Neel Sharma: Doctors need standardised training in non technical skills

Competency Based Medical Education (CBME) forms the backbone of the teaching and assessment of students and doctors in training. However, limitations have been described including the fact that there are endless lists of required abilities, there are logistical issues where trainees progress at their own rate, there can be a lack of mentoring, and there is an over emphasis on milestones as opposed to excellence. Teaching modules that may not directly contribute to outcomes are sometimes cut out and there is a need for excessive resources and technologies (Frank et al, 2010).

There are now calls for curricula to focus on Entrustable Professional Activities (EPAs) which in essence are units of professional practice that can be fully entrusted to a trainee once they have demonstrated the necessary competence to execute a particular activity unsupervised (Ten Cate et al, 2015). This move away from CBME is based on an understanding that competencies are often too theoretical to assess validly. EPAs serve as a more integrated holistic evaluation and incorporate the specific skills as well as trustworthiness of a trainee (Ten Cate et al, 2015).

Greig at el undertook a recent study focusing on the lack of standardization for human factors content in postgraduate training curricula (Greig, Higham, & Vaux, 2015). They emphasized the importance of nontechnical skills such as leadership, decision making, team working, and resource management during training, and highlight that a significant proportion of errors are based on failures of nontechnical skills as opposed to just knowledge and technical errors. The curricula of medical, surgical and critical care specialties were analyzed for non-technical skills, situational awareness, and human factors, as well as additional terms under the headings: task management, team working, and decision making. The authors concluded that non-technical skill terms occurred infrequently on the whole with the main occurrences appearing in critical care specialties. These specialties were in addition the only ones that specified requirements for formal training in nontechnical skills. Overall non critical care specialties lacked specific details on learning objectives.

Utilizing the exact search strategy as employed by Greig et al I undertook my own analysis of the Core Entrustable Professional Activities for the Entering Residency guide as per the AAMC (AAMC, 2014). Based on my own observations, under the domain teamwork the following terms do not exist: assertiveness and authority. Under the domain situational awareness the following terms do not exist detect, vigilance and watch, under the domain decision making the following terms do not exist: option and reevaluate (evaluate however does appear), and under the domain core terms: human factors and simulation do not exist.

Greig et al highlighted that nontechnical skills training has an impact on patient safety in a wide range of clinical domains, but nontechnical skills based learning objectives rarely feature outside critical care specialties. They argue that curricula in general are designed with the assumption that nontechnical skills will be acquired in a non-formalized fashion and call for nontechnical skills to feature explicitly in all curricula.

As yet there is no evidence from fully developed EPA based workplace curricula with recommendations derived from deliberations among expert educators (Ten Cate et al, 2015). Further evaluation is therefore needed to ensure nontechnical skills are incorporated accordingly.

See also: BMJ Careers: Training in human factors needs to be standardised


AAMC. (2014). Core Entrustable Professional Activities for Entering Residency.

Frank JR, Snell LS, Cate OT, Holmboe ES, Carraccio C, Swing SR, et al (2010). Competency-based medical education: theory to practice. Med Teach, 32(8), 638-645. doi: 10.3109/0142159x.2010.501190.

Greig PR, Higham H, & Vaux E. (2015). Lack of standardisation between specialties for human factors content in postgraduate training: an analysis of specialty curricula in the UK. BMJ Quality & Safety. doi: 10.1136/bmjqs-2014-003684.

Cate OT, Chen HC, Hoff RG, Peters H, Bok H, & van der Schaaf M. (2015). Curriculum development for the workplace using Entrustable Professional Activities (EPAs): AMEE Guide No. 99. Med Teach, 1-20. doi: 10.3109/0142159x.2015.1060308.

Neel Sharma graduated from the University of Manchester and did his internal medicine training at The Royal London Hospital and Guy’s and St Thomas’ NHS Foundation Trust. Currently he is a gastroenterology trainee based in Singapore.

Competing interests: None declared.

  • JR

    Hi Dr Sharma,

    I’m currently a simulation fellow. I work at SHO level when I’m on the wards.

    I’ve been devising a simulation training programme for SHO-level medical trainees in my trust.

    My feedback from medical registrars is that human factors is over-emphasised in simulation training for medics. This is because medics aren’t closely supervised on the wards, so they relish feedback on their technical skills when it’s given.

    This is in contrast to critical care specialties, where they are heavily supervised by senior doctors in their training. They receive adequate feedback on their technical skills in real-life practice – simulation then becomes an arena to explore human factors.