To recap: the triad of knowledge, skills, and performance is, I have suggested, a modern trivium, underpinned by a modern quadrivium—literacy, numeracy, oracy, and computeracy.
In its document Working with Doctors; Working for Patients, the General Medical Council defines performance extensionally, listing seven types of activities that it expects doctors to fulfil. Six are prefaced by “You must” and one by “You should”, defined as follows:
- “You must” is used for an overriding duty or principle.
- “You should” [prefaces] an explanation of how you will meet the overriding duty.
- “You should” is also used where the duty or principle will not [always] apply, or where . . . factors outside your control . . . affect whether or how you can follow the guidance.
The first point in the list includes the requirement that I “must” be competent as a manager and a researcher, activities that I would have thought should have been qualified with “may”, i.e. if appropriate. Otherwise, the list seems to me to be unexceptionable, even an instance of self-reference in the sixth point, which says, in effect, that it is the GMC’s guidance that you must follow its guidance, bringing to mind a self-referential drawing by M C Escher (picture).
The relevant definition of “performance” in the OED is “The quality of execution of . . . an action, operation, or process; the competence or effectiveness of a person or thing in performing an action; spec. the capabilities, productivity, or success of a machine, product, or person when measured against a standard.” So, in this sense, “performance” is equivalent to “competence . . . measured against a standard”, although it is not clear in medicine what that standard is or might be. The OED defines competence as “Sufficiency of qualification; capacity to deal adequately with a subject”. How much is sufficient is open to conjecture.
The IndoEuropean root PET meant to rush, leap, fall, or fly. “Feather” is a derivative, via Old Germanic. The god Hermes (Mercury) wore a winged hat, a petasus (Greek πέτασος; picture).
The Greek word for a feather was πτερόν and a wing πτέρυξ, as in pterodactyl and archaeopteryx, the flightless apteryx (the kiwi), and many winged creatures, such as the Aphaniptera (fleas), Cheiroptera (bats), Coleoptera (beetles), Dermoptera (lemurs), Dictyoptera (cockroaches and mantises), Ephemeroptera (mayflies), Hymenoptera (ants, bees, wasps), and Lepidoptera (butterflies and moths). Pteridology is the study of feathery ferns (Greek πτερίς). Aminopterin is the anticancer drug 4-aminopteroyl glutamic acid, a dihydrofolate reductase inhibitor and a derivative of pteroic acid, one of the pterins that give colour to butterfly wings.
Ptosis (Greek πτῶσις) is when something falls, as in proptosis and apoptosis. An asymptote to a curve (ἀσύμπτωτος, not falling together) meets its final target only at infinity. Greek πτῶμα, any misfortune that befalls us, gives us symptoms, which fall together, συμπίπτειν.
A suffixed form PET-NA gave Latin words pinna, a feather or a fin, like the pinna of the ear, and penna, a bird’s feather. Penne are pieces of feather shaped pasta and a pennon is a small flag, fancifully shaped like a feather. Pens for writing were once made from feathers.
The Latin word “petere” means to fall upon, attack, aim at, make for, pursue, strive after, sue for, solicit, ask, seek. It also has a rushing sense, as its root implies. Impetigo spreads rapidly. If it has enough impetus, and if its proponents are not too impetuous, a petition may succeed, especially if the time is propitious, which originally meant “rushing forward” and therefore “eager”, and so, typically of the gods, “well-disposed”.
“Competence” comes from competere (“cum” together + “petere”), to fall or come together, coincide, be convenient, fitting, due, or applicable. To compete in the 16th century meant to be suitable or applicable; this now obsolete meaning gives us “competence” and the more recent “competency”. Competitors, originally fellow seekers, still act together, but in rivalry.
Panache, from another form of the same root, was originally a plume of feathers worn on the pinnacle of a helmet, and one who wore such a plume might be considered to possess panache—elan, swagger, or flamboyance. Panache plays an important part in Edmond Rostand’s play Cyrano de Bergerac, in which “panache” is Cyrano’s dying word.
Perhaps when we perform competently we should also do so with panache.
Jeffrey Aronson is a clinical pharmacologist, working in the Centre for Evidence Based Medicine in Oxford’s Nuffield Department of Primary Care Health Sciences. He is also president emeritus of the British Pharmacological Society.
Competing interests: None declared.