The Milestone Project For Neurosurgical Resident Coordinators

The ACGME currently measures a program’s potential to educate by determining compliance with existing Requirements. Questions such as the following guide the accreditation process as we now know it: 1. Does the program comply with the Requirements? 2. Does the program have established objectives and an organized curriculum? 3. Does the program evaluate its residents and itself?

Rather than concentrating only on assessment of a program’s potential to educate, the future for GME accreditation envisioned by the ACGME Outcome Project emphasizes a program’s actual accomplishments through assessment of program outcomes.

1. Incorporation of a set of general competencies to organize curricula. 2. Support for programs through identification and development of useful, reliable, and valid methods of teaching the competencies. 3. Development of model resident evaluation systems to provide examples of dependable evaluation. 4. Support of a resources support system. Outcome Project activities designed to bring about these changes and to support programs in their implementation include:

The six general competencies are: Patient Care Medical Knowledge Professionalism Systems-based Practice Practice-based Learning and Improvement Interpersonal and Communication Skills

Outcomes project stalls Competencies never integrated into the curriculum Tools to teach competencies are weak Tools for evaluation were slow in coming

Patient Care Medical Knowledge Professionalism Systems-based Practice Practice-based Learning and Improvement Interpersonal and Communication Skills

Pre-requisites for Getting Milestones Right Reframe the competencies in the meaningful context of clinical care Define milestones which can be measured of assessed Define assessable criteria for when a milestone is reached Develop a continuum of education, training and practice

“Entrustable Professional Activities-EPAs” Professional life activities that define the specialty per specialty Each activity can be broken down into elements Ground the competencies in the everyday work of the physician Competency in an element can be measured by some output or outcome that can be observed Complexity of the activities requires an integration of knowledge, skills, and attitudes across competency domains Ten Cate O, Scheele F. Competency-based postgraduate training: Can we bridge the gap between theory and clinical practice. Acad Med;2007:82:

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

Example EPA Caring for a well newborn Know maternal conditions that affect the infant Perform a comprehensive exam to discover congenital anomalies Apply evidence-based guidelines for newborn care Speak to the mother using language that she understands Demonstrate respect for the mother’s cultural background and child-rearing practices Connect with the community pediatrician for transfer of care

Evaluation and treatment of a patient with a subarachnoid hemorrhage PGY-1: knows vascular anatomy knows differential diagnosis PGY-2: initiate patient workup for patient with SAH interprets imaging studies reviews literature on outcomes supervises patient transfer to post hospital facility PGY-4: manages patient with high grade SAH supervises treatment of vasospasm educates and comforts family of a patient with a high grade SAH PGY-6: leads evidence based discussion of treatment options for treatment of intracranial aneurysm performs surgical approach to a common aneurysms

Dreyfus Model Novice-applies rules and facts without context Advance beginner-considers the specific features of a concrete situation Competent-breaks down the problem and considers each step. Takes responsibility Proficient-solves problems with intuition that comes from experience Master-innovates

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 Moved from random to deliberate curriculum EPAs and competencies require each other for meaning

Lessons Learned Competencies are implicit in care delivery They come alive in a clinical context, therefore… Reframing competencies in a clinical context is critical

Entrustment Decisions We make them every day when we work clinically with learners EPAs provide the mechanism for formalizing this process] Direct observation of pre-determine EPAs not random aspects of performance Degree of supervision determines the decision to entrust Entrustment is awarded when the assessor determines the learner can perform EPA without direct supervision

Evaluation and treatment of a patient with a subarachnoid hemorrhage PGY-1: knows vascular anatomy knows differential diagnosis PGY-2: initiate patient workup for patient with SAH interprets imaging studies knows literature on outcomes PGY-4: manages patient with high grade SAH supervises treatment of vasospasm educates and comforts family of a patient with a high grade SAH PGY-6: leads evidence based discussion of treatment options for treatment of intracranial aneurysm performs surgical approach to a common aneurysms