Milestonesand EPAs

The definition of expected outcomes or competencies

Milestones

A significant point in development that identifies the discrete knowledge, skills, and attitudes expected of learners as they progress through training.

Milestones should enable the trainee, program and the certification board to know an individuals trajectory of competency acquisition.

Dreyfus & Dreyfus Development Model

Dreyfus SE and Dreyfus HL. A 1980Carraccio CL et al. Acad Med 2008;83:761-7

Time, Practice, Experience

NoviceAdvanced Beginner

Competent

Proficient

Expert/Master

MS3MS4

PGY1

PGY3

Progression Varies by Trainee & Context

Dreyfus SE and Dreyfus HL. A 1980Carraccio CL et al. Acad Med 2008;83:761-7

Time, Practice, Experience

NoviceAdvanced Beginner

Competent

Proficient

Expert/Master

MS3MS4

PGY1

PGY3

MS4PGY1

PGY3

MS4

PGY1

The Internal Medicine Milestones

142 milestones organized by competency and competency sub-divisions

Framed in behavioral terms (Competence is observed in practice!) that define knowledge, skills, attitudes and behaviors

Linked with potential assessment tools Published in 2009

Patient Care

ACGMECompetency

Developmental Milestones InformingACGME Competencies

ApproximateTime FrameTrainee to Achieve Stage

Assessment Methods/Tools

Clinical skills and reasoning

Manages patients using clinical skills of interviewing and physical examination

Historical Data Gathering1. Acquire accurate and relevant history

from the patient in an efficiently customized, prioritized, and hypothesis driven fashion

2. Seek and obtain appropriate, verified, and prioritized data from secondary sources (e.g. family, records, pharmacy)

3. Obtain relevant historical subtleties that inform and prioritize both differential diagnoses and diagnostic plans, including sensitive, complicated, and detailed information that may not often be volunteered by the patient

6 months

9 months

18 months

Standardized patient

Direct ObservationSimulation

RRCsub-bullet

Milestones Benefits

Provide the learner with a clear path of progression • There are no surprises

Allow for rich formative feedback. Learners know where they are and where they need to go

Define specific behaviors that can focus assessment

Milestones Criticisms

Milestones are reductionistic Checking off a milestones list does not equal

competent practice in a highly complex health care environment

There are 142 curricular milestones Programs can not assess them all• Even over three years!

Milestone Challenges Utilize the milestones to develop meaningful

assessment and evaluation. • Generate data that enables attestation of

desired competence.• What the government, public and the

profession trust physicians are capable of doing

Evolve the milestones to be more manageable that allows attestation of competence in desired outcomes.

ACGME Accreditation Milestones

Will serve as one of nine sets of data that ACGME will use when accrediting programs

Will allow ACGME to track the development of desired competence at the program level

Milestones reporting will occur twice per year and will begin in 2013

ACGME Accreditation Internal Medicine Milestones

Discrete developmental narratives describing the development of competence in the learner in each of the six ACGME general competencies

Define stages of development (informed by assessment data) that provide the framework for making judgment/attestation of competence

23 narrative milestones streams

© 2008, 2009 American Board of Internal MedicineAll rights reserved.

®

Entrustment/Entrustable Professional Activities (EPAs)

A framework for work-based assessment?

Assessment/Evaluation Challenges

Ensure that assessment documents competence in those activities required to achieve the desired outcome of training • Assessment that is meaningful!• Assessment that is manageable!

Entrustable Professional Activities

EPAs represent the routine professional-life activities of physicians based on their specialty and subspecialty

The concept of “entrustable” means:• ‘‘a practitioner has demonstrated the

necessary knowledge, skills and attitudes to be trusted to independently perform this activity.’’1

1Ten Cate O. Acad Med. 2007;82(6):542–547.

An Entrustable Professional Activity

Part of essential work for a qualified professional Requires specific knowledge, skill, attitude Acquired through training Leads to recognized output Observable and measureable, leading to a

conclusion Reflects the competencies expected

EPA’s together constitute the core of the profession

16

ten Cate et al. Acad Med 2007

Training and Safe Patient Care

Trainee performance* X

Appropriate level of supervision**

Must = Safe, effective patient-centered care

* a function of level of competence in context

**a function of attending competence in context

“Entrustment in Medical Education”

Focused assessments around what faculty and training programs already “entrust” trainees to do?

Reflects the most important outcome of training: a trainee’s readiness to bear professional responsibility”

Enables work-based assessment focusing on demonstrating competence in desired outcomes of training.

Thank You