The problem is that a professional practice like medicine is not simply the ability to perform a collection of technical procedures. Medicine is not just a collection of competencies. The professional practice of medicine is so much more. It includes the values underpinning a profession. These values include professionalism, criticality, reflexivity, ethicality, and more. But even these values are frequently mis-described as competencies. This is to distort their nature. We want medical graduates who not only know about these values but who have made these values their own. We want graduates who embody these values . These values inform everything they do. They are not technical skills to be marked off on a checklist. We need to go beyond competency-based thinking and there are well-established options for doing so. Entrustable Professional Activities (EPAs) have been devised as a way to go beyond competencies.
The advantage of EPAs is that they do have more of a practice focus, on the work to be done, whereas competencies can be seen as more abstract and generalized . Unfortunately, the ways in which EPAs are articulated frequently reveal that instrumental thinking is still dominant. EPAs may be a step in the right direction, but we need more insightful ways to articulate the professional practice of medicine (and medical education). Fish  has spoken of competence, as in the overall competence of a professional practitioner. Like professionalism, competence in this sense is always singular. Competence is a holistic notion and can include competencies. We can speak of someone who is a wholly competent doctor meaning someone who can “conduct him/herself and his/her work in different ways on different occasions according to what the situation demands (thus engaging in sound thinking) and being a good doctor as well as having the required skills and knowledge”  (p. 128 emphasis in original). This accepts the need for technical proficiency but goes much further. There is emphasis on the clinical judgment required in practice and the need for dealing with complexity and uncertainty. A major implication of all this is the urgent requirement to rethink our assessments, especially in the clinical years. The mention of being a good doctor also brings out an aspect of medical education that is frequently ignored. It is ignored because the competency-based approach does not have the vocabulary to deal with it.
Barnett and Coate  have spoken of the three axes of higher education, and this includes professional education, such as medical education. The three axes are knowing, doing, and being. Most educators have no problem with knowing and doing but avoid the third item, being. As noted, just above, our education should aim to produce doctors who are professional, critical, ethical, etc. These values are qualities of being. So how can we talk about values sensibly in educational terms that avoid the contortions and distortions of the competency-based approach? The first thing is to be honest and admit that this is not easy. In addition to epistemological approaches that focus on what doctors know, we need ontological approaches that focus on what doctors are. Luckily, there are discourses and vocabularies that can open up our thinking in these ways that come from the humanities and social sciences. For example, neo-Aristotelianism is exciting growing interest [e.g., 9]. This school of thought places emphasis on phronesis, defined as the disposition to act wisely. Phronesis cannot be taught, but we can provide opportunities for our students to develop it by allowing them to have practice experiences that challenge and stretch them, where conventional textbook knowledge is not enough, where the technical procedures they have learned may not go quite according to plan.
Taking our earlier example of a colonoscopy, if a learner is experiencing difficulty, then the teacher can help the learner think through the reasons why this might be, the other options that may be open, and help the learner to make a wise judgment about the best course of action, with the learner fully understanding the principles used to make the decision. This more thoughtful approach predisposes learners to develop practice wisdom. This is a disposition to make good decisions based on their ability to learn reflectively from their own past experiences and to integrate this reflective knowledge with the best available evidence and become better doctors. This practice wisdom is a large part of what makes up the holistic competence referred to earlier. It is the capacity to cope with the uncertainties, the complexities, and the ambiguities that make up so much of medical practice. Ideas such as phronesis and practice wisdom can further our thinking about medical education that go beyond the ideas of the competency-based approach. But there are other dangers of a purely competency-based approach.
Competencies are closely related to the managerialism that has come to dominate so much of higher education. In an age of the so-called massification of higher education where universities are being expected to “turn out” larger numbers of new graduates with the same resources and numbers of faculty and staff as we have in the past, then this poses a serious problem. This may be why managerialism and the competency-based approach are so popular. They provide a false promise of generating new professionals at a low cost. This is a current and future trend that engages, and will continue to engage, and challenge medical educators for some years to come. To provide our students with the opportunities to start developing practice wisdom and become the professionals we want them to be, then we need to interact closely with them, especially in the clinical years. We need to be role models and mentors for them. Role modeling and mentoring are intensive and demanding, and they need low faculty/student ratios as well as educators who know how to be good mentors and role models. As educators, we need to accept this and stand up for this position. There can be no low cost road to becoming a true professional, especially in the health professions.
If we really want to improve medical education, then we need much more interdisciplinary thinking where we can integrate behaviorist ideas such as competencies with ideas from other disciplines such as the humanities and social sciences. This is because medicine (and medical education) is a professional practice demanding a sophisticated and nuanced integration of scientific knowledge and technical procedures with the uncertainties of the real world where small changes in context can require big changes in practice. There is a growing interdisciplinary literature on professional practice and practice-based education that is now exploring these issues [e.g., 4].