Society trusts physicians to be competent, yet no single individual can achieve mastery in all domains.1  How are we to envision a training model in which competency is broadly distributed, and yet the necessary mastery is available in the moment of need? Educational resources are limited. Choices must be made. However, when faced with an either/or decision, we feel exquisite tension. In this tension, we argue, lies the approach. The Polarity Management process—borrowed from business literature and applied here to the competency conundrum—identifies the sources of tension and uses them to drive improvements.2  We contend that, by harnessing these tensions and better training physicians for adaptability, the answer is not either/or, but both/and.

Because no practitioner can master all domains, we must ask important questions: Who must be competent, in what, to what degree, and for how long? Is minimal competence sufficient for all, or is there a higher level of mastery which only some need achieve?3,4  What knowledge, skills, and procedures are at the “core” of our competency framework? Should there be universal competencies in each specialty, or are there other models of training that could be envisioned?

Though it may be applied to any number of cognitive or affective competencies, here we use performance of invasive procedures as an example. Certifying organizations often provide little guidance outlining how learners should achieve procedural competence.1  In the United States, accrediting bodies have reduced the scope of procedures considered core competencies in several specialties—internal medicine residents need only “understand and explain” lumbar puncture (LP); trainees in pediatrics must still demonstrate LP competency, but achievement is not uniform.5,6 

In 2017, Brydges et al found marked heterogeneity in procedural training, concluding it was unlikely that residents were being uniformly trained to competence in all procedures.7  They suggested that educators consider alternate modes of procedural training, perhaps moving away from the core competency approach in which all trainees are expected to achieve competence, to a competent corps of proceduralists in which a designated group of individuals achieve and maintain a high level of competence.7 

Traditionally, medical training has focused on developing core competencies—skills so vital to the nature of a specialty that all trainees should be competent in them. A general pediatrician, neurologist, emergency physician, or critical care specialist would each have received training in LP.8  Though LP is now less frequent during training,8  it is still considered a core procedural competency in pediatrics, and effort has been invested in training every pediatrician to competence.6,9-11  Educators and accrediting bodies are increasingly aware of the challenges for both initial competency assessment (including validity of assessment tools, standard setting, and cost),12  as well as ongoing competency maintenance.13-15 

An alternative to the core competency paradigm designates selected individuals—trained to mastery—to perform specific procedures. This competent corps maintains mastery through deliberate practice.16  In this model, general training focuses on indications, contraindications, and aftercare of procedures such as paracentesis or central lines. Full procedural mastery is left to the competent corps practitioners.17-19 

There are new complexities to the competent corps model: Who would be in this cohort? What specialties and routes of training will be required? Who will oversee certification? How do we balance the urgency, frequency, and risks of the procedure, and potential harm from delay? While feasible in large centers, it is likely not applicable to many smaller rural or critical access centers, in which any distinction may blur and every practitioner will be part of the competent corps by necessity. This complicated calculus works against a one-size-fits-all model.

Considering a core competency or competent corps may seem like an either/or decision. However, neither approach can satisfy all needs in all contexts. The Polarity Management framework can be a useful tool for navigating complex problems in which 2 potential solutions—or polarities—arise in seeming opposition.2,20,21  By understanding these tensions instead through a both/and lens, this approach helps identify solutions that balance seemingly incompatible opposites.22,23  Identifying the positive value of each polarity while also considering and addressing related risks or fears, Polarity Management allows leaders and educators to clarify the risks of emphasizing one polarity over the other.24-26 

The Polarity Management process starts with defining an overall, singular purpose to which the polarities apply.21  In the case of procedural competency, this purpose is to ensure optimal quality and patient safety. The dynamic balancing between the polarities—perceived as tension—can be a driver of improvement. Basing decisions in the specifics of their own context, leaders and stakeholders outline action steps to optimize the positives of each pole and identify early warnings, measurable indicators that will signal when overreliance on one pole is leading to negative effects.

By considering the valued positives and feared negatives of core competency and competent corps as polarities, education and quality leaders can harness the energy of each to optimize educational practice (Figure 1). Rather than choosing sides, educators must appreciate the relative value of each, remaining alert to inherent risks. The Polarity Management process favors a both/and result, customized to the context. Importantly, there is rarely a single final resolution, but instead an ongoing reckoning of polarities in tension.

Figure 1

An Overview of the Polarity Management Framework

Note: PANEL A: Using the core competency and competent corps as polarities, stakeholders begin by identifying values of each pole—positive results that would be expected by focusing on each pole. Stakeholders then identify feared negative outcomes that could result from focus on each pole to the neglect of the other (adapted from Johnson20). PANEL B: A Polarity Management framework example illustrates the tensions of procedural competency. The valued positive outcome and feared negative outcomes of choosing a polar approach are made explicit.

Figure 1

An Overview of the Polarity Management Framework

Note: PANEL A: Using the core competency and competent corps as polarities, stakeholders begin by identifying values of each pole—positive results that would be expected by focusing on each pole. Stakeholders then identify feared negative outcomes that could result from focus on each pole to the neglect of the other (adapted from Johnson20). PANEL B: A Polarity Management framework example illustrates the tensions of procedural competency. The valued positive outcome and feared negative outcomes of choosing a polar approach are made explicit.

Close modal

Following the Polarity Management process, we envision a training system that fosters adaptability as a primary skill. Doing so would allow both a core competency and competent corps approach to specific abilities. It will fall to governing bodies and education leaders to determine whether a given skill is to remain critically important for a given specialty. It will also fall to educators to instill the adaptive expertise in our trainees to be facile enough with a broad range of concepts. Trainees would thus be able to recognize when to perform when called upon, know when to adapt, and be aware when a mastery-trained expert may be required.

Returning to the LP example, a pediatrician will need to be trained to know the indications for an emergency LP in practice. It remains a core competency procedure in the field, despite the limitations of current training. By designing training programs in pediatrics with the aim of developing adaptive expertise, those whose ultimate practice context makes LP performance likely will seek or be offered skill development. Some may seek mastery-level training to become part of a competent corps. In this manner, a time-sensitive diagnostic LP for a septic infant will be performed by the most competent available individual. If a competent corps is not available, this person may be a core competency practitioner, perhaps using just-in-time refresher training followed by quality review.27  A less time-sensitive LP may wait for a designated proceduralist (Figure 2).

Figure 2

Navigating Polarities in Procedural Competency as a Means of Encouraging Adaptive Expertise

Note: A pediatric resident may have a complicated relationship with lumbar punctures. They are expected by graduation to be facile with the procedure and be able to perform it when necessary. However, given resource constraints, they may not maintain proficiency to the extent a “competent corps” would. A lumbar puncture in a septic infant in the middle of the night may require that the resident perform as competently as possible. The same procedure for administration of intrathecal chemotherapy may wait for a dedicated proceduralist, perhaps with resident assistance. In a given training program, we propose explicitly identifying training situations with these types of polar tensions and guiding the trainee as they learn to negotiate them.

Figure 2

Navigating Polarities in Procedural Competency as a Means of Encouraging Adaptive Expertise

Note: A pediatric resident may have a complicated relationship with lumbar punctures. They are expected by graduation to be facile with the procedure and be able to perform it when necessary. However, given resource constraints, they may not maintain proficiency to the extent a “competent corps” would. A lumbar puncture in a septic infant in the middle of the night may require that the resident perform as competently as possible. The same procedure for administration of intrathecal chemotherapy may wait for a dedicated proceduralist, perhaps with resident assistance. In a given training program, we propose explicitly identifying training situations with these types of polar tensions and guiding the trainee as they learn to negotiate them.

Close modal

Far from arguing to maintain the status quo, it is the emphasis on adaptive expertise that will ensure residents learn to negotiate these edges of competence, contributing to higher-level learning. Too, it cannot be overstated that the achievement of competency—as an individual via a core competency or as a member of a competent corps—is but the beginning.28  Having achieved competency once will be of little utility unless and until the systems are in place to ensure ongoing competency maintenance through frequent performance during practice or through ongoing deliberate practice, monitoring, and quality assurance.

As developing and maintaining competency becomes our defining paradigm, leaders in medical education will increasingly need to confront difficult questions regarding who must be competent, in what, when, and for how long. As individual competencies become more closely scrutinized, these questions will require ongoing reconsideration of what is truly at the core of a given specialty. But within this scope, the core competency and competent corps will need to be implemented, with a foundation in training for adaptive expertise.

By making explicit the heretofore tacit assumptions as to how procedural, cognitive, affective, or psychomotor competencies are distributed in a particular specialty's training, Polarity Management makes it possible for systems and individuals to adapt to the complex matching of clinical competency with the situational demands for it.

1. 
Santen
SA,
Hemphill
RR,
Pusic
M.
The responsibility of physicians to maintain competency
.
JAMA.
2020
;
323
(2)
:
117
-
118
.
2. 
Johnson
B.
Polarity management
.
Exec Develop
.
1993
;
6
(2)
:
1
-
5
.
3. 
Dreyfus
SE.
The five-stage model of adult skill acquisition
.
Bull Sci Tech Soc.
2004
;
24
(3)
:
177
-
181
.
4. 
Gallagher
AG.
Metric-based simulation training to proficiency in medical education: what it is and how to do it
.
Ulster Med J.
2012
;
81
(3)
:
107
-
113
.
6. 
Accreditation Council for Graduate Medical Education.
ACGME Program Requirements for Graduate Medical Education in Pediatrics.
7. 
Brydges
R,
Stroud
L,
Wong
BM,
Holmboe
ES,
Imrie
K,
Hatala
R.
Core competencies or a competent core? A scoping review and realist synthesis of invasive bedside procedural skills training in internal medicine
.
Acad Med.
2017
;
92
(11)
:
1632
-
1643
.
8. 
Kilbane
BJ,
Adler
MD,
Trainor
JL.
Pediatric residents' ability to perform a lumbar puncture: evaluation of an educational intervention
.
Pediatr Emerg Care
.
2010
;
26
(8)
:
558
-
562
.
9. 
McMillan
HJ,
Writer
H,
Moreau
KA,
et al
Lumbar puncture simulation in pediatric residency training: improving procedural competence and decreasing anxiety
.
BMC Med Educ.
2016
;
16
:
198
.
10. 
Pasternack
JR,
Dadiz
R,
McBeth
R,
et al
Qualitative study exploring implementation of a point-of-care competency-based lumbar puncture program across institutions
.
Acad Pediatr.
2016
;
16
(7)
:
621
-
629
.
11. 
Petroski
T,
Lawrence
L,
Qiao
H,
Wrotniak
BH.
Using low-cost models for training first-year pediatric residents on 4 Accreditation Council for Graduate Medical Education-required procedures
.
Pediatr Emerg Care
.
2020
;
36
(2)
:
87
-
91
.
12. 
Caverzagie
KJ,
Nousiainen
MT,
Ferguson
PC,
et al
Overarching challenges to the implementation of competency-based medical education
.
Med Teach
.
2017
;
39
(6)
:
588
-
593
.
13. 
Sawyer
T,
White
M,
Zaveri
P,
et al
Learn, see, practice, prove, do, maintain: an evidence-based pedagogical framework for procedural skill training in medicine
.
Acad Med.
2015
;
90
(8)
:
1025
-
1033
.
14. 
Mittiga
MR,
FitzGerald
MR,
Kerrey
BT.
A survey assessment of perceived importance and methods of maintenance of critical procedural skills in pediatric emergency medicine
.
Pediatr Emerg Care
.
2019
;
35
(8)
:
552
-
557
.
15. 
Williams
ES,
Halperin
JL,
Arrighi
JA,
et al
2016 ACC lifelong learning competencies for general cardiologists: a report of the ACC Competency Management Committee
.
J Am Coll Cardiol
.
2016
;
67
(22)
:
2656
-
2695
.
16. 
Ericsson
KA.
Acquisition and maintenance of medical expertise: a perspective from the expert-performance approach with deliberate practice
.
Acad Med.
2015
;
90
(11)
:
1471
-
1486
.
17. 
Hartman
JH,
Bena
JF,
Morrison
SL,
Albert
NM.
Effect of adding a pediatric vascular access team component to a pediatric peripheral vascular access algorithm
.
J Pediatr Health Care
.
2020
;
34
(1)
:
4
-
9
.
18. 
Gorgone
M,
McNichols
B,
Li
D,
Quill
C.
Resident-driven procedure team and speed of obtaining diagnostic paracentesis
.
Jt Comm J Qual Patient Saf.
2021
;
47
(2)
:
137
-
139
.
19. 
Krein
SL,
Kuhn
L,
Ratz
D,
Chopra
V.
Use of designated nurse PICC teams and CLABSI prevention practices among U.S. hospitals: a survey-based study
.
J Patient Saf.
2019
;
15
(4)
:
293
-
295
.
20. 
Johnson
B.
Reflections: a perspective on paradox and its application to modern management
.
J App Behav Sci.
2014
;
50
(2)
:
206
-
212
.
21. 
Johnson
B.
And: Making a Difference by Leveraging Polarity, Paradox or Dilemma. HRD Press;
2020
.
22. 
Holcombe
RF.
Improving health care quality: a polarity management perspective
.
Acad Med.
2015
;
90
(2)
:
259
.
23. 
Van Wyngaard
CJ,
Pretorius
JHC,
Pretorius
L.
Deliberating the triple constraint trade-offs as polarities to manage—a refreshed perspective. IEEE International Conference on Industrial Engineering and Engineering Management. Accessed October 13,
2022
.
24. 
Kinnear
B,
Warm
EJ.
Leadership & professional development: get to the “both/and.”
J Hosp Med.
2019
;
14
(12)
:
761
.
25. 
Wesorick
BL.
Polarity thinking: an essential skill for those leading interprofessional integration
.
J Interprof Healthcare
.
2014
;
1
(1)
:
12
.
26. 
Govaerts
MJB,
van der Vleuten
CPM,
Holmboe
ES.
Managing tensions in assessment: moving beyond either-or thinking
.
Med Educ.
2019
;
53
(1)
:
64
-
75
.
27. 
Ericsson
KA.
Necessity is the mother of invention
.
Acad Med.
2014
;
89
(1)
:
17
-
20
.
28. 
Wood
AM,
Jones
MD
Jr,
Wood
JH,
Pan
Z,
Parker
TA.
Neonatal resuscitation skills among pediatricians and family physicians: is residency training preparing for postresidency practice?
.
J Grad Med Educ.
2011
;
3
(4)
:
475
-
480
.