The problem with a ‘number’

When working as an administrator or practice owner there will come a time where you find yourself needing to select one practitioner over another to come work for you. How do you determine whether the person you are bringing onboard has the skills and capabilities you need for them to be a positive addition to your organisation?

In recent times, many health services have done this via a number. Specifically, a number called ‘Volume of Practice’. This is where a practitioner is required to have performed an action or procedure a certain number of times in order to be deemed ‘competent’.

Hopefully, you can see the obvious problem with this method.

Compare, for example, Joe Smith, an anaesthetist in the city who is easily able to meet his Volume of Practice requirements (due to larger demand for his skills). Smith would automatically be considered more competent than Joe Bloggs, a rural anaesthetist who struggles to achieve the required Volume of Practice simply because the demand is lower.

When being considered for a role, it wouldn’t matter that Joe Bloggs:

  • achieved a higher level of mastery during his training than Joe Smith.
  • had been practising for five years longer than Joe Smith.
  • had greater patient satisfaction ratings than Joe Smith.

Joe Bloggs wouldn’t even be considered for the role because of a ‘sub-standard’ Volume of Practice.

The failings of the Volume of Practice approach are further highlighted by the findings of the British Columbia Privileging Project which reminded us that ‘mere repetition does not beget competence’1.

So, if we don’t use Volume of Practice as a key marker when considering a practitioner for a role, what should we use?

I feel demonstrable mastery of their craft is the first measure.

It’s important to remember that to achieve mastery, deliberate practice, not just practice, is required. What is deliberate practice? It is engaging in practice activities assigned by a teacher with a clear, specific goal of improvement and where the practice activities provide immediate feedback and opportunities for repetition to attain gradual improvement.

Mastery is important because the effort required to maintain skills once mastery is achieved is significantly less than is required in the initial skill acquisition phase. Indeed, both Crocket2 and Hein3 found that deliberate practice and mastery led to higher skill retention than the simple repetition of a task.

After mastery, ongoing training then becomes important. Has the practitioner undertaken adequate education and upskilling activities to maintain their competence?

There also needs to be a measure of performance. Have they consistently achieved a high level of work?

Finally, there needs to be an individualised competency-based assessment of their skills.

What we want to avoid is the assumption that a practitioner possesses a certain level of expertise or competence simply because they attained a piece of paper 20 years ago and have met Volume of Practice requirements thereafter. We should be aiming for practitioners to be operating as close to a level of mastery as is practical.

Remember, if mastery is never achieved, and if Volume of Practice continues to be the way we measure competence, the end result will be the continued promotion of people who are practising a high volume of substandard work. Something that doesn’t serve the medical industry well at all.



1 Backgrounder, British Columbia Privileging Project (notes from article) – December 2014. Rural Coordination Centre of BC – Enhancing Rural Health Through Education

2 Deliberate practice on a virtual reality laproscopic simulator enhances the quality of surgical technical skills: Crochet P, Aggarwal R, Dubb SS, Ziprin P, Ericsson KA: Ann Surg 2011 Jun; 253 (6); 1216-22

3 A training program for novice paramedics provides initial laryngeal mask airway skill and improves skill retention at 6 months: Hein C, Owen H, Plummer J: Simul Healthc: 2010 Feb 5

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