EPAs in the undergraduate medical curriculum Lessons learned

Experiences from across the pond

Olle ten Cate, PhDUniversity Medical Center Utrecht, the Netherlands*

*Thanks to Lisanne Welink MD, Margot Weggemans MD, Suzanne van der Velden MD, Sanne van den Munckhof MD, Marijke van Dijk MD PhD - all UMC

Utrecht

Med Ed Grand Rounds UCSF, October 14, 2015

No conflict on interest to be reported

Financial support received from EU’s 7th Framework Programme, under grant agreement 619349 (WATCHME).

Content – lessons from UMC Utrecht

For consideration when developing EPAs for UME:1. EPAs were not conceived for UME2. Background: Utrecht UME curriculum development3. Identifying the EPAs4. What are adequate levels of supervision 5. Entrustment before entrustment decisions6. Nesting specific EPAs within general EPAs7. Translation into examination rules8. Faculty buy-in 9. When are EPAs EPAs and when not?

EPAs were not conceived for UME

• Essence: bringing trainees to an adequate level for unsupervised practice

• Serving competency-based medical practice through competency-based medical education

• CEPAER initiative has given the impression that EPAs should be mastered before residency;

cf McGaghie et al, AcadMed Nov. 2015:

EPA’s may be used in UME but..

• They are not end stage of summative entrustment for unsupervised practice

• They require careful consideration regarding a number of critical issues

• Role of EPAs and entrustment in years before UME graduation still unclear

• Not all important objectives for UME may be captured in (only) EPAs

Involved are a Curriculum Committee CRU+ (including junior MD staff of Education Center) and groups of faculty, established to develop new courses and clinical clerkships

Utrecht UME curriculum developmentcurriculum

Features of current UME curriculum• Two closely connected phases (3yr Bachelor

-3yr Master)• Integration of basic sciences in 5-week

almost full time ‘blocks’ in first two years (B1+B2)

• Much small group work; limited lectures; constructivist philosophy, not fully PBL

• Early clinical rotations in B3 year (6 weeks internal medicine; 6 weeks surgery), intermittent blocks

• PGY 6: transition to residency: longer clerkships, more responsibility

New features in CRU+ (from 2015)Bachelor phase• Qualitative entrance selection; no lottery• Focus on knowledge retention. Repeated

testing of knowledge. Students must pass block tests and four “CRUX” tests (each including the content of one semester)

• B3 will include an integrated clerkship of 12 weeks (internal medicine, surgery and family medicine)

• Every student adopts a panel of 4 patients or families for 3 years from one family medicine practice

New features in CRU+ (from 2016)Master phase• M1 & M2: 4 units of 6 block weeks

preparing for 12 consecutive weeks of longitudinally integrated clerkship (LINKs), each including 2-4 disciplines

• Every student has own clinical preceptor for each LINK

• EPAs form central feature in the structure and assessment in LINKs

• M3 will not change much, but core EPAs for entering residency will feature too.

Block LINK GREENFamily medicineInternal medicineSurgery

Block LINK REDPediatricsObGynClinical genetics

Block LINK BLUENeurology PsychiatryGeriatrics

Block LINK YELLOWFamily medicine, ENT, Opthalmology, Public health, Dermatology

Block LINK PURPLEInternal medicineSurgeryEM, Anesthesiology

Ma

1Ba

3M

a 2

START: Super-vised Training in• Attitude• Research• Teaching

Sub-internship Elective Research term ElectiveM

a 3

Elective

Elective

Ba 2

Ba 1

Non-clinical block

Non-clinical block

Non-clinical block

Non-clinical block

Non-clinical block

Non-clinical block

Non-clinical block

Non-clinical block

Non-clinical block

Non-clinical block

Non-clinical block

Non-clinical block

Non-clinical block

Non-clinical block

Non-clinical block

Non-clinical block

Non-clinical blocks and elective

Identifying the EPAs

Resources • Dutch national Framework of Objectives for UME

(legally binding)• AAMC Core EPAs for entering residency (13)• A proposed German list of EPAs (Charité U Berlin)Iterative construction of EPA framework• July 2014: 10 EPAs• September 2014: 9 EPAs + 2 integrative Ma3

EPAs• June 2015: 2 Ba-EPAs, 8 Ma1/Ma2 EPAs, 2 Ma3

EPAs• August 2015: 2 Ba3 EPAs; 5 graduation core EPAs

1 Checking basic vital functions of a stable adult patient2 Gathering and reporting basic general patient information that does not

require investigations3 Requesting and collecting basic bodily materials4 Conducting simple therapeutic acts5 Gathering and reporting basic specialty-specific patient information that

does not require investigations6 Requesting, interpreting and sharing basic diagnostic investigations 7 Design and initiating a treatment plan for common disorders8 Breaking bad news to patients and family about non-terminal conditions 9 Conducting basic specialty-specific procedures10

Acting as primary-responsible caregiver for a small ward

UME EPAs first iteration

1 Checking and reporting basic vital functions of a stable adult patient2 Gathering and reporting basic general patient information of a stable adult

patient 3 Requesting and collecting basic bodily materials of stable adults 4 Conducting simple therapeutic acts on a stable patient 5 Requesting, interpreting and sharing results of basic diagnostic

investigations 6 Designing and initiating a treatment plan for common disorders7 Breaking bad news to patients and family about non-terminal, non chronic

conditions 8 Recognizing and acting on an emergency situation in the hospital9 Caring for a patient around end-of-life decisions10 Managing an inpatient ward (integrates 1-9)11 Managing an outpatient clinic (integrates 1-9)

UME EPAs - second iteration

1 BA3 Vital parameters2 BA3 Basic medical procedures3 MA1/2 History and general physical examination4 MA1/2 Common procedures of the physician5 MA1/2 Conducting simple therapeutic acts on a stable patient6 MA1/2 Requesting, interpreting and sharing results of basic diagnostic

investigations7 MA1/2 Designing and initiating a treatment plan for common disorders8 MA1/2 Breaking bad news to patients and family about non-terminal,

non-chronic conditions9 MA1/2 Recognizing and acting on an emergency situation in the hospital10 MA1/2 Caring for a patient around end-of-life decisions11 MA3 Managing an inpatient ward12 AM3 Managing an outpatient clinic

UME EPAs - third iteration

1 The Clinical Consultation2 General Medical Procedures3 Informing and Advising Patients and their Families4 Intercollegial Communication5 Care Under Unsusual Conditions

UME EPAs - fourth iteration

1 The Clinical Consultation

• Taking a medical history• Performing physical examination • Prioritizing a differential diagnosis• Requesting common diagnostic tests• Interpreting diagnostic tests• Designing a treatment plan

2 General Medical Procedures

• Capillary blood taking• Venous blood withdrawal and taking a blood culture• Swabs: oral, nasal, ears, skin, anal or wounds • Giving infusions • Ankle brachial index• Administering a simple bandage and scarf bandage • Urethral catheterization• Suturing and injection of local anesthetic to skin • Perform an ECG• Give intracutaneous, subcutaneous

or intramuscular injections • Arterial blood gas

UME EPAs - fourth iteration

3 Informing and Advising Patients and their Families

• About diagnostic options (incl informed consent) • About prognosis (incl breaking bad news)• About therapeutic options (incl compliance and

obtaining informed consent)

4 Intercollegial Communication

• Discharge letter• Oral handover • Consulting other care providers• Refer to other care providers• Report on medical errors • Give oral patient or research presentation

5 Care Under Unsusual Conditions

• Establishing patient death • Basic and advanced life support

UME EPAs - fourth iteration

UMCU: EPA 1

EPA 2

EPA 3

EPA 4

EPA 5CEPAER

EPA 1: Gather a history and perform a physical examination X

EPA 2: Prioritize a differential diagnosis X

EPA 3: Recommend and interpret common diagnostic and screening tests

X

EPA 4: Enter and discuss orders and prescriptions X X

EPA 5: Document a clinical encounter in the patient record X X

EPA 6: Give an oral presentation of a clinical encounter X X

EPA 7: Form clinical questions and retrieve evidence X

EPA 8: Give or receive a patiënt handover X

EPA 9: Collaborate as a member of an interprofessional team X

EPA 10: Give urgent or emergent care X

EPA 11: Obtain informed consent X

EPA 12: Perform general procedures of a physician X

EPA 13: Identify system failures and contribute to a culture of safety and improvement

X

UMCU EPAs versus AAMC Core EPAs

What are adequate levels of supervision?Issue: Existing entrustment and supervision scale not satisfactory

• Too little gradation in first levels of supervision • Levels 4 and 5 will not be reached during UME

Existing PGME entrustment and supervision scale

1 Not allowed to practice EPA2 Allowed to practice EPA only under proactive, full supervision3 Allowed to practice EPA only under reactive/on-demand

supervision 4 Allowed to practice EPA unsupervised5 Allowed to supervise others in practice of EPA

PGME entrustment & supervision scale UME entrustment & supervision scale (Chen et al 2015, Academic Medicine)

1. Not allowed to practice EPA 1a: Not allowed to observe EPA1b: Allowed to observe EPA

2. Allowed to practice EPA only under proactive, full supervision (direct)

2a: As coactivity with supervisor

2b: With supervisor in room ready to step in as needed

3. Allowed to practice EPA only under reactive/on demand supervision (indirect)

3a: With supervisor immediately available, all findings double checked3b: With supervisor immediately available, key findings double checked3c: With supervisor distantly available (e.g. by phone), findings reviewed

4. Allowed to practice EPA unsupervised 4. Allowed to practice EPA unsupervised 5. Allowed to supervise others in practice of EPA

5. Allowed to supervise others in practice of EPA

But, early 2015, there was Carrie Chen et al.

Issue No early full (‘summative’) entrustment possible yet, but 1. Students need to practice with limited supervision 2. Student cannot always be directly supervised

How to justify that students already perform tasks with limited supervision

Entrustment before entrustment decisions

Entrustment before entrustment decisions

Approach

Ad hoc entrustment occasional permission to practice with limited supervision for educational purposes (to be confirmed every time)

Summative entrustment formalised, default permission to act with limited supervision

Nesting specific EPAs within general EPAs

Issue ‘Perform a physical examination’‘Prioritize a differential diagnosis’‘Recommend common diagnostic tests’

Many general skills of a physician require discipline-specific skills and knowledge

Nesting specific EPAs within general EPAs

Approach • Training of discipline-specific history,

physical examination and specific procedures in designated blocks and LINKs

• Integration in to full EPA in final (Ma3) year

Nesting specific EPAs within general EPAs

Issue ‘Perform a physical examination’‘Prioritize a differential diagnosis’‘Recommend common diagnostic tests’

General skills of a physician require discipline-specific skills and knowledge

EPA1: The Clinical Consultation

Specifications • medical history• physical examination • differential diagnosis• common diagnostic tests• treatment plan

Discipine-specific skills and knowledge

• Medical• Surgical• Pediatric• Gynaecological• Neurological• Psychiatric • Dermatological • ENT• Ophthalmologic

Nesting specific EPAs within general EPAsProcedures

• Capillary blood taking• Venous blood withdrawal and

taking a blood culture• Swabs: oral, nasal, ears, skin,

anal or wounds • Giving infusions • Ankle brachial index• Administering a simple

bandage and scarf bandage • Urethral catheterization• Suturing and injection of local

anesthetic to skin • Performing an ECG• Giving intracutaneous,

subcuta-neous and intramuscular injections

• Measuring arterial blood gas

EPA 2: general medical procedures 5th year students (Ma2)

EPA 2a: basic medical procedures 3rd year students (Ba3)

Nesting specific EPAs within general EPAsProcedures

• Capillary blood taking• Venous blood withdrawal and

taking a blood culture• Swabs: oral, nasal, ears, skin,

anal or wounds • Giving infusions • Ankle brachial index• Administering a simple

bandage and scarf bandage • Urethral catheterization• Suturing and injection of local

anesthetic to skin • Performing an ECG• Giving intracutaneous,

subcuta-neous and intramuscular injections

• Measuring arterial blood gas

EPA 2: general medical procedures 5th year students (Ma2)

EPA 2a: basic medical procedures 3rd year students (Ba3)

Translation to assesment rules & procedures

• No numerical final clerkship scores• End-of LINK qualifications [+expected percentages]:

• “Fail” [5% or less]• “Requires attention” [10 -15%]• “Good” [75 to 80%]• “Excellent” [10% or less]

• Dominant WBA tools:• Short practice observations• Case-based discussions• Patient presentations• Written reports on selected patients• Multi source professional behavior observation

Translation to assesment rules & procedures

• EPA summative entrustment decisions in final year, fed by ‘nested’ small specific ‘EPAs’

• Decision by local director of subinternship + advice by longitudinal family medicine mentor

Required for graduation:• All EPAs must be trusted on Level 3a (indirect

supervision, all findings checked); Level 3b (key findings checked) or 3c (review only) exceeds standard expectation

• E-portfolio support for feedback and entrustment decision making is being prepared

Faculty buy-in

• While EPAs usually make ‘intuitive sense’, nailing down the EPAs and translation to teaching and assessment, requires explanation and adequate understanding

• A recommendable procedure appears monitoring the active role of clinical teachers in development of procedures in the workplace

• Continuous returning to the definition of EPA• Focus of discussion: when to leave students alone

When are EPAs EPAs and when not?

• “Identify system failures and contribute to a culture of safety and improvement”

• “scientifically active”• “Intercollegial communication”Titles are insufficient to determine this, operationalization of the (set of) acivities is necessary.Entrustable: Acts requiring trust – by colleagues, patients, society. Prohibited for unqualified persons.Professional: Confined to occupations with extra-ordinary legal qualification.Activities: Tasks that must be done. May be scheduled, may be listed in work descriptions.

Thank you