Challenges and Solutions in Running Effective Clinical Competency Committees in the International Context

Diversity of Members and Expectations of Trainee Performance

Group decision-making forms the core of CCC meetings.¹³ The 3 main principles of group decision-making that shape CCC process are: (1) utilizing data from multiple assessment tools, (2) having a shared mental model around a competency framework, and (3) having structured discussions to reach a consensus regarding trainee performance.^9,13 It is the latter 2 principles that can pose specific challenges in the international context.

In many ACGME-I-accredited institutions, CCCs consist of faculty members from significantly diverse training backgrounds and health delivery systems, many of whom lack personal experience with a competency-based framework. This lack of experience or familiarity with CBME causes evaluators to rely heavily on their own training, and often shapes their expectations of residents and influences their views on assessments and evaluations, leading evaluators to compare residents against their personal standards and frame of reference, rather than against a standardized competency framework.¹⁴ These variations in cultural and training backgrounds can also influence how faculty rate and interpret assessment scores,¹⁵ impacting the accuracy of evaluations of resident competence.¹⁶ This variability may be compounded at the CCC level, where members assimilate aggregate data into a consensus assessment of resident performance.

Faculty-to-faculty communication affects CCC dynamics. A critical component of successful CCCs is the use of structured open dialogue to facilitate consensus among members.^9,13 Research has shown that communication styles differ across cultural contexts.²⁸ For example, many non-Western societies demonstrate a preference for collectivistic communication styles, which avoid disagreement and favor harmonious group relations.²⁸ Diversity in culture also affects assumptions about CCC purpose and how the group's decisions are used to judge trainee performance. In Hofstede's cultural dimensions theory,²⁹ Asian and Middle Eastern countries have a tightly integrated collectivist society. CCC members in some Eastern cultures may, therefore, be less inclined to participate in the sharing of unknown information, open discourse, or voicing unpopular opinions for fear of disrupting the group's harmony or concerns about potentially provoking offense from peers. Another important factor influencing CCC dynamics is the hierarchical structures of some Eastern cultures, which place a high value on professional position and social status. This might impede junior faculty members' ability to openly voice their opinions, speak out of turn, or openly disagree with senior faculty opinions.³⁰

Feedback to Residents

The effectiveness of CCC decisions is closely related to the ability to inform resident performance through effective feedback. These conversations can be complicated if the feedback provider and recipient do not have a shared understanding of the goals of feedback. This challenge is compounded in the international arena where sociocultural factors play an important role and can significantly affect the provision and receipt of feedback.³¹ In some countries, faculty may be uncomfortable or unwilling to engage in feedback conversations, as they can be challenging. This is especially true when negative feedback is involved, as there is a fear of offending the trainee, leading to rejection of feedback and subsequent damage to the educator-learner relationship.^27,31 Conversely, while praise can motivate and reinforce positive behaviors, it may not be given, reflecting a cultural stance of excellence as a minimal expectation.³² In some societies, feedback, irrespective of type, is often taken personally.³² While this may be a universal challenge, it is especially significant in Eastern cultures, where the distinction between professional and personal attributes is often blurred.^3,4 These dynamics often result in fear of giving, seeking, and receiving feedback.

Another significant cultural construct affecting feedback in Eastern (particularly Asian) cultures is modesty.³² Individuals who speak highly of themselves and their achievements may be seen as arrogant, self-promoting, or grandiose. As such, during self-assessment of Milestones or self-reflection for CCCs, residents are often observed to rank themselves lower than expected, with a tendency to focus on areas for improvement while downplaying strengths. They may also avoid seeking feedback for fear of appearing to seek praise.²⁷