Assigning Milestone Evaluations in Internal Medicine Melvin Blanchard, MD, FACP Program Director, Internal Medicine Chief, Division of Medical Education Department of Medicine

Outline Internal Medicine program overview ACGME Charges re Competencies Response by IM community ACGME counter response Our program’s approach to evaluation

Internal Medicine Overview Discipline encompassing the study and practice of health promotion, disease prevention, diagnosis, care and treatment of adults 1 of 4 physicians in the US IM residents Our program: 151 trainees 2/3 inpatient; 1/3 outpatient BJH, VA, community, international ~50 rotations Category Positions Number of training programs 393 Positions in match 6177 First year fellows 4584

ACGME Charge - 1 1999 – ACGME launched the Outcomes Project Required PDs to assess trainees in 6 competencies Patient Care Professionalism Practice-Based Learning and Improvement Interpersonal and Communication skills Medical Knowledge Systems-Based Practice Competencies required of a physician to deliver competent medical care

ACGME Charge - 2 2009 – ACGME charged specialties with identifying milestones of competency development Observable developmental steps How do we know that PGY-2 resident will be competent at graduation? How do we know that graduates from the 393 IM programs can deliver same quality of IM care?

IM Community Response 2009-12: Published 142 Milestones Aka Curricular Milestones Point in development that facilitates assessment of progression from beginner to expected proficiency at end of training Published 16 Entrustable Professional Activities (EPAs) KSAs critical to practice specialty Milestones and EPAs categorized by 6 competencies

EPAs Manage patients with diseases across multiple care settings. Provide age-appropriate screening and preventative care. Resuscitate, stabilize, and care for unstable or critically ill patients. Provide perioperative assessment and care.  Manage transitions of care. Facilitate family meetings. Enhance patient safety. Improve the quality of health care at individual and systems levels. Demonstrate personal habits of lifelong learning. Demonstrate professional behavior.

ACGME Counter Response 142 milestones is too numerous Not optimal format for reporting to the ACGME ACGME and ABIM combined forces Developed milestones for reporting educational outcomes Aka Reporting Milestones or Milestones Grouped into 22 sub-competences Grouped into 6 competencies With each competency associated with 2 – 5 sub-competencies

Copyright © American College of Physicians. From: The Internal Medicine Reporting Milestones and the Next Accreditation System Ann Intern Med. 2013;158(7):557-559. doi:10.7326/0003-4819-158-7-201304020-00593 Figure Legend: Copyright © 2012 The Accreditation Council for Graduate Medical Education and The American Board of Internal Medicine. Date of download: 2/5/2014 Copyright © American College of Physicians. All rights reserved.

Competencies Curricular milestones Reporting milestones Milestones Entrustable Professional Activities Narratives Sub-competencies

Competencies to Milestones MK PC PBLI SBP Works in teams Cost conscious Transition of care Disregards communication Inconsistent Recognizes importance Uses resources Coordinates care Competencies Sub- competencies Milestones Curricular Milestones 5 levels of milestones: Critical deficiency to Aspirational EPAs Entrustable Professional Activities

What did we do? Broke 22 sub-competencies into sub-sub competencies Each sub-sub competency can be used as a question on a rotation evaluation Rotations divided among 5 faculty Each faculty work with core faculty/rotation directors to select evaluation questions appropriate to rotation Tracked assignment to assure each sub-competency measured multiple times Data from conference attendance, ITE, journal club participation, etc. also feed into evaluation system

1. Gathers and synthesizes essential and accurate information to define each patient’s clinical problem(s). (PC1) Critical Deficiencies   Ready for unsupervised practice Aspirational Does not collect accurate historical data. Inconsistently able to acquire accurate historical information in an organized fashion. Consistently acquires accurate and relevant histories from patients. Acquires accurate histories from patients in an efficient, prioritized, and hypothesis-driven fashion. Obtains relevant historical subtleties, including sensitive information that informs the differential diagnosis. Does not use physical exam to confirm history. Does not perform an appropriately thorough physical exam or misses key physical exam findings. Consistently performs accurate and appropriately thorough physical exams. Performs accurate physical exams that are targeted to the patient’s complaints. Identifies subtle or unusual physical exam findings. Relies exclusively on documentation of others to generate own database or differential diagnosis. Does not seek or is overly reliant on secondary data. Seeks and obtains data from secondary sources when needed. Fails to recognize patient’s central clinical problems. Fails to recognize potentially life threatening problems. Inconsistently recognizes patients’ central clinical problem or develops limited differential diagnoses. Uses collected data to define a patient’s central clinical problem(s). Synthesizes data to generate a prioritized differential diagnosis and problem list. Efficiently utilizes all sources of secondary data to inform differential diagnosis. Effectively uses history and physical examination skills to minimize the need for further diagnostic testing. Role models and teaches the effective use of history and physical examination skills to minimize the need for further diagnostic testing.

Milestone distribution across Rotations Sub-competency 1 2 3 4 5 6 7 8 Competency PC1 PC2 PC3 PC4 PC5 MK1 MK2 SBP1 Inpt Gen Med   Rheum CAER Neuro GI consult NF