Promoting Sustainability-Oriented Medical Education: Development of a Competency Model for Physicians Specializing in Laser and Energy-Based Device Therapy

Abstract

Laser- and energy-based device (EBD) treatments in aesthetic medicine pose substantial environmental challenges, including high energy consumption, carbon emissions, and disposable medical waste. Although sustainable healthcare has gained global attention, no competency framework currently exists to guide physicians in integrating environmental sustainability into aesthetic medicine. This study applied McClelland’s (1973) Competency Model Theory (CMT) to develop a sustainability-oriented competency model for physicians specializing in laser and EBD treatments. Using a mixed-methods design, competency-based interviews were conducted to identify the key tasks and sustainability-related competencies, followed by expert panel validation using content validity and Kendall’s coefficient of concordance. The final model consists of 33 competencies across six domains: sustainable operations, regulatory and ethical knowledge, physician patient communication, dermatological science, EBD techniques, and maintenance care. Experts rated most competencies as highly or very highly important and frequently used, and Kendall’s W confirmed significant consensus across domains. The model provides standardized competency benchmarks that can support future curriculum development, professional training, and sustainable healthcare governance. This study extends CMT into the field of environmental sustainability in medicine and offers a structured framework to reduce ecological footprints and promote low-carbon, socially accountable practices.

1. Introduction

The Global Green and Healthy Hospitals (GGHH) network, launched by Health Care Without Harm (HCWH), currently includes more than 70,000 hospitals and medical centers worldwide. Within this network, HCWH’s International Strategic Plan 2024–2028 reported that over 700 hospitals have formally pledged to implement sustainability initiatives [1]. The Sustainable Development Goals (SDGs) are increasingly applied in healthcare systems as guiding indicators, and the World Health Organization (WHO) has urged healthcare institutions to actively reduce emissions and build climate-resilient systems [2]. Nevertheless, no healthcare system has yet achieved full climate resilience, hindered by gaps in sustainability-related training, workforce shortages, and limited institutional capacity [3].

In response to these global efforts, Taiwan enacted the Climate Change Response Act in 2023 [4]. and launched a nationwide hospital carbon inventory program the following year [5,6]. Studies indicate that nearly 70% of healthcare-related emissions originate from supply chains and staff commutes [7,8]. However, aesthetic medicine, particularly energy-intensive laser- and energy-based device (EBD) treatments, remains largely absent from sustainability policies, despite challenges such as high carbon emissions, disposable waste, and refrigerant use [9]. Current training programs seldom integrate low-carbon clinical practices [10]. Moreover, Taiwan lacks competency standards specific to aesthetic medicine. The Workforce Development Agency has issued benchmarks only for non-medical occupations, such as massage or home care, while the Ministry of Health and Welfare (MOHW) does not formally recognize aesthetic medicine as a medical specialty [11,12]. This regulatory and educational gap highlights the absence of structured and sustainability-oriented competencies for physicians specializing in laser and EBD treatments.

Healthcare education increasingly adopts Competency-Based Medical Education (CBME) as its prevailing model. Recent scoping and systematic reviews have mapped its implementation and evaluation across specialties [13,14]. Canada’s large-scale Competence by Design reform has demonstrated the transformative potential of CBME in postgraduate education [15]. In addition, newer competency frameworks have begun to incorporate domains such as health equity [16]. Nevertheless, environmental sustainability and specialty-specific competency standards remain underdeveloped. In aesthetic medicine, existing studies have primarily focused on documenting the risks and complications of laser and EBD practice; however, no comprehensive competency model has yet been developed to integrate sustainability into clinical decision-making, underscoring the urgent need for a structured and sustainability-oriented framework in this field [17].

The Competency Model Theory (CMT), proposed by McClelland in 1973, provides an ideal framework for addressing this gap. Unlike traditional approaches based on intelligence testing, CMT emphasizes observable behaviors of high-performing individuals, offering an integrated model of knowledge, skills, and attitudes [18]. The CMT has been widely applied in healthcare to design recruitment strategies [19]. It is also used in hospital administration to measure competency improvements before and after the implementation of training programs and to assess their impact on managerial performance [20]. Spanish researchers have developed digital CMT models based on the information use habits of medical professionals to enhance training outcomes [21]. Such models offer quantifiable and standardized competency indicators, which are essential for improving both training quality and patient care [22].

As global sustainability standards tighten, aesthetic medicine professionals require competency frameworks that align with international goals. However, no validated sustainability-oriented competency model currently exists for physicians specializing in aesthetic medicine laser and EBD treatments. To bridge this gap, the present study applied McClelland’s CMT with a mixed-methods design to construct and validate a comprehensive framework. The proposed model integrates clinical expertise with low-carbon practices and environmentally responsible operations. This framework aims to raise professional standards and serve as a reference for educational institutions in curriculum design, professional training, and the cultivation of sustainable talent, ensuring that aesthetic medicine advances toward both clinical excellence and environmental accountability.

2. Current Study

2.1. Global Context and Challenges in Developing Sustainability Competencies in Healthcare

Carbon emissions from the healthcare sector represent a substantial share of global greenhouse gas emissions. The healthcare sector would rank as the fifth-largest emitter worldwide if considered a country. As major consumers of energy, healthcare systems exert significant environmental pressure, which must no longer be overlooked [1,23]. Poor facility design, inefficient equipment usage, and inadequate management contribute to environmental harm that directly affects both healthcare professionals and the communities they serve [24]. Additionally, the medical manufacturing industry produces products such as topical ointments, aerosol formulations, single-use plastics, and other materials that contain ecotoxic compounds, generating increasing concern about their impact on ecosystems and the climate [25]. Thus, the healthcare industry faces not only external scrutiny over its environmental impact, but also the internal necessity of transforming institutional structures and redefining professional competencies in alignment with global sustainability imperatives.

The SDGs encompass 17 interlinked global targets designed to promote peace, prosperity, and planetary health, calling for collective action by all nations [26]. McCormack et al. (2024) highlighted the urgent need for healthcare professionals to enhance their awareness of climate-related health risks, particularly for fulfilling SDG 3: “Good health and well-being” [27]. Numerous SDG indicators are both directly and indirectly connected to the development of climate-resilient and environmentally sustainable healthcare systems [28]. For example, Mulligan’s empirical research in dentistry illustrates how clinical decisions between single-use and reusable materials relate to SDG 12: “Responsible consumption and production.” Hospitals are sites of high-intensity material and energy consumption; mismanagement of such resources presents a critical barrier to achieving SDG 12 [29].

In response, many medical education systems are integrating content on climate-related disease into their core curricula and promoting green prescribing practices aligned with SDG 13: “Climate action” [30]. Equipping healthcare professionals to act as climate advocates in clinical and policy settings requires that they understand the environmental and social determinants of disease, contribute to the design of resilient healthcare systems, and support proactive prevention strategies [31].

In the face of escalating environmental and climate risks, healthcare systems must not only revise their operational models and resource management strategies but also undergo a transformation in education and professional competency development. Only by equipping healthcare workers with sustainability-oriented competencies can the global health workforce effectively respond to the call for action set forth by the SDGs.

2.2. Sustainable Development in Aesthetic Medicine Laser and EBD Practices

The above studies have found that there are still many sustainable governance and competency models in professional fields that have not yet been included in the overall policy blueprint and research discussions, especially in the field of aesthetic medicine, which is mainly self-funded. Aesthetic medicine not only covers the traditional medical professional fields of dermatology and plastic surgery but also involves new technologies, such as laser- and energy-based device treatments and injection techniques, with the global market projected to grow by around 7% annually between 2024 and 2029 [32]. In the framework of sustainable development, the environmental footprint of aesthetic medicine treatment mainly derives from written patient information, waste management, and drug use. It is also necessary to take carbon reduction measures and make good use of artificial intelligence (AI)-driven optimization technology to reduce energy consumption. Physicians need to have a deep understanding of the impact of their diagnosis and treatment behaviors on the environment [33,34].

Laser and EBD treatments are transitioning from being purely clinically driven to being guided by sustainability principles, placing new demands on professional competency definitions. In response, some laser and EBD manufacturers have introduced eco-conscious device designs and materials, including reusable packaging, minimally invasive tools, and waste reduction protocols, revealing future opportunities for alternative energy integration and biocompatible innovation [35,36].

However, in current clinical practice, these green innovations have yet to be widely implemented within the context of laser and EBD treatments. There remains a heavy reliance on single-use consumables, and the adoption of sustainable alternatives or materials largely depends on institutional culture or individual physician awareness [37,38]. In other words, physicians lack standardized operational guidelines and institutionalized training frameworks for key sustainability-related competencies, such as “sustainable consumables selection,” “equipment environmental impact assessment,” and “low-carbon treatment design.” As a result, implementation often remains at the theoretical or supply chain level and is rarely internalized into routine clinical competency practices. Developing these competencies not only supports physicians in achieving therapeutic outcomes but also enhances their accountability regarding their environmental and social responsibilities.

2.3. Summary of the Literature and Positioning of the Current Study

In 2024, the Joint Council for Cosmetic Practitioners (JCCP) and the Cosmetic Practice Standards Authority (CPSA) jointly issued a code of practice titled Public Narrative, aimed at ensuring the safe, legal, and ethical use of products, equipment, and drugs in the provision of aesthetic medicine treatments. The document also encourages institutions and professionals to meet established professional competencies and standards [39]. However, its content primarily centers on the qualifications, training, clinical safety, and regulatory supervision of cosmetic practitioners. It does not incorporate sustainability-related competencies such as the selection of sustainable consumables, environmental impact assessments of equipment, or low-carbon treatment planning. It does not incorporate sustainability-related competencies, leaving a critical institutional and educational gap.

A similar regulatory and professional gap persists within the aesthetic medicine sector in Taiwan. Due to rising market demand and the absence of clear regulations, many specialists enter the aesthetic medicine field without formal training, which elevates the risks associated with clinical practice [40].

Patient health and safety remain fundamental to aesthetic medicine. Accordingly, qualification standards require all practitioners to hold relevant specialist certifications and complete professional training to ensure they have the competencies necessary to deliver safe and effective care [41]. Within the broader framework of sustainable development, aesthetic medicine institutions are expected to adopt carbon reduction strategies, promote circular economy principles, and integrate environmentally friendly technologies to advance sustainability goals [42]. In response, Taiwan’s National Development Council has conducted a survey on strategic talent development for precision health and proposed the establishment of competency-based occupational standards across the healthcare industry as a key initiative to clarify the competencies required for practitioners and to enhance talent cultivation and workforce readiness [43].

Looking at the current clinical practice and institutional status of aesthetic medicine laser and EBD treatments, it can be seen that sustainable development has not been systematically integrated into the professional training and competency model in this field. Related sustainable behaviors are mostly driven by the culture of individual institutions or physician autonomy, while consistent behavioral norms and competency-building models are lacking. Faced with the global wave of sustainable medical transformation, a key challenge in bridging the current gap between theory and practice is to clearly define the sustainability-related skills required of physicians specializing in laser and EBD treatments and to construct a competency model with professional consensus.

This present study therefore applied the CMT and adopted a mixed-methods design to construct a competency model for physicians specializing in aesthetic medicine laser and EBD treatments (hereafter, the L&EBD Competency Model) that integrates the sustainable development perspective. The following three main research questions were posed to respond to this institutional gap and practice discrepancy so as to provide a feasible basis for subsequent policy-planning and education and training:

RQ1: What sustainability-related competencies should physicians possess in current clinical practices involving aesthetic medicine laser and EBD treatments?

RQ2: Can expert consensus be achieved on the L&EBD Competency Model constructed using McClelland’s CMT?

RQ3: Is there agreement among experts regarding the appropriateness and completeness of the proposed competency model?

3. Methodology

3.1. Participants

Since Taiwan currently lacks a formal specialist certification system for aesthetic medicine, physicians must independently pursue relevant training and education. The Chinese Society of Cosmetic Surgery and Anti-Aging Medicine (CSCSM), established by clinical physicians committed to aesthetic medicine education [44], is one of the certification bodies officially recognized by the MOHW under its aesthetic medicine training division [45]. Having been established for over three decades and with a membership in the thousands, the CSCSM is significantly representative within the field. Therefore, this study selected CSCSM member physicians as the primary research participants.

To enhance sample representativeness, a purposive sampling strategy was employed. Participants were required to have more than ten years of clinical experience in aesthetic medicine and at least five years of hands-on experience specifically in laser and EBD treatments. This criterion was based on the standards for professional competency development, including training duration and career maturity. As noted by Winter and Hibble, healthcare professionals typically require three to five years of intensive training to deliver high-quality care [46].

To further ensure the authenticity and representativeness of the competency framework, data were collected from benchmark-level industry experts recognized as leaders in the field. The CSCSM, as the most authoritative professional organization in Taiwan’s aesthetic medicine sector, identified and invited these experts to participate in the competency modeling process. This approach enhanced both the quality and industry recognition of the resulting model and aligns with best practices in competency modeling, which emphasize the involvement of benchmark-level subject matter experts through structured interviews and expert consensus [47].

All participants were certified by the CSCSM as qualified experts and voluntarily joined competency-based interviews, panel meetings, and surveys. Informed consent was obtained, and participants were fully briefed on the study’s purpose, procedures, confidentiality measures, and their right to withdraw at any time without consequence. In the development of the competency model stage, there was no educational intervention, clinical trial, biological sampling, or collection of identifiable health information. All data were anonymized to ensure privacy and ethical compliance.

3.2. Research Method

This study is grounded in McClelland’s CMT, which emphasizes deriving observable knowledge, skills, and attitudes from actual job performance. A mixed-methods design was employed, integrating both qualitative and quantitative approaches to ensure methodological rigor and validity.

In the qualitative phase, the Competency-Based Interviews (CBIs) method was used to guide participants in recalling real clinical experiences and critical incidents. These narratives provided behavioral evidence that was systematically coded and inductively organized into preliminary competency indicators [48]. To enhance conceptual generalization, the five-level abstraction ladder was applied to progressively transform clinical experiences into competency indicators, thereby forming the foundation of a preliminary competency model for physicians specializing in aesthetic medicine laser- and energy-based device (EBD) treatments [49,50].

In the quantitative phase, content validity was examined through a two-stage expert review. The first panel meeting ensured that the competency items aligned with clinical practice, while the second involved a structured survey using a five-point Likert scale. Mean scores (μ) were calculated as indicators of central tendency, and Kendall’s coefficient of concordance (W) was employed to evaluate the degree of expert consensus.

Through a triangulated design integrating CBIs, expert panel reviews, and quantitative analysis, this study ensured that the competency model development process maintained methodological rigor and professional consensus, while strengthening both the internal validity and external applicability of the results.

3.2.1. Competency-Based Interviews (CBIs)

The first phase of this study employed CBIs, guided by the framework of McClelland’s CMT. The interview design focused on the actual clinical performance of physicians specializing in aesthetic medicine laser and EBD treatments and encompassed clinical application scenarios, job responsibilities, required professional competencies, and existing gaps. These interviews served as an empirical foundation for identifying and categorizing relevant competencies.

The structured interview protocol included questions such as “Can you describe the complete process of Aesthetic Medicine Laser and EBD treatment, from initial consultation to completion?” “What specific tasks are physicians responsible for at each stage of this process?” “For novice physicians specializing in Aesthetic Medicine Laser and EBD treatment, what additional professional knowledge or skills would be necessary to perform these tasks effectively?”, and “When executing these responsibilities, what knowledge and skills are required for operating specific instruments, facilities, equipment, or software, particularly those relevant to sustainable development?”

To ensure semantic clarity and contextual appropriateness, the interview guide was reviewed by two physicians with over ten years of clinical and instructional experience in laser and EBD treatment. Refinements were made based on their feedback to enhance clarity, accuracy, and relevance.

In this phase, a total of six physicians, four male and two female, were interviewed individually for approximately 1.5 h each. The data collected included interview transcripts, observational notes, and supporting documents [51,52]. These were coded and organized to extract key competencies.

3.2.2. Panel Meeting

To verify the content validity of the draft competency model [53], a first-round panel meeting was convened with a group of domain experts containing a total of seven experts (four males and three females). All participants had more than ten years of clinical and educational experience in aesthetic medicine, particularly in laser and EBD treatments. They were invited as clinical physicians and senior educators in the field. During this round, the experts evaluated the core competencies identified in the CBIs phase, refining descriptions, clarifying classifications, and ensuring logical consistency and practical relevance. The initial draft served as the basis for discussion, leading to the first version of the model.

In the second round, eleven domain experts (nine males and two females) participated. This group included seniors with experience in aesthetic medicine, particularly in laser and EBD treatments, as well as expertise in regulatory affairs from governmental agencies, each with more than ten years of relevant experience. This round aimed to verify expert consensus on the revised competency model and to incorporate perspectives from both clinical and regulatory domains.

In the second round, experts participated in a structured evaluation. A questionnaire was designed based on the competencies identified through CBIs and refined in the first-round panel meeting. The instrument adopted a five-point Likert scale across three dimensions—importance, frequency of use, and level of difficulty—with response options ranging from 1 (very low) to 5 (very high). Each item also included a section for open-ended feedback, and space for general comments.

The collected responses underwent statistical analysis to assess internal consistency. Expert opinions would be examined to determine conceptual alignment [54]. The mean score (μ) was selected as the primary measure of central tendency, given its lower susceptibility to variability compared to other indicators [55]. In addition, Kendall’s coefficient of concordance (W) was designated to evaluate the degree of agreement among experts, thereby ensuring that the competency indicators could be tested for both content validity and professional consensus.

4. Results

This study verified the content validity of the CBIs findings and the outcomes of the first panel meeting, culminating in the development of the competency model for physicians specializing in aesthetic medicine laser and EBD treatments. This model delineates three primary job responsibilities: T1—conduct clinical assessments and propose treatment plans; T2—perform laser and EBD treatments; and T3—track treatment results. These responsibilities were further operationalized into eight work tasks: T1 includes three tasks related to pre-treatment diagnosis and treatment planning; T2 comprises three tasks corresponding to pre-, intra-, and post-procedural care; and T3 involves two tasks related to post-treatment outcome monitoring and follow-up.

The 8 tasks are broken down into 28 behavioral indicators, 2 work outputs, 24 knowledge competencies, and 9 skill competencies. Competencies aligned with the SDGs encompass six key themes: sustainability characteristics in aesthetic medicine industry operations, treatment programs (including medical sustainability), and instrument features and treatment principles (including carbon footprint and environmental standards). The knowledge and skill competencies were further categorized into six core competency domains: (1) sustainable operations analysis and industry trends, (2) regulatory and medical ethics, (3) physician–patient consultation and communication, (4) foundational dermatological science, (5) laser and EBD treatment techniques, and (6) cosmeceutical and maintenance knowledge.

4.1. Competency Rating by Domain Experts

The second panel meeting employed a structured questionnaire to evaluate the consistency among eleven domain experts in interpreting the sustainable development competency model for physicians specializing in aesthetic medicine laser and EBD treatments. The instrument assessed 33 sustainability-oriented competencies across three dimensions—importance, frequency of use, and level of difficulty—using a 5-point Likert scale.

To interpret the responses, the mean score (μ), was calculated for each item and classified into discrimination intervals.

Table 1. Classification criteria for degree discrimination intervals based on mean scores.

Interval	Importance	Frequency of Use	Difficulty
μ > 4.5	Highly important	Very high frequency of use	Very high difficulty
3.5 < μ ≦ 4.5	High importance	High frequency of use	High difficulty
2.5 < μ ≦ 3.5	Medium importance	Medium frequency of use	Medium difficulty
1.5 < μ ≦ 2.5	Low importance	Low frequency of use	Low difficulty
μ ≦ 1.5	Very low importance	Very low frequency of use	Very low difficulty

presents the classification criteria, where values of μ ≤ 1.5 indicates “very low,” whereas μ > 4.5 indicates “very high”.

Descriptive statistics, including mean scores, were computed to analyze the responses (see

Table 2. Descriptive statistics and degree discrimination of competency indicators in sustainable aesthetic medicine.

Competence Indicator	Frequency Distribution of Likert Scale					Mean Score	Classified of Degree
	5	4	3	2	1
1. Sustainable operations analysis and industry trends
1.1 K01 Sustainability Principles in Aesthetic Medicine Industry Operations
Importance	2	6	3	0	0	3.91	High
Frequency of use	6	3	1	1	0	4.27	High
Difficulty	5	5	1	0	0	4.36	High
1.2 K02 Aesthetics
Importance	7	4	0	0	0	4.64	Very high
Frequency of use	5	4	2	0	0	4.27	High
Difficulty	0	8	3	0	0	3.73	High
1.3 K03 Beauty Trends and ESG Developments
Importance	7	4	0	0	0	4.64	Very high
Frequency of use	3	7	1	0	0	4.18	High
Difficulty	8	3	0	0	0	4.73	Very high
2. Regulatory and medical ethics
2.1 K18 Medical Regulations and Risk Prevention Knowledge
Importance	10	1	0	0	0	4.91	Very high
Frequency of use	6	4	1	0	0	4.45	Very high
Difficulty	4	7	0	0	0	4.36	High
2.2 K19 Treatment Consent Form Content
Importance	5	6	0	0	0	4.45	Very high
Frequency of use	1	10	0	0	0	4.09	High
Difficulty	1	6	4	0	0	3.73	High
2.3 K21 Medical Ethics in Aesthetic Medicine
Importance	8	3	0	0	0	4.73	Very high
Frequency of use	9	2	0	0	0	4.82	Very high
Difficulty	3	8	0	0	0	4.27	High
3. Aesthetic Medicine physician patient consultation and communication
3.1 K04 Physician–Patient Relationship and Consultation
Importance	6	5	0	0	0	4.55	Very high
Frequency of use	1	5	5	0	0	3.64	High
Difficulty	7	4	0	0	0	4.64	Very high
3.2 K11 Medical Record-Writing SOAP
Importance	3	7	1	0	0	4.18	High
Frequency of use	5	6	0	0	0	4.45	High
Difficulty	5	6	0	0	0	4.45	High
3.3 S01 Listen Correctly
Importance	9	2	0	0	0	4.82	Very high
Frequency of use	4	7	0	0	0	4.36	High
Difficulty	4	7	0	0	0	4.36	High
3.4 S02 Communication
Importance	6	5	0	0	0	4.55	Very high
Frequency of use	4	7	0	0	0	4.36	High
Difficulty	8	3	0	0	0	4.73	Very high
3.5 S05 Express Persuasion
Importance	5	6	0	0	0	4.45	High
Frequency of use	6	5	0	0	0	4.55	Very high
Difficulty	4	7	0	0	0	4.36	High
3.6 S08 Patient Orientation
Importance	7	4	0	0	0	4.64	Very high
Frequency of use	6	5	0	0	0	4.55	Very high
Difficulty	4	7	0	0	0	4.36	High
4. Foundational dermatological science
4.1 K05 Dermatopathology in Aesthetic Medicine
Importance	6	5	0	0	0	4.55	Very high
Frequency of use	5	3	3	0	0	4.18	High
Difficulty	4	7	0	0	0	4.36	High
4.2 K06 Skin Physiology
Importance	5	6	0	0	0	4.45	High
Frequency of use	1	7	2	1	0	3.73	High
Difficulty	3	4	4	0	0	3.91	High
4.3 K07 Skin Characteristics and Common Aesthetic Medicine Issues
Importance	7	4	0	0	0	4.64	Very high
Frequency of use	2	6	3	0	0	3.91	High
Difficulty	7	4	0	0	0	4.64	Very high
4.4 K08 Tissue Anatomy
Importance	3	6	2	0	0	4.09	High
Frequency of use	3	6	2	0	0	4.09	High
Difficulty	5	5	1	0	0	4.36	High
4.5 K09 Anatomy and Physiology
Importance	4	6	1	0	0	4.27	High
Frequency of use	4	6	1	0	0	4.27	High
Difficulty	5	5	1	0	0	4.36	High
4.6 K12 Treatment Principles, Effects, Side Effects, and Risks of Various Projects
Importance	7	4	0	0	0	4.64	Very high
Frequency of use	1	7	3	0	0	3.82	High
Difficulty	6	5	0	0	0	4.55	Very high
4.7 S03 Skin Quality Assessment
Importance	3	8	0	0	0	4.27	High
Frequency of use	5	6	0	0	0	4.45	High
Difficulty	6	4	1	0	0	4.45	High
4.8 S04 Problem Analysis and Solution
Importance	8	3	0	0	0	4.73	Very high
Frequency of use	7	3	1	0	0	4.55	Very high
Difficulty	4	3	4	0	0	4.00	High
5. Laser and EBD treatment techniques
5.1 K10 Aesthetic Medicine Laser Science
Importance	4	7	0	0	0	4.36	High
Frequency of use	6	5	0	0	0	4.55	Very high
Difficulty	2	9	0	0	0	4.18	High
5.2 K13 Contraindications and Precautions for Various Treatments
Importance	8	3	0	0	0	4.73	Very high
Frequency of use	7	4	0	0	0	4.64	Very high
Difficulty	4	7	0	0	0	4.36	High
5.3 K15 Treatment Program (Including Medical Sustainability)
Importance	5	5	1	0	0	4.36	High
Frequency of use	1	6	4	0	0	3.73	High
Difficulty	5	6	0	0	0	4.45	High
5.4 K16 Device Characteristics and Treatment Mechanisms (Including Carbon Footprint and Environmental Compliance)
Importance	3	5	3	0	0	4.00	High
Frequency of use	5	3	3	0	0	4.18	High
Difficulty	5	5	1	0	0	4.36	High
5.5 K17 Post-Treatment Physiological Responses
Importance	4	6	1	0	0	4.27	High
Frequency of use	3	5	3	0	0	4.00	High
Difficulty	2	7	2	0	0	4.00	High
5.6 K20 Laser and EBD Treatment Safety and Protection Concepts
Importance	7	3	1	0	0	4.55	Very high
Frequency of use	2	7	2	0	0	4.00	High
Difficulty	9	2	0	0	0	4.82	Very high
5.7 K22 Physiological Responses, Care, and Pharmacological Knowledge
Importance	4	7	0	0	0	4.36	High
Frequency of use	5	6	0	0	0	4.45	High
Difficulty	4	5	2	0	0	4.18	High
5.8 K23 Sustainability-Oriented Medical Waste Management Procedures
Importance	6	4	1	0	0	4.45	High
Frequency of use	1	5	4	1	0	3.55	High
Difficulty	1	5	5	0	0	3.64	High
5.9 K24 Infection Prevention and Control Concepts
Importance	4	7	0	0	0	4.36	High
Frequency of use	8	2	1	0	0	4.64	High
Difficulty	7	4	0	0	0	4.64	High
5.10 S06 Laser and EBD Treatment and Low-Carbon Sustainable Operation Technology
Importance	10	1	0	0	0	4.91	Very high
Frequency of use	6	4	1	0	0	4.45	High
Difficulty	4	7	0	0	0	4.36	High
5.11 S09 Protective Measures Technology
Importance	4	7	0	0	0	4.36	High
Frequency of use	6	4	1	0	0	4.45	High
Difficulty	5	5	1	0	0	4.36	High
6. Cosmeceutical and maintenance knowledge
6.1 K14 Aesthetic Medicine Skincare Science (Cosmeceuticals)
Importance	1	7	3	0	0	3.82	High
Frequency of use	6	3	2	0	0	4.36	High
Difficulty	5	4	2	0	0	4.27	High
6.2 S07 Home Care and Maintenance Planning
Importance	5	6	0	0	0	4.45	High
Frequency of use	4	5	2	0	0	4.18	High
Difficulty	1	6	4	0	0	3.73	High

). In the “Regulations and Medical Ethics” domain, K18 (Medical Regulations and Risk Prevention Knowledge) received an average importance rating of 4.91, while K21 (Medical Ethics in Aesthetic Medicine) obtained a frequency-of-use score of 4.82, reflecting a strong consensus among domain experts on the necessity of legal and ethical training. Similarly, K10 (Aesthetic Medicine Laser science) had a high frequency of use (4.55), and S06 (Laser and EBD treatment and low-carbon sustainable operation technology) obtained the highest importance score (4.91), underscoring the practical demand for integrating sustainability into clinical technologies.

Most competencies were rated high (3.5 < μ ≤ 4.5) or very high (μ > 4.5) for both “importance” and “frequency of use.” Notably, 28 of 33 competencies were rated “very high” in importance, indicating a substantial level of expert consensus on their relevance to sustainable clinical practice.

4.2. Consensus Consistency (Kendall’s W)

The thirty-three identified knowledge and skill competencies were categorized into six core domains. To examine the degree of expert consensus in each domain, Kendall’s coefficient of concordance (W) was applied. As shown in

Table 3. Kendall’s coefficient of concordance (W) for expert consensus across competency domains.

Competency Domain	Dimension	Kendall’s W	χ2	p-Value
1. Sustainable operations analysis and industry trends	Importance	0.412	13.071	0.001 **
	Frequency of use	0.227	6.400	0.041 *
	Difficulty	0.510	11.214	0.004 **
2. Regulatory and medical ethics	Importance	0.543	7.600	0.022 *
	Frequency of use	0.484	10.640	0.005 **
	Difficulty	0.287	6.320	0.042 *
3. Aesthetic Medicine physician patient consultation and communication	Importance	0.333	11.654	0.040 *
	Frequency of use	0.260	14.289	0.014 *
	Difficulty	0.431	10.187	0.007 **
4. Foundational dermatological science	Importance	0.257	14.560	0.042 *
	Frequency of use	0.327	20.164	0.005 **
	Difficulty	0.306	18.329	0.006 **
5. Laser and EBD treatment techniques	Importance	0.204	22.489	0.013 *
	Frequency of use	0.355	39.034	0.001 **
	Difficulty	0.296	32.519	0.001 **
6. Cosmeceutical and maintenance knowledge	Importance	0.571	4.000	0.046 *
	Frequency of use	0.529	7.412	0.025 *
	Difficulty	0.714	5.000	0.025 *

Note: * = significant at p < 0.05 level; ** = significant at p < 0.05 level.

, all domains achieved statistically significant consistency levels (p < 0.05), indicating significant consistency among experts.

In the domain of sustainable management analysis and industry trends, the level of difficulty yielded a concordance coefficient of W = 0.510 (p = 0.004), reflecting consensus on the instructional and practical challenges associated with teaching sustainability-oriented knowledge. Additionally, in the domain of laser and EBD treatment technologies, the frequency-of-use dimension reached W = 0.355 (p = 0.001), suggesting that competencies within this category are widely applied in clinical settings. These results confirm that the competency items refined through CBIs and the initial expert panel review achieved robust expert consensus, supporting their validity for integration into sustainable clinical competency frameworks.

Overall, the L&EBD Competency Model was developed in this study through a CBIs process and a two-stage panel meeting protocol. The majority of the identified competency indicators received high or very high levels of consensus, and the results for Kendall’s coefficient of concordance confirmed statistically significant agreement among domain experts. These findings demonstrate the model’s strong practical representativeness and educational relevance.

Moreover, the outcomes effectively address the three research questions posed in this study and offer a robust foundation for advancing sustainability-oriented education and establishing standardized competencies for laser and EBD treatments within the field of aesthetic medicine. The full competency framework is provided in Supplementary Table S1.

5. Discussion

5.1. Core Sustainable Competencies Identified

According to McClelland’s CMT, physicians specializing in aesthetic medicine laser and EBD treatments require competencies that integrate clinical expertise with sustainability awareness. Core domains include dermatology, photoelectric treatment technologies, sustainable operations and ESG principles, medical regulations and risk prevention, informed consent, and physician–patient communication. These competencies support transparent consultation, sustainability-oriented treatment planning, clinical decision-making, and proficient device operation The findings align with prior studies emphasizing that competencies must reinforce physician–patient consensus, the adequate communication of treatment methods, and comprehensive risk management [56].

5.2. A Competency Model That Aligns with Expert Consensus Consistency

This study delineated three primary responsibilities: T1—conduct clinical assessments and propose treatment plans; T2—perform laser and EBD treatment; and T3—track treatment results. These were further expanded into 8 core work tasks, which were then broken down into 28 behavioral indicators, 2 key work outputs, 24 knowledge-based competencies, 9 skill-based competencies, and 6 attitudinal dimensions.

Strong expert consensus was confirmed during validation, with findings consistent with reports from the Cosmetic Practice Standards Authority and Arizton Advisory & Intelligence, which highlight patient expectations for holistic, sustainable care [39,57].

However, structural gaps persist in Taiwan’s training capacity, as noted by KPMG Taiwan [58] and the Taiwan International Institute of Obstetrics, which found that current frameworks insufficiently prepare physicians for low-carbon mandates and environmentally responsible practice [59]. The model therefore offers both theoretical advancement and practical benchmarks to inform future training and governance.

5.3. Linking Competencies to Sustainability

Experts emphasized that physicians in aesthetic medicine laser and EBD treatments play a key role in advancing sustainability. Environmentally, they can lower carbon footprints by selecting energy-efficient devices and equipment and adopting paperless workflows; socially, they ensure transparent communication, patient safety, and respect for patient rights; from a governance perspective, they contribute through their adherence to clear Standard Operating Procedures (SOPs), legal compliance, and operational transparency.

These recommendations align with the WHO Operational Framework for Building Climate Resilient and Low-Carbon Health Systems [3] and the MOHW’s 2025 Continuing Education Seminar on green medicine and net-zero practices [60]. At the national level, the Minutes of the Fourth Committee Meeting, convened by the Office of the President, highlighted systemic barriers, including rigid regulations, financial pressures tied to hospital scale, and the gap between policy directives and clinical operations [61].

This study also identified sustainability-oriented competencies such as integrating low-carbon methods into treatment planning, applying sustainable protocols, and managing medical waste responsibly. Together, these competencies illustrate how clinical expertise must be coupled with environmental responsibility, reinforcing the link between aesthetic medicine and sustainable healthcare governance.

6. Conclusions

Rooted in McClelland’s CMT, this study developed and validated a comprehensive sustainability-oriented competency model for physicians specializing in aesthetic medicine laser and EBD treatments. The framework integrates clinical expertise with sustainability awareness across six key domains: sustainable operations, regulatory and ethical knowledge, physician–patient communication, dermatological science, EBD techniques, and maintenance care.

The findings confirmed strong expert consensus on the critical role of these physicians in advancing sustainability within clinical practice. This demonstrates the close connection between clinical professionalism and environmental responsibility and reflects the global transition toward responsible governance and low-carbon healthcare systems. The study offers a novel perspective on embedding sustainability into aesthetic medicine and provides a theoretical foundation for future competency-based education frameworks.

Practically, the model ensures that workforce capacity can meet both clinical demands and the growing expectations for sustainable and socially accountable care. Institutional leaders may draw on the framework to design training standards, incorporate sustainability indicators into performance evaluations, and promote green procurement. Physicians, in turn, can embed environmental considerations into clinical decision-making, advancing patient-centered yet environmentally responsible care. Collectively, the study bridges the gap between theory and practice, offering actionable guidance for talent development and policy design to drive sustainability transformation in aesthetic medicine.

7. Research Limitations

This study fills an important gap by constructing a competency model for physicians specializing in aesthetic medicine laser and EBD treatments aligned with sustainable development principles. It also provides a reference framework for policymakers and training institutions. Nevertheless, several limitations must be acknowledged, as described below.

7.1. Limited Geographic Scope

This study primarily focused on benchmark physicians in Taiwan specializing in aesthetic medicine laser and EBD treatments. While this provides representativeness, it also imposes a limitation in geographic scope. Nevertheless, consistent with McClelland’s competency model theory, competency construction is inherently characterized by cross-context transferability and replicability [18]. Although competency modeling is time- and resource-intensive, its outputs can serve as foundational frameworks for other organizations or countries to adapt and revise according to local regulatory systems, clinical workflows, and needs, thereby reducing redundant development costs [47]. Accordingly, subsequent researchers can leverage this property to draw on the present findings, accelerating the model’s application across diverse healthcare settings and within the international aesthetic medicine domain, and further advancing the standardization of laser and EBD competencies, as well as sustainability-oriented practice [39].

7.2. Narrow Stakeholder Representation

The present research primarily involved benchmark physicians, which fulfills the requirements for competency construction, but subsequent applications have not yet incorporated the perspectives of patients, administrators, or ESG related professionals regarding the needs and acceptability of sustainable development in medicine. In future studies, expanding stakeholder participation to include patients, healthcare administrators, and ESG professionals will be essential. These stakeholders can jointly contribute both to the evaluation of training program needs and to the assessment of managerial competency applications [31]. This inclusion would enhance the comprehensiveness of the competency framework, expand the social impact of sustainable healthcare, and provide a more holistic understanding of how sustainable development influences the aesthetic medicine industry [62].

7.3. Absence of Quantitative Sustainability Assessment

While this study identified sustainability-related competencies, it did not quantitatively measure the outcomes or impacts of sustainable practices. In future studies, researchers could develop and validate performance indicators related to sustainable development, such as carbon reduction, resource efficiency, and patient-centered environmental preferences, in order to assess their influence on clinic operations, service quality, and patient satisfaction. Such quantitative assessments would not only complement the competency framework but also strengthen the evidence base for integrating sustainability into aesthetic medicine practice.