Competencies, Milestones & EPAs:

What Does It All Mean?

Susan B. Promes, MD, FACEP

Professor and Program Director

Department of Emergency Medicine

Director, Curricular Affairs

Office of GME

Historical Perspective ACGME Outcomes Project

Initiative to increase emphasis on educational outcomes

In 1999, Advisory committee identified six competencies and programs

Why Outcomes? Accountability Process vs. Product Department of Education Requirements Political Need

Criticism of Modern Medical Education

How can we ensure the public

that our graduates are competent?

Criticism of Modern Medical Education

Is there a better way to ensure competence than just time spent in a

training program?

We believe that in the future, expertise rather than experience will underlie competency-based practice and…

certification.

Aggarwal & Darzi, NEJM 2006

Competency Based Medical Education Flexibility for individuals Efficiency Less time-oriented Public accountability Relevance assured Transparent standards Logical progression

Six ACGME Competencies Medical Knowledge Patient Care Practice Based Learning and

Improvement System Based Practice Professionalism Interpersonal and Communication Skills

Medical Knowledge

Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and how to apply this knowledge to patient care.

Acquisition Analysis Application

Patient Care

Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.

Gathering information Synthesis Partnering with patients/families

Professionalism

Residents must demonstrate professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.

Professional behavior Ethical principles Cultural competence

Systems-based Practice

Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide optimal health care.

Health care delivery system Cost effective practice Patient safety and advocacy/Systems

causes of error

Interpersonal and Communication Skills

Residents must be able to demonstrate interpersonal and communication skills that result in effective informationexchange and teaming with patients, their patients families, and professional associates.

Communicating with patients and families Communicating with team members Scholarly Communication

Practice-based Learning and Improvement

Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices.

Life-long learning Evidence based medicine Quality improvement Teaching skills

Measuring the unmeasurable

Knows

Shows how

Knows how

Does

“Domain independent” skills

“Domain specific” skills Cees van der VleutenMaastricht University

Measuring the unmeasurable

Importance of domain-independent skills If things go wrong in practice, these skills

are often involved (Papadakis et 2005; 2008) Success in labor market is associated with

these skills (Meng 2006)

Cees van der VleutenMaastricht University

Measuring the unmeasurable Self assessment Peer assessment Patient assessment Multisource feedback Journals or logs Simulation Portfolio assessment

Cees van der VleutenMaastricht University

Competency defined An observable ability of a health

professional, integrating multiple components such as knowledge, skills, values and attitudes.

The International CBME Collaborators 2009

Special thanks to Drs. Hauer, Chen, Young, O’Sullivan and ten Cate

Competent defined Possesses the required abilities in all

domains in a certain context at a defined stage of medical education or practice.

The International CBME Collaborators 2009

Special thanks to Drs. Hauer, Chen, Young, O’Sullivan and ten Cate

Competence defined Entails more than the possession of

knowledge, skills and attitudes; it requires you to apply them in the clinical environment to achieve optimal results

Ten Cate, Medical Teacher, 2010

Special thanks to Drs. Hauer, Chen, Young, O’Sullivan and ten Cate

Competency

Competent

Competence

Recent Events MedPac, IOM and Macy Foundation call

for GME Reform Concern for Gov’t regulation of GME

New ACGME Program Requirement V.A.

The specialty-specific Milestones must be used as one of the tools to ensure residents are able to practice core professional activities without supervision upon completion of the program. (Core)

Supervision Direct Indirect

With Supervision Immediately Available With Supervision Available

Telephonic or electronically

Oversight Provide review after care is delivered

New ACGME Program Requirement V.A.

The specialty-specific Milestones must be used as one of the tools to ensure residents are able to practice core professional activities without supervision upon completion of the program. (Core)

Seven ACGME Specialties Roll Out Milestones Diagnostic Radiology Emergency Medicine Internal Medicine Neurosurgery Orthopedics Pediatrics Urology

Milestones defined

Meaningful, measurable markers of progression of competence What abilities does the

trainee possess at a given stage?

What can the trainee be entrusted with?

Special thanks to Drs. Hauer, Chen, Young, O’Sullivan and ten Cate

© Copyright 2012 ACGME and American Board of Emergency Medicine

When Do You Trust the Trainee? When is a professional activity

mastered? Set thresholds / minimum standards Allow unsupervised practice

Direct vs.. Indirect Supervision Full entrustment

ACGME requires Program Directors to attest to a trainee’s competence.

ACGME requires Program Directors to attest to a trainee’s competence.

Dreyfus Model

Entrustable Professional Activities (EPAs)

Define important clinical activities Link competencies / milestones Include professional judgment of

competence by clinicians

Special thanks to Drs. Hauer, Chen, Young, O’Sullivan and ten Cate

EPA defined A core unit of work reflecting a

responsibility that should only be entrusted upon someone with adequate competencies

Ole ten Cate

Medical Teacher 1010;32:669-675

CONTEXT is key!

Mulder, ten Cate, Daalder and BerkvensMedical Teacher 2010; 32: e453-459

Building a Competency Based Workplace Curriculum around EPAs: The Case of PA Training

Competency vs.. EPA

Competency EPA

Work Descriptors

Essential Parts of Professional Practice

Discharge PatientCounsel PatientLead Family DiscussionDesign Treatment PlanPerform ParacentesisResuscitate if needed

Person Descriptors

Knowledge Skills, Attitudes and Values

Content expertiseCollaboration abilityCommunication abilityManagement AbilityProfessional AttitudeScholarly Approach

Special thanks to Drs. Hauer, Chen, Young, O’Sullivan and ten Cate

Next Steps Refinement of Milestones Identify Assessment Methods Collection and Reporting Out on Data

Conclusion Competency Based Education is

here to stay for the foreseeable future