Approaching Milestones Documentation: Tricks, Tips, and Examples Describing What We Want in a Family Physician: From Competencies to Milestones Allen F Shaughnessy, PharmD, MMedEd Tufts University Family Medicine Residency At Cambridge Health Alliance

Where We’re Going What is the goal of the Milestones Process? The M&Ms of Assessment: Measurable and Meaningful The Goldilocks concept of assessment methods: Not too general, not too specific Using EPAs to document milestones

Milestone Purpose Residents can do what we think they can do Assure the public Evaluate residency training Line up curriculum with goals Resident feedback Competence/ confidence

The Problems with Milestones Not progressive < ?

The Problems with Milestones Multiple, conflicting definitions at each level

The Problems with Milestones Not directly measurable Which one(s)? On paper or in practice? Once, some of the time, most of the time?

Drilling down into a Milestone General Competency Statement: PC-1 “Cares for acutely ill or injured patients in urgent and emergent situations and in all settings”

Drilling down into a Milestone

Fitting the pieces Milestone Specific levels Measurable behavior Embodied competencies Assessment Unsupervised practice

PC-1 Cares for acutely ill or injured patients in urgent and emergent situations and in all settings Inside pics Level 1. Gathers essential information about the patient (history, exam, diagnostic testing, psychosocial context)

PC-1 Cares for acutely ill or injured patients in urgent and emergent situations and in all settings Inside pics Level 2. Consistently recognizes common situations that require urgent or emergent medical care.

PC-1 Cares for acutely ill or injured patients in urgent and emergent situations and in all settings Level 3. Consistently recognizes complex situations requiring urgent or emergent medical care.

PC-1 Cares for acutely ill or injured patients in urgent and emergent situations and in all settings Level 4. Coordinates care of acutely ill patient with consultants and community services.

PC-1 Cares for acutely ill or injured patients in urgent and emergent situations and in all settings Not all houses are the same!

Levels of Assessment Global Assessment (faculty review) “Pretty good physician” Geographic assessment (Precepting) “Good outpatient work” Professional Activity “Manages her patients with hypertension well” Competency Knows the definitions of the stages of hypertension Task Analysis Selects an appropriate cuff for blood pressure measurement

` Competency The ability to do something successfully; a quality or state of being Entrustable Professional Activity A professional activity; the “unit of work” that can be entrusted to competent doctor Milestones “Developmentally-based family medicine-specific attributes that family medicine residents can be expected to demonstrate as they progress through their programs.”

Miller’s Pyramid In action, over time OSCE, brief observation Testing Case discussion

Anatomy of an EPA Be able to demonstrate how to evaluate a patient with urinary symptoms (history, physical, laboratory tests to order) Be able to explain how to differentiate between uncomplicated and complicated urinary tract infection and pyelonephritis Be able to develop an appropriate treatment plan for patients with uncomplicated and complicated UTI and pyelonephritis, including hospitalization and phone treatment. Areas of competence + + Taking care of a patient with acute urinary symptoms Entrustable Professional Activity

From EPA to Milestones Taking care of a patient with acute urinary symptoms Entrustable Professional Activity PC1: Level 2 MK2: Level 1

EPAs link to Milestones The patient with acute urinary symptoms The woman with abnormal vaginal bleeding The patient with vomiting and/or nausea EPAs + + PC-1 Cares for acutely ill or injured patients in urgent and emergent situations and in all settings Milestone The patient with a cough + The patient with acute pain + + +

How to Measure Performance? Observation Behaviors Skills Communication Written reflection Attitudes Cognition Case discussions, chart review (“can do”) Precepting (“does”)

Points collected..

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The full picture of a learner

Drilling down into a Milestone Global Assessment

Competency Assessment