Core Competencies in Neurological Surgery: A Matrix Curriculum

1. Core Competencies in Neurological Surgery:A Matrix Curriculum Society of Neurological Surgeons American Board of Neurological Surgery ACGME Residency Review Committee for Neurological Surgery

2. The Matrix Project

3. Core Competencies • Synthesis • SNS • Committee on Resident Education (CoRE) • Content editor • ACGME • Format • ABNS • Medical Knowledge • RRC • Technical Skills Both organizations deal with medical knowledge and technical skills

4. Neurological Surgery Curriculum • Consistent with ACGME format • Core competencies • Consistent with ABNS • Primary exam content • Oral exam content • Consistent with RRC goals • Institutional • Chief Resident cases

5. Competencies • Objectives • ACGME Core Competencies • Primary exam categories, key words • RRC case categories • Teaching methods • Reading, lecture, modules, Bootcamp, hands on, etc • Assessment tools • PD, SANS, Primary exam, 360 evals, etc • Educational goals

6. Physician Performance Diagnostic Inventory Unsatisfactory Early Learner Progression Competent Proficient Expert

7. Unsatisfactory • Rarely demonstrates competence AND is unexpected to become competent within the assigned time frame. • Consistently makes poor decisions or has a consistently unsatisfactory approach to solving problems that results in poor care delivery or unacceptable behavior. • Repeatedly appears incapable of understanding concepts, performing tasks, exercising judgment or demonstrating behaviors that are important to show ability to learn the element being evaluated.

8. Early Learner • Demonstrates competence occasionally; usually shows ability to learn in routine, repetitive or non-stressful situations • Requires supervision • Incapable or inconsistent in using experience to address circumstances that are unexpected or non-typical • The early learner is at a novice level and shows aptitude but has not yet had sufficient experience, training or skill acquisition to achieve competence • Unlike the unsatisfactory (who believes they already know it all), wants to engage in learning

9. Competent • Demonstrates competence most of the time and under routine circumstances • Can perform without supervision in usual or predictable circumstances • Has developed adequate internal resources, knowledge or skills to make good decisions or perform acceptably in routine cases • IMPORTANTLY, the competent physician recognizes limitations and accesses support when needed, especially for more challenging situations • This is the level expected from those at the completion of training and indicates that they can effectively address the majority of routine situations and will access support when needed in other cases.

10. Proficient • Demonstrates competence most of the time and under most circumstances through applying intuition to guide an analytical thought process in complex and unpredictable situations • Has a good grasp of information, excellent skills and sound principles and applies them to guide actions in unusual or challenging circumstances • Is consistently trusted to deal effectively with complex problems • Has developed enough internal understanding, ability to flexibly apply knowledge and sufficient skills that they can reliably handle challenging situations without the need for external support.

11. Expert • Demonstrates competence almost always through understanding the conceptual whole with appropriate intuitiveness and adaptability to the circumstance • Can recognize errors or inadequacies in knowledge, judgment, skills or behavior in complex situations and is capable of effective remediation • Is a persuasive lifelong learner • Understands the contextual “whole” and is fluid and flexible in performance • Has a seeming 6th sense (or a well developed “internal gyroscope”) of how to respond to even the most unpredictable and challenging situations. Is a resource mentor, teacher, and role model in this area.

12. Physician Performance Diagnostic Inventory Unsatisfactory Fail Early Learner Junior Resident (R1-2)* Competent Senior Resident (R3-6)* Proficient Chief Resident/Junior Staff Expert Us *RRC definitions

13. Matrix Curriculum • Educational goals will vary • Training level • Subspecialty • Successful residents will not be EXPERT • Highest level of expectation will be PROFICIENCY • e.g., Complex spinal surgery • Lowest level will be EARLY LEARNER • e.g., Endovascular Surgical Neuroradiology

14. Matrix Curriculum

15. Matrix Curriculum Training Level : PGY1

16. Matrix Curriculum Training Level : PGY7

17. Cerebrovascular Competencies

18. Medical Knowledge • ABNS Primary Exam Categories • A: Anatomy • B: Neurobiology • C: Pathology • D: Imaging • E: Neurology • F: Neurosurgery • G: Critical Care • H: Core Competencies

19. Medical knowledge

20. Medical Knowledge

21. Medical Knowledge

22. Technical Skills RRC Case Categories (Proposed)

23. Matrix Curriculum • Adheres to ACGME format • Uses established goals of ABNS and RRC • Acknowledges levels of educational goals • Requires more integration of stakeholders • SNS • ABNS • RRC • It can be rapidly implemented • It is a dynamic process

24. Process for the Matrix Project • SNS, ABNS and RRC agree to proceed with Matrix Project • Pilot proposals under development in Neurointensive Care and Endovascular Surgical Neuroradiology • ABNS agrees to appoint SNS representatives to Primary Exam Committee • SNS bylaws change to place ABNS and RRC representatives on SNS Council (ad hoc)

25. Process for the Matrix Project • Orientation of Joint Section leadership to the Project • AANS annual meeting, Denver, CO April 10-14, 2011 • Orientation of SNS members to the Project • SNS annual meeting, Portland, OR May 21-24, 2011

26. Joint Sections Development of curriculum proposal Subspecialty specific curriculum initiation SNS Curriculum Sub-Committee Vet curriculum proposal SNS CoRE Committee Ensure proposal in Matrix format Final Approval of Matrix curriculum element SNS Council Pass proposal to SNS Members and PDs SNS Members and PDs Comments, suggestions, and revisions

27. The ACGME Milestones Project

28. ACGME Milestones Project • Translate “general” competencies into specific competencies to be met by all residents • Create “core” resident outcomes in the competencies, not “standardization” of all outcomes.

29. Current Curricula Choose educational experiences within institution, faculty Curriculum “time-based” “Educate” residents Identify/develop evaluation tools -formative -summative “Circumstantial Practice”

30. Future Curricula Design educational Experiences, rotations, faculty The required outcomes in each domain of Clinical Competency (Milestones) Produce proficient physicians National evaluation tools to measure outcome -formative and summative -clinical outcomes tracking New knowledge or skill set External accountability for outcome “Intentional Practice”

31. Entrustable Professional Activities • Equating competency with the point at which one is ready to practice a a static view • Competence is content and context specific • Notion of context fits well with Milestones and “entrustable professional activities” (EPAs)

32. Entrustable Professional Activities • Professional life activities that define the specialty • Ground the competencies in the everyday work of the physician • Activities lead to some output or outcome that can be observed • Complexity of the activities requires an integration of knowledge, skills, and attitudes across competency domains • 50-100 per specialty

33. Entrustment and Competence • Entrustment occurs when direct supervision is no longer needed • Faculty understand entrustment more than competence • Entrustment infers competence • Doesn’t suggest that graduating residents reach a standard of performance to practice every EPA without direct supervision • Opens the door for structured learning after residency as part of MOC

34. Back to the Future? • Similarities with Apprenticeship model • Relationships are critical • Assessment is embedded in a clinical setting taking care of real patients • Direct observation (not inference) is key • Differences from Apprenticeship model • Expanded competencies • Move from random to deliberate curriculum • EPAs and competencies require each other for meaning

35. Milestones Project Status • Draft products created • Internal Medicine • Pediatrics • General Surgery • Development underway • Urology • Obstetrics-Gynecology • Poised to begin • Opthalmology • Radiology • Transitional year • Neurological Surgery

36. Where Do We Start? • ACGME invitation or specialty expression of interest • Certification board and ACGME conversation • Decide on structure, working group chair, and membership • Get started with ACGME staff direction

37. Group Organization and Membership • Working group (n=10-15) MD educational experts (Board, RRC, PD organization); 2-3 ACGME staff • Advisory group (n=3-13) Organizational leaders (Board, ACGME, RRC, specialty organizations)

38. Charge to the Milestone Group • Develop milestones • Milestone – behavior, attitude, or outcome related to general competency domains that describe a significant accomplishment expected of a resident by a particular point in time • Identify assessment tools • Vital, since this is where Outcomes Project failed

39. Cerebrovascular Milestones

40. Summary • Neurological Surgery is a the beginning of a process to redefine residency curriculum • The Matrix Project • This project will coordinate the efforts of SNS, ABNS and the RRC • The AANS and CNS will participate through their Joint Sections, and Executive Committees • This process will converge with an effort by ACGME to redefine how residents are trained • The Milestones Project