Olle ten Cate

1. U of Leeds - 11 Jan 2010 - Critical Perspectives on Professional Learning New conceptualisations of professional work: entrustable professional activities and the implications for lifelong learning Olle ten Cate Centre for Research and Development of Education at University Medical Centre Utrecht

2. Overview • Four problems of medical training • Competency-based medical training: why must we go for it, and what are the risks? • Objectives of medical education viewed as a portfolio of attainments • The future: crossing horizontal and vertical boundaries between educational tracks?

3. Some problems that medical education faces Problem 1. Fully trained physicians are too old, too smart, and too expensive* *Bleker & Blijham, 1999

4. Some problems that medical education faces Problem 2. Physicians do not keep up with information growth in medicine Physicians’ minds cannot store but a fraction of available, relevant knowledge Essential new medical knowledge often does not reach practice

5. Some problems that medical education faces Problem 3. Training potentially threatens patient safety And patient safety issues potentially threaten medical training, paradoxically endangering future patient safety

6. Some problems that medical education faces Problem 4. Trainees cannot anymore be “exploited” to work/train 80 hours or more per week European working time directive: max 48 hrs How do we accomodate this loss of clinical experience?

7. In conclusion, we need: • fewer years in formal training, but more serious life long learning requirements • to stop pretending to teach and train all there is to be known • to prepare trainees for safe health care, using less trial and error during training • more efficient use of training time, if we have less of it

8. Competency-based medical education? What is CBME? Why is it a “paradigm shift”*? Why does it meet with mixed feelings? How does it relate to our problems? Reconceptualisation of competency-based training in the medical domain *Carraccio et al, 2002

9. Features of genuine CBME • Outcome-based, not process-based: what is attained is key, not just what is done • Focus on competencies that integrate knowledge, skill, attitude • Time-independent: length of training for defined outcomes is not pre-set • Individualized: trainees and contexts are not identical • Particularly applicable in workplace-learning

10. Why should we go for it? • It focuses on the real thing: competence • It may enforce more effective training • It may provide better a guarantee for well trained physicians • It can turn a workplace into a learning environment

11. Why is CBME a paradigm shift? • workplaces typically do not assess competencies well • competence is rather assumed after pre-set rotation periods • time-independent workplace learning is hardly ever organized, or even tried • individualized training requires a different look at supervision

12. Current risky practice of CBME • Outcome-based competency-frameworks: CanMEDS (Canada, many other countries, a.o. the Netherlands), ACGME (USA), Modernising Medical Careers (UK) • Competency frameworks read nice, but are complex to implement • The original aim, i.e. targeting real, relevant outcome, tends to get out of sight

14. Where it goes wrong • Competence is decomposed in competencies • Competencies are further decomposed in (thick, unread) documents with “teachable and assessable” elements • Integration and connection with health practice gets lost • Targeted methods to teach subcompenties are rare • Instruments to validly asses sub-competencies lack • Second-best methods get used: self-assessment, reflective portfolios • Regulatory bodies start enforcing unnatural teaching behaviour • Bureacracy overwhelms the fun of teaching and training Grant, 1999; Talbot, 2004; Spence, 2009; Pereira & Dean 2009; Lurie et al, 2009

15. Postgraduate medical Foundation Program, yr 2 obligations(www.foundationprogramme.nhs.uk)

16. CBME loses its glare... • CBE and “New Learning” in Dutch secondary education has become a national disaster • CBME evokes criticism in the UK • CBME in Canada and the USA are in need of support • Professional teacher responsibility decreases • Not because of its essence; because how it is implemented and regulated.

17. What makes professionals tick* • Sense of autonomy • Sense of competence • Sense of relatedness, i.e. being valued by significant others Professional pride in clinical educators is at stake. Can we revive their role?** *Self-determination Theory, Ryan & Deci, 2000; **Ten Cate, 2006

18. Is there a way out? • Redefine competence • Start with concrete clinical activities, then link these to competency domains • Value individual differences • Capitalise on professional judgment of competence by clinicians • Take deliberate “decisions of entrustment” for concrete “entrustable” activities • Build an “attainments portfolio” to document competence in a CBE curriculum

19. Competence. What would like to use as criterion to select your doctor? • Has she passed all her tests and exams? • How long has she taken to finish her studies? • What were her grades in skills exams? • Will she follow protocols well? • Can I trust that she will manage my case in the best possible way?

20. Does Shows How Knows How Knows Miller’s Pyramid Behaviour in the workplace Behaviour in simulation exams Applied knowledge Factual knowledge

21. Results (impact) Behavior (transfer to workplace) Learning (knowledge and skills) Reaction (recognition, satisfaction) Kirkpatrick’s hierarchy of education outcomes Addition of “external” outcome parameters Conventional assessment procedures

22. Primary focus • Primary focus: critical activities, successfully carried out • Secundary focus: domains of competence in the trainee, required for it Any clinical teacher will understand the primary focus, many have problems valuing the second

23. CBME in practice • Acknowledge (“certify”) competence for essential clinical activities once they are observably mastered • View a license as a “set of certificates”, all attained during postgraduate training (constituting an “attainments-portfolio”) • “Finish” training once the attainments-portfolio is sufficiently filled

24. The Entrustable Professional Activity • is part of essential professional work in a given context • is independently executable, within a time frame • leads to recognised output of professional labour • is observable and measurable in process and outcome, leading to a conclusion (‘well done’ or ‘not well done’) • requires specified knowledge, skill and attitude, generally acquired through training • is usually confined to qualified personnel only • should reflect competencies, important to be acquired EPAs together constitute the core of the profession Ten Cate, 2005

25. Competencies EPAs person-descriptors work-descriptors knowledge, skills, attitudes, values essential parts of professional practice content expertise collaboration ability communication ability management ability professional attitude scholarly approach perform a vena puncture perform an appendectomy treat a skin laceration risk assessment for surgery request organ donation design a therapy protocol Competencies vs Activities

26. Competencies-activities grid activi-ties can be obser-ved and assessed competencies are to be inferred

27. When is “competence” reached? • when a professional activity is mastered • ...on a threshold level • ...that permits unsupervised practice • ...and full entrustment Competence may be viewed as one stage on a continuum

28. Growth of competence over time

29. Learning curve in surgical trainees Tassios et al. Endoscopy 1999;31:702-706

30. Quality of care related to cases seen by internists Hayashino et al. BMC MedEduc 2006,56:33

31. Increase of skills in anesthetists Konrad et al., Anest Analg. 1998;86:635-639

32. training deliberate professional practice Growth of competence over time expert proficient competent advanced novice Cf Dreyfus & Dreyfus, 1986

33. Competence and trust • Entrustment decisions imply a competence recognition • It happens all the time: when trainees suddenly are asked carry out critical tasks (e.g., in a night shift) • How deliberate and individual should such decisions be?

34. EPA4 EPA2 EPA3 EPA1 Compe- tence EPA5 thres- hold Justified entrustment decisions training deliberate professional practice Competency curves of one trainee Ten Cate et al, sumbitted

35. EPA4 EPA2 EPA5 EPA1 Compe- tence EPA3 thres- hold training deliberate professional practice Another person Justified entrustment decisions Ten Cate et al, submitted

36. CBME requires flexibility Intra-trainee variation: professional skills do not reach competence threshold levels at the same time in one trianee, i.e. all at graduation Inter-trainee variation: residents differ in prior knowledge & skills, learning ability, general attitude --> variation in how much and how fast they learn Context variation: clinical opportunities, requirements of local practice (epidemiology, facilities, culture), education-mindedness of staff Opposed to the current one-size-fits-all training

37. CBME requires personalisation • Postgraduate medical training has moved toward standardisation and metrics • The supervisor’s subjective professional judgment should be revalued • Competence simply is not fully ‘objective’, but the interplay of personal ability and the working context* Next: an example from physician assistant training *Ten Cate et al, submitted

38. How working with EPAs fits with CBMEThe case of the Physician Assistant workplace curriculum* • PA: a new profession in health care • PAs must alleviate doctor workload by taking over medical tasks • The Dutch 2.5 yr course includes a 2.5 yr parttime workplace attachment • The PA workplace curriculum is now fully designed as CBME and EPA-based *Recent development project at UMC Utrecht; Mulder et al - in preparation

39. How working with EPAs fits with CBMEThe case of the Physician Assistant workplace curriculum • PAs are recruited from nursing an allied health personnel with varying background • A clinical supervisor (MD) designs the curriculum with well described EPAs • PAs build an attainments portfolio of EPAs that serves as diploma attachment and CV • PAs have identical core curriculum, but vastly different workplace curricula • License will be based on a set of EPAs

40. Example: Planned neurology workplace curriculum for a particular PA in training

41. Training of “Care for patients with lumbosacral radicular complaints” Planned entrustment decision and documentation “Independent” practice Example: Planned neurology workplace curriculum for a particular PA in training(1 Block = 10 weeks)

42. Level of supervision is adapted • Level 1: not allowed to practice the 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 Competence threshold reached; formal entrustment decision, “STAR” (Statement of Awarded Responsibility) is documented in portfolio and in institutional registers, after confirmation by three staff members

43. Why can patient safety benefit? • Supervisors must deliberately consider the level of supervision for each (major) critical task for each trainee • Current practice: clinicians (anesthesiology) have little idea what level of supervision matches trainee progress* *Sterkenburg et al. submitted

44. CBME, EPAs and lifelong learning • If a doctor’s competence is defined by a portfolio of attained EPAs, there is less need for a fixed time frame • Specialists may add EPAs to their CV “after training” • Trainees may add EPAs from neighboring disciplines • In general - horizontal and vertical boundaries may be crossed

45. CBME, EPAs and lifelong learning • If postgraduate training time is limited, EPAs may be added during the whole working life, while working and training stay connected • Imagine a postgraduate medical course of 5 years, reduced to 3 years - in stead, the volume of 2 years of training vertically spread out over 10 years, 1 day a week of serious learning and teaching, and mastering new EPAs...

46. Model I Model II year13 year12 year11 year10 year 9 year 8 year 7 year 6 year 5 year 4 year 3 year 2 year 1 Mo Tue Wed Thu Fri Mo Tue Wed Thu Fri

47. Not all our problems can be solved.. • .. but competency-based education may help a bit, if well applied....

48. References used • Carraccio C, Wolfsthal SD, Englander R, Ferentz K, Martin C. Shifting paradigms: from Flexner to competencies. Academic Medecine. 2002; 77: 361-7. • Dreyfus HL, Dreyfus SE. Mind Over Machine. New York, NY: Free Press; 1988 • Grant J. The Incapacitating Effects of Competence: a Critique. Adv in Health Sc Educ.1999;4:271-277. • Hayashino Y, Fukuhara S, Matsu Ki, Noguchi Y, Minami T, Bertenthal D, Peabody JW, Mutoh Y, Hirao Y, Kikawa K, Fukumoto Y, Hayano J, Ino T, Sawada U, Seino J, Higuma N, Ishimaru H. Quality of care associated with number of cases seen and self-reports of clinical competence for Japanese physicians-in-training in internal medicine. BMC Medical Education 2006, 6:33 doi:10.1186/1472-6920-6-33 • Konrad C, Schupfer G, Wietlisbach M, Gerber H. Learning Manual Skills in Anesthesiology: Is There a Recommended Number of Cases for Anesthetic Procedures? Anesth Analg 1998;86:635-9 • Lurie SJ, Mooney CJ, Lyness JM. Measurement of the general competencies of the Accreditation Council for Graduate Medical Education: a systematic review. Acad Med 2009;84:301–309 • Mulder H, ten Cate O, Dalder R, Berkvens J. Building a competency-based workplace curriculum around entrustable professional activities: the case of physician assistant training • Pereira EAC, Bean BJF. British surgeons’ experiencs of mandatory online workplace-based assessment. J R Soc Med 2009;102:287-293 • Ryan RC, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist 2000:55(1): 68-78 • Spence D. The errr portfolio. BMJ 2009;339:b2863 • Sterkenburg JA, Barach P, Kalkman CJ, Gielen M, Ten Cate ThJ. Supervising Physicians’ Decisions to Entrust Residents with Unsupervised Tasks (submitted) • Talbot M. Monkey see, monkey do: a critique of the competency model in graduate medical education. Med Educ. 2004;38:587–592. • Tassios PS, Ladas SD, Grammenos I, Demertzis K, Raptis SA Acquisition of Competence in Colonoscopy: The Learning Curve of Trainees Endoscopy 1999; 31 (9): 702–706 • Ten Cate O. Entrustability of professional activities and competency-based training. Medical Education 2005;39:1176-1177 • Ten Cate O. Trust, Competence and the Supervisor’s role in Postgraduate Training. BMJ 2006;333:748-751 • Ten Cate O, Scheele F. 2007. Competency-based postgraduate training: can we bridge the gap between educational theory and clinical practice? Acad Med 2007; 82:542–547. • Ten Cate O, Snell L, Carraccio C. Medical competence: The interplay between individual ability and the health care environment. Medical Teacher (accepted for publication)