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Practising Within Competence



“Competence” is a term that carries substantial  responsibility.  Regardless of profession, when we say one is competent, certain expectations are raised. Airline pilots in their duties of flying passengers are held accountable to a set of standards. They are expected to keep themselves well practised in emergency drills, as well as to maintain continued mastery of technical and professional knowledge. There are similar public expectations of medical practitioners as professionals.

What defines competency and how can we ensure that we are practising within the limits of competency? In  this article, we attempt to answer these questions and also explore the ethical obligations to  practise within competence. In an era of multi- disciplinary management and inter- professional collaboration, the concept of extending competency from the individual to the team is considered


What is competence?

The Medical Registration Act (MRA) (Chapter 174) clearly states that the aim of the MRA is to “protect the health and safety of the public by providing for mechanisms to ensure that registered medical practitioners are  competent and fit to practise medicine”. It further establishes that to achieve registration in Singapore as a medical practitioner, one must “satisfy the Medical Council that he has special knowledge and skill and sufficient experience in any particular branch of medicine”.1

The 2016 edition of the Singapore Medical Council Ethical Code and Ethical Guidelines (2016 ECEG)2 further illustrates the point by stating that a doctor should not engage in “unsupervised practice of an area of medicine without having the appropriate knowledge and skills or the required experience”.


2016 ECEG on practising within competence

The 2016 ECEG, under Section A3 (Practising within competence, maintaining and improving performance, and offering the current standard of care), recommends four key points for good medical practice:2

  1. You must practise within the limits of your own competence. You must not engage in unsupervised practice of an area of medicine without having the appropriate knowledge and skills or the required experience.
  2. You must keep your knowledge and skills up to date throughout your working life, so as to always provide care that is generally accepted as current.
  1. You must provide information to your patients of options for their care that are generally accepted to be more beneficial to them than what are available to them where you practise.
  2. If you cannot provide services that are necessary for your patients, or most beneficial for your patients, you must offer to refer them to other doctors or institutions which can provide the most appropriate services.

This brings to mind two important items required to practise within com- petence: Maintaining knowledge and competency through accredited training and continuing medical education (CME), as well as proper management of care options and referrals.

When it comes to acquiring and maintaining knowledge and competency, the medical practitioner is expected to be up to date with the most appropriate management, treatment and surgical techniques. It is apparent that the constant acquisition of knowledge  is the key to ensuring competency as defined above. Maintaining up-to-date knowledge is an ethical obligation involving the principles of beneficence and non-maleficence.

Upon deciding that the management of the patient is out of one’s area of competence, one should not persist in treating, but instead refer to a clinician who has the appropriate expertise to manage the patient. The care of the patient should be continued until he/she is properly handed over to the specialist. If the specialist referral is declined by the patient, the medical practitioner could also consider treating in consultation with a specialist.


Further thoughts: practising beyond individual competency

Currently, every medical practitioner strives to ensure that the best care is provided at each patient encounter. But is this sufficient? Imagine the case of a patient with multiple comorbidities being treated at multiple centres for each of them. Without integration, the best care at each individual encounter does not equate to the best overall care. Individual competency does not always translate into team competency.

The American Board of Medical Specialties defines the six core com- petencies for quality care as medical knowledge, patient care and procedural skills, interpersonal communication skills, practice-based learning and improvement, systems-based practice, and professionalism. Of the six domains of physician competency, two of them (systems-based practice and interpersonal communication) are team- based competency skills.3

It is also interesting to note that other professions that require their practitioners to work in teams place strong emphasis on team competency. Take the shipping industry for example, ship captains working in a multi-crew environment have integrated team training sessions built in as part of their competency requirements.4 The captain not only has to ensure individual proficiency in his ship- handling skills but also his team-based competencies like communication and management. This team-based training is done in a simulated environment where the entire crew is subjected to various scenarios. This is also practised in the aviation industry.

On the ethical premise of ensuring beneficence to the patient, perhaps further emphasis on team competencies will be needed to provide the best care. Structured team training and evaluations can help prevent the best care by competent individuals from descending into poor overall care for the patient.

There is no doubt that the definition of competency needs to be extended to include team competency. Inevitably, there is a need to enhance integrated team training sessions in a simulated environment.



In conclusion, competence is defined as having sufficient skills and experience to provide appropriate care for patients. This serves to safeguard the  health and safety of the general public. Medical practitioners should strive to keep current with advancing medical science through  CME, and refer cases if it is deemed that limits of competence are exceeded. Beyond individual proficiencies, it is also apt to consider team competencies, especially in an age of an increasingly multidisciplinary approach to complex healthcare issues.



  1. Medical Registration Act (Chapter 174). Singapore Statutes Online. Available at: http://bit. ly/2JOnxiK.
  2. Singapore Medical Council. SMC Ethical Code and Ethical Guidelines (2016 edition). Available at:
  3. American Board of Medical Specialties – Core Physician Competencies. Available at: http://bit. ly/2x6yM1b.
  4. Wilhelmsen – Bridge Team Management Course. Available at: