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Such qualities as British neurology may be said to have are the result of a system of training built not on theory but on decades of common practice. The minor obstacle of membership of the Royal College of Physicians aside, one became a neurologist when a sufficient number of senior neurologists decided one had become a neurologist. Neither the required standard nor the criteria for its application were made explicit; indeed, to ask what standard there could be but the opinion of a senior neurologist would have seemed absurd.
It is no longer so. These days the decision to award a neurology trainee the title of specialist (consultant) depends on the demonstrable acquisition of a set of so-called competencies.1 This notion relies on two simple premises: first, that clinical activity may be atomised into individual functions, and second, that each function may be characterised by the outcome of its application. A competency is established when the performance of a function is shown to be sufficient to guarantee a specified outcome, as determined by some kind of test instrument. Once the full set of competencies is achieved, the trainee becomes a specialist.
This idea represents a radical departure from the past and—given that there is no one but neurology specialists to determine what passes for competence—one that may drastically and irrevocably change the face of the profession forever. One would therefore have thought that the basis on which the change was justified had been rigorously examined and the potential consequences carefully considered. If so, then surprisingly little has been written on the subject; indeed, next to nothing by anyone unconnected with implementing the changes and therefore free of any vested interest. It therefore seems to me necessary to subject the proposals to a cool and disinterested analysis, at the level …
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