Preparing the Future Primary Care Workforce Together Primary Care Faculty Development Initiative (PCFDI) CBME in the Ambulatory Setting Nov

Outline CBME background Frameworks and outcomes Key concepts and definitions Frameworks and outcomes Where we are/where we need to be The role of milestones and entrustment in the assessment and evaluation of competence

Competency versus Competent Competency: an observable ability of a health professional, integrating multiple components such as knowledge, skills, values and attitudes. Competent: demonstrating the required abilities in all domains in a certain context at a defined stage of medical education or practice. Adapted from: The International CBME Collaborators, 2009 3

What does competency-based medical education means to you?

Competency-Based Medical Education is an outcomes-based approach to the design, implementation, assessment and evaluation of a medical education program using an organizing framework of competencies Bottom line: CBME = Outcomes-based Medical Education (OBME) So what is the outcome, and what is the framework? The International CMBE Collaborators 2009

The Framework: ACGME Competencies Medical knowledge Patient care and procedural skills Interpersonal and communication skills Practice-based learning and improvement Systems-based practice Professionalism

Outcome?

The Outcome Frenk J, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010

What is the outcome? A competent (at a minimum) practitioner aligned with: IOM Six Aims for Quality CMS Triple Aim National Priorities Partnership

Individual Physician Readiness: The Gaps Office-based Practice Competencies Inter-Professional team skills Clinical IT Meaningful Use skills Population management skills Reflective practice and CQI skills Care Coordination Continuity of Care Leadership and management skills Systems thinking Procedural Skills The health care system is complex. The comment is frequently made that it is not due to the physician. It’s the system, the payers, the incentives etc. However, you can look at physician performance. Jay Crossen did just that in recent graduates entering the Kiaser –Perm Health care system in California. This is the data on all trainees and is not specialty specific. Crosson Health Affairs 2011

Is CBME/OBME Just a “Fad”? Pet rocks Leisure suits Streaking Disco music Yugos Pokemon Tickle me Elmo …probably not…

Is CBME/OBME a Paradigm Shift? Thomas Kuhn (1962): “Normal science, the activity in which most scientists inevitably spend almost all of their time, is predicated on the assumption that the scientific community knows what the world is like. Much of the success of the enterprise derives from the community’s willingness to defend that assumption, if necessary at considerable cost” Thomas S. Kuhn. The Structure of Scientific Revolutions. University of Chicago Press. Chicago. 1962. Pg. 5.

Could the Same be True of UME and GME? “Normal medical education, the activity in which most faculty inevitably spend almost all of their time, is predicated on the assumption that the medical educational community knows what the world is like. Much of the success of the enterprise derives from the community’s willingness to defend that assumption, if necessary at considerable cost” Thomas S. Kuhn. The Structure of Scientific Revolutions. University of Chicago Press. Chicago. 1962. Pg. 5.

Is CBME/OBME a Paradigm Shift? Maybe…but perhaps that is not the main point: CBME is yet another stage on what should be the ongoing evolution and improvement of medical education The focus on outcomes is worthy of our attention

The Transition to Competency Fixed length, variable outcome Structure/Process Knowledge acquisition Single subjective measure Norm referenced evaluation Evaluation setting removed Emphasis on summative Competency Based Education Competency Based Knowledge application Multiple objective measures Criterion referenced Evaluation setting: DO Emphasis on formative Variable length, defined outcome Caraccio et al 2002

The definition of expected outcomes or competencies Milestones The definition of expected outcomes or competencies

Milestones A significant point in development that identifies the discrete knowledge, skills, and attitudes expected of learners as they progress through training. Milestones should enable the trainee, program and the certification board to know an individuals trajectory of competency acquisition.

Dreyfus & Dreyfus Development Model PGY3 Expert/ Master PGY1 Proficient MS4 Competent MS3 Advanced Beginner Reality is skills develop over time and training. We expect different levels of competence for different skills. For example history taking Novice Time, Practice, Experience Dreyfus SE and Dreyfus HL. A 1980 Carraccio CL et al. Acad Med 2008;83:761-7

Reporting Milestones-IM

“Curricular” Milestone ACGME Competency Developmental Milestones Informing ACGME Competencies Approximate Time Frame Trainee to Achieve Stage Assessment Methods/Tools Clinical skills and reasoning Manages patients using clinical skills of interviewing and physical examination Historical Data Gathering Acquire accurate and relevant history from the patient in an efficiently customized, prioritized, and hypothesis driven fashion Seek and obtain appropriate, verified, and prioritized data from secondary sources (e.g. family, records, pharmacy) Obtain relevant historical subtleties that inform and prioritize both differential diagnoses and diagnostic plans, including sensitive, complicated, and detailed information that may not often be volunteered by the patient 6 months 9 months 18 months Standardized patient Direct Observation Simulation I specifically have a box around the 18 month milestone in preparation for the next slide… Sub-bullet “Curricular” Milestone

Milestones Benefits Provide the learner with a clear path of progression There are no surprises Allow for rich formative feedback. Learners know where they are and where they need to go Define specific behaviors that can focus assessment

Milestones Criticisms Milestones are too reductionist Checklist = competence Checking off a milestones list does not equal competent practice in a highly complex health care environment Operationalize the milestones to develop and apply meaningful assessment and evaluation.

Entrustment/Entrustable Professional Activities (EPAs) A framework for work-based assessment?

Entrustable Professional Activities EPAs represent the routine professional-life activities of physicians based on their specialty and subspecialty 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. Acad Med. 2007;82(6):542–547.

An Entrustable Professional Activity Part of essential work for a qualified professional Requires specific knowledge, skill, attitude Acquired through training Leads to recognized output Observable and measureable, leading to a conclusion Reflects the competencies expected… EPA’s together constitute the core of the profession Here is a table that was produced by Olle ten Cate who developed the framework for EPA’s and has been instrumental to the work of our community. I like this example because it provides some concrete description of what an EPA might look like – Part of the essential work for qualified professional – similar to what I just read Requires specific knowledge, skill, attitude – makes sense if it is Acquired though training - not something that you are born with or comes pre-packaged Leads to a recognized output – you know it when you see it Observable and measurable – Reflects the competencies expected (competencies – the things that they are able to do) The Milestones fit into this picture here with the last two bullets – where Milestones link to EPA’s – more on this to come. Also important to note that the EPA’s together constitute the core of the profession – emphasize together Consider these criteria when reviewing some examples of what I think are EPA’s. ten Cate et al. Acad Med 2007

“Entrustment in Medical Education” Focused assessments around what faculty and training programs already “entrust” trainees to do? Reflects the most important outcome of training: a trainee’s readiness to bear professional responsibility” Enables work-based assessment focusing on demonstrating competence in desired outcomes of training.

Baystate Ambulatory LMT Model Learners: have Direct supervision Faculty member sees every patient Managers: have Indirect supervision Faculty member discretion to see patient Teachers: Oversight from faculty Resident discretion to allow patients to leave before precepting Adapted from Sudeep K. Aulakh & Michael J. Rosenblum. Presented at ICRE 2012, Ottawa.

Ambulatory Milestone: Demonstrates patient-centered interviewing using the Invite, Listen, Summarize format Failure -Frequently does not use these skills Needs work -Inconsistently uses these skills Competent -Consistently uses Invite & Listen; Summarizes in a reporter fashion Proficient -Consistently uses all three skills, Summarizes interpreted information Expert -Consistently uses all three skills, Summarizes interpreted information in complex cases Competencies: Interpersonal communication & Patient Care Adapted from Sudeep K. Aulakh & Michael J. Rosenblum. Presented at ICRE 2012, Ottawa.

Competencies, Milestones and EPAs Characteristic Competencies Milestones EPAs Granularity Low Moderate to High Low to Moderate Synthetic/Integrated Moderate High Practicality (application) Conceptual

The Synthesis – Analytic Tension Physicians do not apply each competency independently in caring for patients As a result, judging overall performance is a synthetic/integrative assessment activity However, You will often have to pull things apart (analysis) to create shared mental models and to provide meaningful and actionable feedback to the resident

What has this resident been entrusted to do? Lets watch a video. What has this resident been entrusted to do? If this were your institution, could you attest that the resident had the required competence to provide this care?

With Your Neighbor - Pick a goal of training that would meet a national priority for ambulatory-based care. Identify two to three entrustments in training that could serve as a focus for assessment in that competency? What assessment methods would you use? What process will you use to make an entrustment decision? What facilitators and barriers would you face?

Judgment and Synthesis: as Guiding Framework and Blueprint The “System” Accreditation: ACGME/RRC Institution and Program Residents Program Aggregation Assessments within Program: Direct observations Audit and performance data Multi-source FB Patient experience Simulation ITExam Judgment and Synthesis: Committee NAS Milestones Board Reporting No Aggregation Faculty, PDs and others Certification: Board Milestone and EPAs as Guiding Framework and Blueprint

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