My last critique on competence-based models comes from my understanding of the nature of the medical profession and its relationship with society. This relationship has been referred to as a ‘social contract’, meaning that society grants the medical profession the privilege of self-regulation, as long as physicians make patients’ interests their first priority, demonstrate integrity, morality and their commitment to excellence [11
]. The privilege of self-regulation boils down to the profession defining and monitoring its own quality standards, educating and training future peers, and regulating entrance to and removal from the profession. In theories on the professions and professionalism, doctors deserve this self-regulating authority based on their unique body of knowledge, the complexity of professional practice and their dedication to serving patients’ interests, as laid down in the Hippocratic oath. If executed well, the self-regulating role of the medical profession may best assure the quality of patient care, and protect patients from too much influence of governmental and market powers (commercialism) [12
]. If the medical profession has to give in to its privileges, this can be seen as a process of de
professionalization. Instead of defining and controlling patient care, doctors than, in ultimo, become the executers of care which may be designed or prescribed by layman. We have witnessed this deprofessionalization process over the past decades, when third-party payers, hospital managers, quality experts and patient safety professionals gained substantial grounds in the medical profession. Consequently, physicians have been confronted with redesigned patient care processes, told to comply with new quality and safety standards and protocols, and made to measure and register their interactions in detail. Indeed, they have lost some self-steering power. In this line of thinking, educationalists may be seen as the next group of experts to enter the medical profession. By pushing competence models—a new logic
—and life-long competence-based education—indeed a new practice
—the medical profession’s self-regulating practices and privileges may slowly be further trimmed down. Competence-based models thus fuel the process of de
professionalization. Before positioning non-doctors to take control over another part of medical practice as we know it today, society deserves to first see the evidence of the superior idea of competence-based education. If I were a physician I would want to see this evidence in terms of improved patient outcomes.