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Domains of Professional Competence APTA Combined Sections Meeting

February 5, 2015

The authors declare no conflict of interest.

Permission of authors required to reproduce these slides. Page 1

Domains of Professional

Competence: Looking Across the

Educational Continuum

Furze J, Jensen GM, Rapport MJ, Christensen N, Briggs M

Paschal K, Hartley G, Nordstrom T

APTA Combined Sections Meeting

February 5, 2015

Indianapolis, IN

Objectives

Upon completion of this session, participants will be able to:

1. Identify the arguments that are part of the public demand for enhanced accountability (including outcome measures and competency-based education) for health professions education.

2. Compare and contrast the evolution of physical therapist education (entry-level through residency and fellowship) with models of competency domains being discussed in medical and pharmacy education.

3. Discuss a working framework of key domains related to patient-centered competencies spanning entry-level through residency/fellowship education.

4. Engage in panel-audience discussion of challenges and opportunities for developing a learning trajectory of professional competencies across levels of education.

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Outline

• Professional Competency: Exploring What it Means for Physical Therapists

– Learning as a journey and not an ending point in time

– Importance of work-place learning

• Clinical Learning Milestones across a Career – Dreyfus & Dreyfus Model of Skill Acquisition

– Skill development across time

– Assessment of learning – individualized learning

• Lessons from the Health Professions: A Systems Analysis– Comparing and contrasting models of education within doctoring professions

• Laying a Foundation: Considering Common Domains of Competence- Existing silos of specialization

– Trajectory of professional competence

– Proposed core competencies across residency/fellowship education

• Stakeholder Discussant Panel– CAPTE, ABPTRFE, ACOTE

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CaduceusMac2014

CSM2015


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Professional Competency:

What Does it Mean for Physical Therapists

Gail Jensen, PT, PhD, FAPTA

Jennifer Furze, PT, DPT, PCS

What is the Need?

• Entry-level education

– Where are we now?

– Where do we need to be in the future?

– Learning as a journey and trajectory

– Robustness of work-place learning

(clinical experiences and exposure)

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Professional Competence:

Key Concepts

• Multidimensional concept

• Understanding EXPERTISE and adaptive

(flexible) expertise

• Moving beyond behaviors to DISPOSITIONS

• Elements that are non-negotiable

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Flexible Expertise

• What is flexible expertise?

(Do I have it???)

• Flexible or adaptive expertise - Focus on

DEVELOPMENT

• Emphasis on Flexibility and Innovation

• There is more to expertise than

KNOWLEDGE

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Precursors for Development of

Flexible EXPERTISE(Birney, Beckmann, Wood, 2012)

• Self-reflection (meta-cognitive skills)

• Deliberate practice

– Highly structured

– Requires effort

– Emphasis on improving performance beyond

“sufficient”

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Virtue

Knowledge

Clinical reasoning

Student Novice

Professional Development

Movement

Clinical reasoningVirtue

Knowledge Movement

Learning Trajectory Across Time

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Competent Expert

Professional Development

Clinical reasoning

Virtue

MovementKnowledge

Clinical reasoning

Virtue

MovementKnowledge

Philosophy

of Practice

Learning Trajectory Across Time

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What is the Need?

• Residency/Fellowship Education

– Where are we now? Where do we need to be in the future?

• Current emphasis on technical skills and certifications

• Need to explore the theoretical constructs of education and educational research

• Need to meet the societal need

• Effectiveness of work-place learning

• Need to look at the continuum of learning across time

– Are there common competencies across residency/fellowship programs?

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Workplace Learning(O’Brien, 2013; Billet, 2014)

• Learning for PRACTICE

• Powerful and ROBUST and Long lasting

• Relationships are critical

• Clinical instructors/mentors facilitate or

inhibit AFFORDANCES for learning

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Workplace Learning (WPL)

(adapted from O’Brien, 2011)

Learning throughparticipation

Tasks and activities• Support for development learning

• Student assumes responsibility

Relationships within the practice community• Invitational/welcoming• Personal, engagement• Supported participation

Work practice environment• Workload/ Time pressure

• Organization of work• Multiple roles/demands

Individuals engage in thinking and acting MORE than doing a task

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Discussion Points

• Importance of both didactic and clinical

education (work-place learning)

• As a profession, are we doing a good job of

building communication and collaboration

between academic and clinical education as

both are VITAL to learning?

– If so, how are we doing this well?

– If not, how can we improve?

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Clinical Learning Milestones

Across A Career

Jennifer Furze, PT, DPT, PCS

Nicole Christensen, PT, PhD, MAppSc


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Dreyfus & Dreyfus Model of Skill

Acquisition

Carraccio et al, 2008

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Skill Development Across the Continuum

(Teaching & Learning + Assessment)

Knowledge, Skills, & Abilities

Time

Novice Adv Beginner Comp Prof Expert

Entry-levelResident

& Fellow

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Example: Clinical Reasoning Abilities Acquisition Over Time…

Novice

•Following a check-list, rote

•Skills performance-

focused

•Reasoning may not be

connected to actions

•Rarely recognizes

emerging data

•Therapist-centered; not collaborative

Adv Beginner

•Deductive dominates

• Inconsistently prioritizes

•Reflects-on-action

• Inconsistently recognizes

emerging data

• Inconsistently

patient-centered; rarely

collaborative

Competent

•Deductive & Inductive, not

well integrated

•Prioritizes well

simple > complex cases

• Inconsistently Reflects-in-

action

•Recognizes but inconsistently responds to

emerging data

•Patient-centered;

inconsistently

collaborative

Proficient

• Integrates deductive and

inductive well

•Prioritizes well

•Metacognitive; reflects-in-

action

•Responds to emerging data

•Patient-centered;

collaborative

Expert

•Fluid deductive & inductive;

grounded in clinical context

• Prioritizes well

•Highly metacognitive;

reflects-in-action & on

bigger picture

•Responds

quickly to emerging data

•Patient-centered; highly

collaborative

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Novice

• Reasoning may not be connected to actions

Adv Beginner

• Reflects-on-action

Competent

• Inconsistently Reflects-in-action

Proficient

• Metacognitive; reflects-in-action

Expert

• Highly metacognitive; reflects-in-action & on bigger picture

Requires Educator to Reflectively Progress

Learning Facilitation Strategies Over Time

• Identify gaps in

skills &

knowledge;

• Link to blind spots

• Questioning,

modeling &

teaching

• Focus on awareness

of depth, breadth, &

accuracy of self-

reflection abilities

• Progressively

challenge reflection

in action

• Progressive

challenge to breadth,

depth & accuracy of

self-reflection

• Challenged to reflect

beyond this one

situation

Progression of the Learner

Progression of Facilitation Strategies

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Assessment of Learning

• Includes - Knowledge, Skills, & Abilities

– Assess learner’s current abilities

• Beginning of curriculum and throughout

• Individualized learning vs one size fits all

• Active learning strategies

– Students perform mental gymnastics when

thinking/performing with cases/patients

– Practice for success

• Repetition with variables

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Assessment of Learning

Entry-Level Education

• Asses student’s knowledge and abilities at beginning

• Work toward meeting “standard bar” that all students need to meet

• Work toward pushing beyond “standard bar” depending on student’s abilities– Even though a student may be

marked as competent on the CPI, the learning doesn’t end there, additional teaching and learning can occur

Residency/Fellowship Education

• Assess resident’s knowledge and abilities at beginning

• Work toward meeting collaborative goals (student & mentor)

• Work toward pushing beyond competent and toward proficient or even farther if possible

– CHALLENGE for both resident & mentor

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Competence

Knows

Knows How

Does

Performance or hands on assessment

Written, Oral orComputer based assessment

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Discussion Points

• How do people perceive competency-based

education?

– Quantitative approach – resident performs a skill 5

times (one right answer)

– Qualitative approach – developmental continuum

over time (grapple with thinking and complexity of

the situation)

– Assessment – Both quantitative and qualitative?

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Lessons from the Health

Professions: A Systems Analysis

Matthew Briggs, PT, DPT, PhD, SCS, AT

Mary Jane Rapport, PT, DPT, PhD, FAPTA


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Doctoring Health Care Professions with

Residency/Fellowship Training

Medicine

Dentistry

Pharmacy

Psychology

Optometry25

PharmacyAmerican Society of

Health System

Pharmacists

(ASHP)

DentistryCommission on Dental

Accreditation

(CODA)

PsychologyAmerican

Psychological

Association

Commission on

Accreditation

APA-CoA

OptometryAccreditation Council

on Optometric

Education

(ACOE)

Physical

TherapyAmerican Board of

Physical Therapy

Residency &

Fellowship Education

(ABPTRFE)

1962 1984 1996 1997

MedicineAmerican College of

Graduate Medical

Education

(ACGME)

XXXX

Accreditation Groups for Doctoring

Healthcare Professionals

Is the same group used

for Entry-Level

Accreditation?

NO

NOYES

NO

YES YES

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PharmacyResidency# 1326

DentistryResidency &

Fellowship# ?

PsychologyResidency# 95

OptometryResidency# 187

Physical

TherapyResidency# XX

Fellowship# XX

1962 1984 1996 1997

MedicineResidency#

Fellowship#

XXXX

Number of Programs

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PharmacyAcademic-based

Clinic/Hospital-based

DentistryAcademic Based

PsychologyAcademic-based


Consortiums

OptometryClinic/Hospital Based

but academic

institution must be a

sponsor

Physical

TherapyAcademic-based


Large Collaborative

Consortiums

1962 1984 1996 1997

MedicineXXX

XXX

XXXX

Program Models

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Doctoring Healthcare Professions

without Residency/Fellowship

Training and Accreditation

• Occupational Therapy (MOT/OTD)

• Chiropractic

– The Council on Chiropractic Education (CCE) is

considering this process.

– CCE has established rules stating the residency

program must be affiliated with a sponsoring

institution with an accredited Doctorate of

Chiropractor program

• Audiology

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Training Programs

• Initial focus: Education and skill

• Now more focus on COMPETENCY

– Is the basis for additional training

• Other measures (in MD education)

– Milestones

– Entrustable Professional Activities (EPAs)

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Competency-Based

Education Frameworks

• Accreditation Council for Graduate Medical Education. Common program requirements: general competencies. –August 2011

Medicine

“YES”

• ADEA Competencies for the New General Dentist. – 2011

• Badner et al. 2010

Dentistry

“YES”

• Pharmacy Education Taskforce A Global Competency Framework – 2012

• Hill et al. 2006

Pharmacy

“DEVELOPMENT”

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Competency-Based Outcomes

in Higher Education

• 1990’s competency-based movement in medicine in US

• Developed general competencies – License MD’s based upon outcomes and capabilities versus

length of time in training

– Tension with competency-based education• Specific goals and objectives to meet competencies are reduced to

a checklist

• Don’t take into account the higher-order thinking and contextual factors of practice

– Balanced with Entrustable Professional Activities (EPA) –meaningful acts in practice

(ten Cate, 2014)

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Physical Therapy Residency and

Fellowships

• Opportunity for professional growth

• Opportunity for clinical specialization

• Opportunity for advanced clinical skills

– General: eg, clinical reasoning

• Opportunity for development of competencies

– through all phases of education and training

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Discussion Points

• How has what we learned from the other

health professions about residency and

fellowship guided us?

• Based upon this, are we moving in the right

direction?

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Laying a Foundation: Considering

Common Domains of Competence

Mary Jane Rapport, PT, DPT, PhD, FAPTA

Nicole Christensen, PT, PhD, MAppSc

Trajectory of Competency

Development:

Entry Level RESIDENCY Fellowship

Learning and Professional

Development

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Entry-Level Education

• Competencies: CAPTE

• Established by our profession

• Mirror other professions

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Residency and Fellowship Education

• Currently competencies seated with each DSP

In the future competencies may be based in a

document specific to residency practice

• Core competencies – cross specialization

• Conclave held in November 2012

• Process of reaching common core competency

domains

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Existing Common Areas of DSP

Neurologic Competencies

• I. Knowledge Areas of

Neurologic Clinical Specialists

• II. Practice Expectations

– A. Professional Roles,

Responsibilities, and Values

• Leadership

• Education

• Consultation

• EBP

• Virtuous Behavior

– B. Patient/Client Management

Pediatric Competencies

• I. Knowledge Areas of Pediatric Clinical Specialists

• II. Professional Roles, Responsibilities, & Values– A. Professional Behaviors

– B. Leadership

– C. Education

– D. Administration

– E. Consultation

– F. EBP

– G. Research

• III. Practice Expectations

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Trajectory of Competency

Development:

Entry Level RESIDENCY Fellowship

Learning and Professional

Development

COMPETENCIES COMPETENCIES

40

Proposed Competency Domains

in Physical Therapy

Professionalism

InterprofessionalSkills &

Communication

Clinical Reasoning

Inquiry Skills

Systems-based Practice

Clinical Skills

Knowledge for

Practice

41

Competencies Across and

Within the ProfessionsProposed Common Core PT

Residency Competencies

Professionalism

Interprofessional

Skills & Communication

Clinical Reasoning

Inquiry Skills

Systems-based practice

Clinical Skills

Knowledge for practice

Medical Core Competencies

Professional-

ism

Practice-

based learning

Systems-

based practice

Interpersonal &

communication skills

Patient care

Medical

knowledge

Interprofessional

Collaborative

Practice

Competency Domains

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Examples of

Competency Development

• Knowledge for practice

– EL: general, broad base

– R: deeper, specialized

– F: refined, highly specialized

• Clinical reasoning

– EL: competent; may be proficient in some aspects

– R: highly proficient/some aspects of expertise

– F: expertise in subspecialty practice area

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Knowledge for

Practice

DPT Education:

The Wading Pool

44

Knowledge for Practice

Residency Education:

The Lap Pool

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Knowledge for Practice

Fellowship Education: The Dive Pool

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Interprofessional Collaborative

Practice Competency Domains

Values/Ethics for IP

Practice

Roles & Responsibilities

Teams & Team Work

IP Communication

Patient &

Family

Centered

Community

&

Population

Oriented

Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for

interprofessional collaborative practice: Report of an expert panel. Washington, D.C.:

Interprofessional Education Collaborative. 47

Proposed Competency Domains in

Physical Therapy

• Knowledge for practice

• Clinical reasoning

• Inquiry skills

• Clinical skills

• Systems-based practice

• Interprofessional skills & communication

• Professionalism

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February 5, 2015



Discussion Points

• What feedback do you have on the 7

proposed common competency domains (on

previous slide) we have offered for all PT

residency/fellowship programs?

49

Stakeholder Discussant Panel

Greg Hartley, PT, DPT, GCS,

Karen Paschal, PT, DPT, MS, FAPTA

Terry Nordstrom, PT, EdD

Proposed Competency Domains in

Physical Therapy

Professionalism

InterprofessionalSkills &

Communication

Clinical Reasoning

Inquiry Skills

Systems-based Practice

Clinical Skills

Knowledge for

Practice

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February 5, 2015



Discussion Points

• Final comments & wrap up

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References

• Birney DP, Beckman JF, Wood RE. Precursors to the development of flexible expertise: Metacognitive self-evaluation as antecedences and consequences in adult learning. Learning and Individual Differences. 2012;22(5):563-574.

• Billet S, ten Cate O. Competency-based medical education: origins, perspectives, and potentialities. Med Educ. 2014;48:325-332.

• O’Brien B. Envisioning the Future. In: Hafler J, ed. Extraordinary Learning in the Workplace. New York: Springer. 2011; 165-194.

• O’Brien BC, Irby D. Enacting the Carnegie Foundation call for reform of medical school and residency. Teach Learn Med. 2013; 25(S1): S1-S8.

• Expert practice in physical therapy. In: Jensen GM, Gwyer J, Hack LM, Shephard KF. Eds. Expertise in Physical Therapy Practice. 2nd ed. St. Louis, MO: Elsevier; 2007: 168.

• Carraccio C, Benson B, Nixon J, Derstine P. From the educational bench to the clinical bedside: translating the Dreyfus developmental model to the learning of clinical skills. Acad Med. 2008; 83:761-767. 53

References• Miller GE. The assessment of clinical skills/competence/performance. Acad Med.

1990; 65: 563-7.

• ten Cate O, Billet S. Competency-based medical education: origins, perspectives,

and potentialities. Med Educ. 2014;48:325-332.

• Cooke M. A more ambitious agenda for medical education research. JGME. 2013;

5: 201-202.

• Hayward LM, Black LL, Mostrom E, Jensen GM, Ritzline PD, Perkins J. The first two

years of practice: A longitudinal perspective on learning and professional

development of promising novice physical therapists. Phys Ther. 2013; 93: 369-

383.

• Jones S, Bellah C, Godges J. A comparison of professional development and

leadership activities between graduates and non-graduates of physical therapists

clinical residency programs. JOPTE. 2008;22: 85-88.

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References

• Kulig K. 18th John H.P. Maley Lecture: Residency education in every town: is it just so simple?

Phys Ther. 2014;94:151–161.

• Smith K, Tichenor CJ, Schroeder M. Orthopedic residency training: A survey of the graduates

perspective. JOSPT. 1999;29:635-655.

• Association of American Medical Colleges. Core Entrustable Professional Activities for

Entering Residency (CEPAER). November 2013.

• Baron R. Can we achieve public accountability for graduate medical education outcomes?.

Acad Med. 2013; 9:1199-201.

• Carraccio C, Englander R. From Flexner to competenices: reflections on a decade and the

journey ahead. Acad Med. 2013;88: 1067-1073.

• Englander R, Cameron T, Ballard A, Dodge J, Bull J, Aschenbrener C. Toward a common

taxonomy of competency domains for the health professions and competencies for

physicians. Acad Med. 2013; 88: 1088-1094. 55

References

• Srinivasan M, Li S, Myers F, Pratt D, Collins J, Braddock C, Skeff K, West D, Henderson M, Hales R, Hilty D. Teaching as a competency: Competencies for medical educators. Acad Med. 2012;86:1212-1220.

• Interprofessional Education Collaborative Expert Panel. Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative, 2011.

• ten Cate O, Snell L, Mann K, Vermunt J. Orienting teaching toward the learning process. Acad Med. 2004; 79:219-228.

• ten Cate O, Scheele F. Viewpoint: Competency-based postgraduate training: can we bridge the gap between theory and clinical practice. Acad Med. 2007;82: 542-547.

• Relationship of GME to Industry and Other Funding Sources ACGME—October 2011—2: http://www.acgme.org/acgmeweb/Portals/0/PFAssets/PublicationsPapers/GME-Funding-Industry-Other-Sources.pdf

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References

• Accreditation Council for Graduate Medical Education. Common program requirements: general competencies. – August 2011: https://www.acgme.org/acgmeweb/tabid/429/ProgramandInstitutionalAccreditation/CommonProgramRequirements.aspx

• Rider E. and Namotniak R, eds. A Practical Guide to Teaching and Assessing the ACGME Core Competencies. hcPro: 2007.

• Iglehart J. The Residency Mismatch. N Engl J Med. 2013, 369;4: 297-299.

• Badner V, Ahluwalia KP, Murrman, MK et al. A competency-based framework for training in advanced dental education. Journal of Dental Education. 2010, 74;2: 130-139.

• Neurologic Physical Therapy Description of Specialty Practice, Specialty Council on Neurologic Physical Therapy, American Board of Physical Therapy Specialties, 2004.

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February 5, 2015



References

• Pediatric Physical Therapy Description of Specialty Practice, Specialty Council on Pediatric Physical Therapy, American Board of Physical Therapy Specialties, 2011.

Website References

• www.acgme.org

• www.ashp.org

• www.ada.org

• http://www.adea.org/dental_education_pathways/Pages/AfterDentalSchool.aspx

• http://www.ada.org/en/education-careers/dental-student-resources/career-options-after-dental-school/understanding-advanced-dental-education/program-options-and-descriptions

• www.apa.org/ed/accreditation/about/coa/

• www.aoa.org/optometrists/for-educators/accreditation-council-on-optometric-education?sso=y

• http://www.abptrfe.org

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Documents

Domains of Professional Competence APTA Combined Sections ... · Domains of Professional Competence APTA Combined Sections Meeting ... – Dreyfus & Dreyfus Model of Skill ... •Accreditation