Core Competencies in Neurological Surgery: A Matrix Curriculum

Core Competencies in Core Competencies in Neurological Surgery:Neurological Surgery:A Matrix CurriculumA Matrix Curriculum

Society of Neurological SurgeonsSociety of Neurological SurgeonsAmerican Board of Neurological SurgeryAmerican Board of Neurological Surgery

ACGME Residency Review Committee for ACGME Residency Review Committee for Neurological SurgeryNeurological Surgery

The Matrix ProjectThe Matrix Project

Core CompetenciesCore Competencies

• SynthesisSynthesis– SNS SNS

• Committee on Resident Education (CoRE)Committee on Resident Education (CoRE)– Content editorContent editor

– ACGMEACGME• Format Format

– ABNSABNS• Medical KnowledgeMedical Knowledge

– RRCRRC• Technical SkillsTechnical Skills

Both organizations deal with medical knowledge and technical skills

Neurological Surgery CurriculumNeurological Surgery Curriculum

• Consistent with ACGME formatConsistent with ACGME format– Core competenciesCore competencies

• Consistent with ABNSConsistent with ABNS– Primary exam contentPrimary exam content– Oral exam contentOral exam content

• Consistent with RRC goalsConsistent with RRC goals– InstitutionalInstitutional– Chief Resident casesChief Resident cases

CompetenciesCompetencies

• ObjectivesObjectives– ACGME Core CompetenciesACGME Core Competencies– Primary exam categories, key wordsPrimary exam categories, key words– RRC case categoriesRRC case categories

• Teaching methodsTeaching methods– Reading, lecture, modules, Bootcamp, hands on, etcReading, lecture, modules, Bootcamp, hands on, etc

• Assessment toolsAssessment tools– PD, SANS, Primary exam, 360 evals, etcPD, SANS, Primary exam, 360 evals, etc

• Educational goalsEducational goals

Early LearnerEarly Learner

CompetentCompetent

ProficientProficient

ExpertExpert

UnsatisfactoryUnsatisfactory

Progression

Physician Performance Diagnostic Physician Performance Diagnostic InventoryInventory

• Rarely demonstrates competence AND is unexpected to Rarely demonstrates competence AND is unexpected to become competent within the assigned time frame. become competent within the assigned time frame.

• Consistently makes poor decisions or has a consistently Consistently makes poor decisions or has a consistently unsatisfactory approach to solving problems that results in unsatisfactory approach to solving problems that results in poor care delivery or unacceptable behavior. poor care delivery or unacceptable behavior.

• Repeatedly appears incapable of understanding concepts, Repeatedly appears incapable of understanding concepts, performing tasks, exercising judgment or demonstrating performing tasks, exercising judgment or demonstrating behaviors that are important to show ability to learn the behaviors that are important to show ability to learn the element being evaluated.element being evaluated.


• Demonstrates competence occasionally; usually shows ability Demonstrates competence occasionally; usually shows ability to learn in routine, repetitive or non-stressful situations to learn in routine, repetitive or non-stressful situations

• Requires supervisionRequires supervision• Incapable or inconsistent in using experience to address Incapable or inconsistent in using experience to address

circumstances that are unexpected or non-typicalcircumstances that are unexpected or non-typical• The early learner is at a novice level and shows aptitude but The early learner is at a novice level and shows aptitude but

has not yet had sufficient experience, training or skill has not yet had sufficient experience, training or skill acquisition to achieve competenceacquisition to achieve competence

• Unlike the unsatisfactory (who believes they already know it Unlike the unsatisfactory (who believes they already know it all), wants to engage in learningall), wants to engage in learning


• Demonstrates competence most of the time and under routine Demonstrates competence most of the time and under routine circumstances circumstances

• Can perform without supervision in usual or predictable Can perform without supervision in usual or predictable circumstancescircumstances

• Has developed adequate internal resources, knowledge or skills to Has developed adequate internal resources, knowledge or skills to make good decisions or perform acceptably in routine cases make good decisions or perform acceptably in routine cases

• IMPORTANTLY, the competent physician recognizes limitations and IMPORTANTLY, the competent physician recognizes limitations and accesses support when needed, especially for more challenging accesses support when needed, especially for more challenging situations situations

• This is the level expected from those at the completion of training This is the level expected from those at the completion of training and indicates that they can effectively address the majority of and indicates that they can effectively address the majority of routine situations and will access support when needed in other routine situations and will access support when needed in other cases.cases.

CompetentCompetent

• Demonstrates competence most of the time and under most Demonstrates competence most of the time and under most circumstances through applying intuition to guide an analytical circumstances through applying intuition to guide an analytical thought process in complex and unpredictable situations thought process in complex and unpredictable situations

• Has a good grasp of information, excellent skills and sound Has a good grasp of information, excellent skills and sound principles and applies them to guide actions in unusual or principles and applies them to guide actions in unusual or challenging circumstances challenging circumstances

• Is consistently trusted to deal effectively with complex problems Is consistently trusted to deal effectively with complex problems • Has developed enough internal understanding, ability to flexibly Has developed enough internal understanding, ability to flexibly

apply knowledge and sufficient skills that they can reliably apply knowledge and sufficient skills that they can reliably handle challenging situations without the need for external handle challenging situations without the need for external support.support.


• Demonstrates competence almost always through understanding the Demonstrates competence almost always through understanding the conceptual whole with appropriate intuitiveness and adaptability to conceptual whole with appropriate intuitiveness and adaptability to the circumstancethe circumstance

• Can recognize errors or inadequacies in knowledge, judgment, skills or Can recognize errors or inadequacies in knowledge, judgment, skills or behavior in complex situations and is capable of effective remediation behavior in complex situations and is capable of effective remediation

• Is a persuasive lifelong learnerIs a persuasive lifelong learner• Understands the contextual “whole” and is fluid and flexible in Understands the contextual “whole” and is fluid and flexible in

performanceperformance• Has a seeming 6th sense (or a well developed “internal gyroscope”) of Has a seeming 6th sense (or a well developed “internal gyroscope”) of

how to respond to even the most unpredictable and challenging how to respond to even the most unpredictable and challenging situations. Is a resource mentor, teacher, and role model in this area.situations. Is a resource mentor, teacher, and role model in this area.

ExpertExpert


CompetentCompetent


ExpertExpert


Junior Resident (R1-2)*Junior Resident (R1-2)*

Senior Resident (R3-6)*Senior Resident (R3-6)*

Chief Resident/Junior StaffChief Resident/Junior Staff

UsUs

FailFail

Physician Performance Diagnostic Physician Performance Diagnostic InventoryInventory

*RRC definitions

Matrix CurriculumMatrix Curriculum

• Educational goals will varyEducational goals will vary– Training levelTraining level– SubspecialtySubspecialty

• Successful residents will not be EXPERTSuccessful residents will not be EXPERT– Highest level of expectation will be PROFICIENCYHighest level of expectation will be PROFICIENCY

• e.g., Complex spinal surgerye.g., Complex spinal surgery

– Lowest level will be EARLY LEARNERLowest level will be EARLY LEARNER• e.g., Endovascular Surgical Neuroradiologye.g., Endovascular Surgical Neuroradiology

Matrix CurriculumMatrix CurriculumCompetency Objective Teaching

MethodsAssessment

ToolsEducational

Goals

Medical Knowledge and

Skills

Neuroanatomy •Lecture series•Textbooks•AANS/SNS On-line modules•Resident courses•Bootcamps

•Inservice Exams•SANS•ABNS Primary Exam

Proficient(4)


Competency Objective Teaching Methods

Assessment Tools

Educational Goals

Medical Knowledge(Technical

Skills)

• Lumbar Puncture• Ventriculostomy• CSF Sample• Shunt tap• Traction• Stereotactic frame

placement

•AANS/SNS On-line modules•Conferences•Supervised learning •Bootcamp

•Faculty and Program Director evaluations

Proficient(4)

Training Level : PGY1


Competency Objective Teaching Methods

Assessment Tools

Educational Goals

Medical Knowledge(Technical

Skills)

• Craniotomy for Aneurysm clipping

• Aneurysm coiling

•AANS/SNS On-line modules•Conferences•Supervised learning

•Faculty/ Program Director evaluations

• Competent(3)

• Early learner

(2)

Training Level : PGY7

Cerebrovascular CompetenciesCerebrovascular Competencies

Milestone Competency ABNSKeyword

Oral ExamTopic

TechnicalSkill

RRC CatCase?

Teaching Method

AssessmentTools

PPDIJ/S/C

Understand AngiographyPARQ

Medical knowledge

Imaging/angiography

Imaging/angiography

N/A No Lecture/reading Primary exam S3C4

Place femoral arterial catheter

Neuroanatomy N/A Imaging/angiography

Endovascular surgical neuroradiology

No Hands-on PD/faculty S3C3

Know anatomy of intracranial vessels

Medical knowledge

Neuroanatomy/vascular

Imaging/angiography

N/A No Lecture/reading Primary exam J2S3 C4

Medical KnowledgeMedical Knowledge

• ABNS Primary Exam CategoriesABNS Primary Exam Categories– A: AnatomyA: Anatomy– B: NeurobiologyB: Neurobiology– C: PathologyC: Pathology– D: ImagingD: Imaging– E: NeurologyE: Neurology– F: NeurosurgeryF: Neurosurgery– G: Critical CareG: Critical Care– H: Core CompetenciesH: Core Competencies

Medical knowledgeMedical knowledge



Technical SkillsTechnical Skills

RRC Case Categories(Proposed)


• Adheres to ACGME formatAdheres to ACGME format• Uses established goals of ABNS and RRCUses established goals of ABNS and RRC• Acknowledges levels of educational goalsAcknowledges levels of educational goals• Requires more integration of stakeholdersRequires more integration of stakeholders

– SNSSNS– ABNSABNS– RRCRRC

• It can be rapidly implementedIt can be rapidly implemented• It is a dynamic process It is a dynamic process

Process for the Matrix ProjectProcess for the Matrix Project SNS, ABNS and RRC agree to proceed with Matrix SNS, ABNS and RRC agree to proceed with Matrix

ProjectProject Pilot proposals under development in Pilot proposals under development in

Neurointensive CareNeurointensive Care and and Endovascular Surgical Endovascular Surgical NeuroradiologyNeuroradiology

ABNS agrees to appoint SNS representatives to ABNS agrees to appoint SNS representatives to Primary Exam CommitteePrimary Exam Committee

• SNS bylaws change to place ABNS and RRC SNS bylaws change to place ABNS and RRC representatives on SNS Council (ad hoc)representatives on SNS Council (ad hoc)

Process for the Matrix ProjectProcess for the Matrix Project Orientation of Joint Section leadership to the ProjectOrientation of Joint Section leadership to the Project

AANS annual meeting, Denver, CO April 10-14, 2011AANS annual meeting, Denver, CO April 10-14, 2011

• Orientation of SNS members to the Project Orientation of SNS members to the Project – SNS annual meeting, Portland, OR May 21-24, 2011SNS annual meeting, Portland, OR May 21-24, 2011

Joint Sections

SNS Curriculum Sub-Committee

SNS CoRE Committee

SNS Council

SNS Members and PDs

Subspecialty specific curriculum initiation

Development of curriculum proposal

Ensure proposal inMatrix format

Vet curriculum proposal

Final Approval of Matrix curriculum element

Pass proposal toSNS Members and PDs

Comments, suggestions,and revisions

The ACGME Milestones ProjectThe ACGME Milestones Project

ACGME Milestones ProjectACGME Milestones Project

• Translate “general” competencies into specific Translate “general” competencies into specific competencies to be met by all residentscompetencies to be met by all residents

• Create “core” resident outcomes in the Create “core” resident outcomes in the competencies, not “standardization” of all competencies, not “standardization” of all outcomes. outcomes.

Current CurriculaCurrent Curricula

“Educate” residentsCurriculum “time-based”

Choose educational experiences within institution,

faculty

Identify/develop evaluation tools -formative-summative

“Circumstantial Practice”

Future CurriculaFuture Curricula

Produce proficientProduce proficientphysicians physicians

The requiredThe requiredoutcomesoutcomes in each in each domain of Clinical domain of Clinical

Competency (Milestones)Competency (Milestones)

DesignDesign educational educational Experiences,Experiences,

rotations, facultyrotations, faculty

National evaluation tools to measure outcomeNational evaluation tools to measure outcome -formative and summative-formative and summative-clinical outcomes tracking-clinical outcomes tracking

““Intentional Practice”Intentional Practice”

External accountabilityExternal accountabilityfor outcome for outcome

New knowledge or skill set

Entrustable Professional ActivitiesEntrustable Professional Activities

• Equating competency with the point at which Equating competency with the point at which one is ready to practice a a static viewone is ready to practice a a static view

• Competence is content and context specificCompetence is content and context specific• Notion of context fits well with Milestones Notion of context fits well with Milestones

and “entrustable professional activities” and “entrustable professional activities” (EPAs)(EPAs)

Entrustable Professional ActivitiesEntrustable Professional Activities

• Professional life activities that define the specialtyProfessional life activities that define the specialty• Ground the competencies in the everyday work of Ground the competencies in the everyday work of

the physicianthe physician• Activities lead to some output or outcome that can Activities lead to some output or outcome that can

be observedbe observed• Complexity of the activities requires an integration of Complexity of the activities requires an integration of

knowledge, skills, and attitudes across competency knowledge, skills, and attitudes across competency domainsdomains

• 50-100 per specialty50-100 per specialty

Entrustment and CompetenceEntrustment and Competence

• Entrustment occurs when direct supervision is no Entrustment occurs when direct supervision is no longer neededlonger needed

• Faculty understand entrustment more than Faculty understand entrustment more than competencecompetence

• Entrustment infers competenceEntrustment infers competence• Doesn’t suggest that graduating residents reach a Doesn’t suggest that graduating residents reach a

standard of performance to practice every EPA without standard of performance to practice every EPA without direct supervisiondirect supervision

• Opens the door for structured learning after residency Opens the door for structured learning after residency as part of MOC as part of MOC

Back to the Future?Back to the Future?

• Similarities with Apprenticeship modelSimilarities with Apprenticeship model– Relationships are criticalRelationships are critical– Assessment is embedded in a clinical setting taking care of Assessment is embedded in a clinical setting taking care of

real patientsreal patients– Direct observation (not inference) is keyDirect observation (not inference) is key

• Differences from Apprenticeship modelDifferences from Apprenticeship model– Expanded competenciesExpanded competencies– Move from random to deliberate curriculumMove from random to deliberate curriculum– EPAs and competencies require each other for meaningEPAs and competencies require each other for meaning

Milestones Project StatusMilestones Project Status• Draft products createdDraft products created

– Internal MedicineInternal Medicine– PediatricsPediatrics– General SurgeryGeneral Surgery

• Development underwayDevelopment underway– UrologyUrology– Obstetrics-GynecologyObstetrics-Gynecology

• Poised to beginPoised to begin– OpthalmologyOpthalmology– RadiologyRadiology– Transitional yearTransitional year– Neurological SurgeryNeurological Surgery

Where Do We Start?Where Do We Start?

ACGME invitation or specialty expression of ACGME invitation or specialty expression of interestinterest

Certification board and ACGME conversationCertification board and ACGME conversation• Decide on structure, working group chair, and Decide on structure, working group chair, and

membershipmembership• Get started with ACGME staff directionGet started with ACGME staff direction

Group Organization and Group Organization and MembershipMembership

• Working group (n=10-15) MD educational Working group (n=10-15) MD educational experts (Board, RRC, PD organization); 2-3 experts (Board, RRC, PD organization); 2-3 ACGME staffACGME staff

• Advisory group (n=3-13) Organizational Advisory group (n=3-13) Organizational leaders (Board, ACGME, RRC, specialty leaders (Board, ACGME, RRC, specialty organizations)organizations)

Charge to the Milestone GroupCharge to the Milestone Group

• Develop milestonesDevelop milestones– Milestone – behavior, attitude, or outcome Milestone – behavior, attitude, or outcome

related to general competency domains related to general competency domains that that describe a significant accomplishment expected of describe a significant accomplishment expected of a resident a resident by a particular point in timeby a particular point in time

• Identify assessment toolsIdentify assessment tools– Vital, since this is where Outcomes Project failedVital, since this is where Outcomes Project failed

Cerebrovascular MilestonesCerebrovascular Milestones

Milestone Competency ABNSKeyword

Oral ExamTopic

TechnicalSkill

RRC CatCase?

Teaching Method

AssessmentTools

PPDIJ/S/C

Understand AngiographyPARQ

Medical knowledge

Imaging/angiography

Imaging/angiography

N/A No Lecture/reading Primary exam S3C4

Place femoral arterial catheter

Neuroanatomy N/A Imaging/angiography

Endovascular surgical neuroradiology

No Hands-on PD/faculty S3C3

Know anatomy of intracranial vessels

Medical knowledge

Neuroanatomy/vascular

Imaging/angiography

N/A No Lecture/reading Primary exam J2S3 C4

SummarySummary

• Neurological Surgery is a the beginning of a process to Neurological Surgery is a the beginning of a process to redefine residency curriculumredefine residency curriculum– The Matrix ProjectThe Matrix Project

• This project will coordinate the efforts of SNS, ABNS This project will coordinate the efforts of SNS, ABNS and the RRCand the RRC

• The AANS and CNS will participate through their Joint The AANS and CNS will participate through their Joint Sections, and Executive CommitteesSections, and Executive Committees

• This process will converge with an effort by ACGME to This process will converge with an effort by ACGME to redefine how residents are trainedredefine how residents are trained– The Milestones ProjectThe Milestones Project

Documents

Core Competencies in Neurological Surgery: A Matrix Curriculum