placement, and of Levett-Jones and Lathlean on nursing education. These two studies found that features of the new setting such as a sense of belonging were important.

Key Outcomes

29 trainees, from PGY3-5 and recent graduates, participated in the study. 16 identified as female. Mean age was 30. Each had completed at least one geographically distant “community rotation”.

The authors identified 5 key stages that trainees seemed to describe in adapting to a new faraway training site. This they assembled into the Bates Hierarchy of Contextual Competence. As trainees pass through these stages, they bring their knowledge, past experiences, motivations, and abilities related to recognizing important local features that require rapid adaptation.

Key Conclusions

The authors conclude that these themes provide insight into how trainees The authors conclude that contextual competence involves a trainee moving through a hierarchy of 5 stages of adaptation to a different setting. The authors suggest that this has major implications for meded curriculum leaders, teachers, and learners.  Further, they feel this study provides further elaboration of the elements of contextual competence.

Spare Keys – Other take home points for clinician educators

  1. This is a beautiful application of constructivist grounded theory to an issue in medical education.
  2. Many aspects of success in health professions practice are tacit, and not taught or even well-articulated. More work is needed on the tacit nature of learning in HPE (see upcoming work by Stella Yiu).
  3. Competence is contextually bound. This paper reminds us of some of the mechanisms.

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