Competency-based Medical Education An Overview with Attention to Narratives, Entrustments, and Milestones

1. Competency-based Medical EducationAn Overview with Attention to Narratives, Entrustments, and Milestones

2. Outline • Definition of CBME • Frameworks • Outcomes • Implication for GME training • Assessment and evaluation strategies • Narratives • Entrustable Professional Activities (EPAs) • Milestones

3. What does competency-based medical education means to you?

4. Competency-Based Medical Education The International CMBE Collaborators 2009 is an outcomes-based approach to the design, implementation, assessment and evaluation of a medical education program using an organizing framework of competencies

5. Framework - ACGME General Competencies • Medical knowledge • Patient care and procedural skills • Professionalism • Interpersonal and communication skills • Practice-based learning and improvement • Systems-based practice

6. So What is the Outcome and Who Determines it? The Profession? The Public? Policy Makers?

7. The Profession? • The “core” of Internal Medicine? • Competence in the six ACGME general competencies? • Safe and effective patient care? • The Public? • Trust that a doctor can do certain things? • Policy Makers? • Meeting the needs of the complex and aging US health population? • Medicare goals?

8. Traditional versus CBME: Start with System Needs Frenk J. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010 8

9. A new paradigm In Competency-Based Medical Education (CBME) we must truly know the trainee has demonstrated competence and is ready to progress to the next stage of their career: • Requires clear definition of expected competencies • Requires valid and reliable assessment and evaluation to confirm competency is consistently demonstrated in the clinical environment

10. The CBME Basics Outcome Data Assessment Curriculum

11. “Unsupervised Safe and Effective Patient Care Data Assessment Curriculum

12. Judgment or Attestation Evaluation – judgment about competence based upon available assessment data. Who makes the judgment that the outcome has been reached? The literature supports the benefit of: Group (competency committees) rather than individual decisions. Schwind,(2004), Williams,(2005) Thomas (2011) Narratives describing learners rather than numbers. Regehr, (2007), Crossley (2011)

13. “Unsupervised Safe and Effective Patient Care Portfolio of Criteria Referenced Data Assessment Curriculum

14. Clinical Competency Committee • Periodic review – professional growth opportunities for all • Early warning systems • Structured Portfolio • Entrustment-based assessment OSCE • Mini-CEX or CSR • Medical record audit/QI project • Clinical question log Multisource feedback • Monthly Evaluations • Research Project • Trainee contributions (personal portfolio) • Trainee • Review portfolio • Reflect on contents • Contribute to portfolio • Program Leaders • Review portfolio periodically and systematically • Develop early warning system • Encourage reflection and self-assessment Summative Assessment Process - FasTrack • Licensing, Certification, and Accreditation • ABIM • ACGME Assessment and Evaluation System: Components Advisor

15. “Safe and Effective Patient Care Portfolio of Criteria Referenced Data Entrustment Focused Assessment Curriculum

16. Assessment Challenges Ensure that assessment and evaluation of milestones document competence in those activities that define the profession – (the outcome!) Entrustable professional activities or EPAs? What the public (and the profession) trust physicians are capable of doing.

17. Entrustable Professional Activities EPAs represent the routine professional-life activities of physicians based on their specialty and subspecialty Why is a fellowship trained geriatrician different that a general internist? 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, Scheele F. Competency-based postgraduate training: can we bridge the gap between theory and clinical practice? Acad Med. 2007;82(6):542–547.

18. “Entrustment in GME” What do faculty and training programs “entrust” trainees to do? Progressive independence while delivering patient care Family meetings – determining “goals of care” Capture multiple competencies “work-based” entrustments serve as foci for assessment and evaluation What justifies these “entrustments”?

19. EPA in Practice ten Cate et al, 2007 • Individual faculty member making entrustment decision for a specific trainee • Level 1 – not allowed to practice EPA • Level 2 – practice with full supervision • Level 3 – practice with supervision on demand • Level 4 – “unsupervised” practice allowed • Level 5 – supervision task may be given

20. EPA in Practice • Program director with competency committee • Determine resident progression to next steps of training • Attestation to accreditation or certification bodies regarding developmental progression • Attestation to public that resident is entrusted to practice independently

21. “Safe and Effective Patient Care” Portfolio of Criteria Referenced Data Entrustment Focused Assessment Milestones

22. Milestones • A significant point in development. • The IM milestones • are organized by the ACGME general competency domains • define the abilities (K/S/A) expected of IM residents as they progress through training • Framed in behavioral terms • They are observable • Sets the stage for assessment of competence

23. Patient Care RRC sub-bullet

24. Tracking the Learner Fully Competent A B C Finish PGY3 Start PGY1 A’ Lucey and Boote EPA based assessment

25. Putting It All Together Entrustable Professional Activities, Entrustment in GME, and Assessments

26. Attestation of Competency In Desired Outcome Portfolio (Entrustment/ EPA generated assessment data) Entrustment -focused Assessment Entrustment-focused Assessment Entrustment-focused Assessment Selected key milestones Selected key milestones Selected key milestones Milestones = discrete K/S/A expected of learners as they progress through training

27. Lead a Health Care Team Lead a Resident Team (Competency Committee) Multisource Feedback (Health Care Team) Direct Observation (Core Faculty) Chart Stimulated Recall (Core Faculty) P-Communicates feedback to health care team IPCS-Role model/teach effective communication during transitions of care PBLI-Actively participate in teaching conferences SBP-Minimize unnecessary care PBLI-Classify and articulate clinical questions PC-Develop prioritized DDx for common inpt and outpt conditions IPCS-Effective team communication SBP-Understands roles of team and system PBLI-Welcomes feedback

28. Code Team Leader (18 month) COMPETENCE Ward Supervisor (24 month) Distance Supervision in Ambulatory (6 month) Running Family Meeting (30 Month) Nightfloat (12 month) Caverzagie

29. The Pace of Change?

30. Questions