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The purpose of medical education is to improve patient care
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Milestones… A short, brief, introductory overview
Stephen A. Wilson, MD, MPH, FAAFP UPMC St Margaret May 10, 2013
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Acknowledgements Wendy Biggs, MD Sam Cullison, MD Julie Dostal, MD
Larry Mauksch, MEd Judy Pauwels, MD The Next Accreditation System and ACGME Milestones: Learning to Use Competency Assessment to Focus on Outcomes
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6 ACGME Competencies Next Accreditation System Described (NEJM 2/12)
6 ACGME Competencies Patient Care Medical Knowledge Problem-Based Learning and Improvement Interpersonal and Communication Skills Professionalism System-based Practice Competency Based Accreditation 2005 ACGME Strategic Plan – Innovation Outcomes Efficiency Communication Next Accreditation System Described (NEJM 2/12) Continuous Accreditation Outcome measures (Milestones) Institution Accountability (CLER)
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Why is CBA important? Best Residents: How have you helped him/her grow and prepare to be one of our leaders? Challenging Residents: What struggles have faculty had in describing what is wrong and identifying how to help? House – problms are not just MK or PC. More to us than dx and tx One of the reasons we have difficulty is that we have not developed a common, articulate language among ourselves or with our residents
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Competency Assessment
Embraces the notion that capabilities of residents have to be measured, rather than assuming the attainment of competence is an inherent part of the training process.
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Competency Assessment
Well functioning residency program is a - coherent - purposeful - integrated design and delivery of managed learning that enables residents to become competent and capable clinicians
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Characteristics of Good Assessment
Measures actual performances Identifies areas for improvement Satisfies reasonable request for accountability Practical Done over time to discern growth David Leach, MD Executive Director, ACGME
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Milestones Progressive responsibility Created by each specialty
Narratives about the “DOES” in Miller’s Pyramid Less range restriction Based on the 6 Competencies
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Milestones Trained observers Observable steps Continuum to competency
For reporting Not evaluation Existing tools used Trained observers Multiple observations Clinical competency committee assesses progress
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Miller’s Assessment Pyramid
Miller, G. E. The assessment of clinical skills/competence/performance. 1990 Acad Med 65(9 Suppl): S63-7. Adapted from Holmboe and Hawkins. Evaluation of Clinical Competence, Mosby 2008 Impact on the patient Does Faculty observation (with real patients) Shows how Standardized patients Knows how Matching or critical response questioning Knows Multiple choice questions 13
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Competency Based Education
Adapted from Miller, G. E. The assessment of clinical skills/competence/performance. 1990 Acad Med 65(9 Suppl): S63-7. Does Implements and evaluates CBE in residency program Shows how Demonstrates use of direct observation feedback to learner Knows how Can describe and generate competency assessment tools/skills Knows Can define formative & summative assessment Impact on Training 14
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Culture Shift Assume that your program is capable of developing competence in every resident, and the purpose of assessment is simply to document attainment as it occurs.
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Direct Observation: Methods
Faculty Time Demand Educational Pros Educational Cons Direct observation in the room High Loss of income or other activity Clear view Can teach on the fly Trainee initially self conscious Risk of upstaging relationship Video review Trainee self observes, strong educational options Delayed practice Requires technical expertise and expense Closed circuit Moderate Some income loss or other activity Fast practice Faculty development Distraction, time limitation, Reliability? Peer Very Low ++Observations ++Reflection ++Practice Less depth, versatility, You (faculty) are observed Low Role modeling Observer self Faculty growth Passive trainee role
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About changeable behavior?
Giving Feedback … Timely Kind Honest Provisional & curious Specific Not judgmental About changeable behavior?
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Medical Knowledge (MK) (early draft)
Sub-competency Competency Medical Knowledge (MK) (early draft) MK 2. Apply critical thinking skills in patient care Beginning Resident Junior Resident Senior Resident Graduating Resident Personal Physician Demonstrates basic linear analytic decision making capabilities Demonstrates the capacity to correctly interpret basic clinical tests and images Demonstrates synthesis of multiple information resources to make routine clinical decisions Begins to integrate social and behavioral sciences with biomedical knowledge in patient care Demonstrates sound clinical judgment in non-routine situations Analyzes and prioritizes information to make clinical decisions that are individualized for each patient Moves from individual thinking to family and population considerations Integrates and synthesizes knowledge to make decisions in complex clinical situations Prioritizes care based on urgency, importance and prognosis. Integrates in-depth medical and personal knowledge of patient and family and community to decide, develop and implement treatment plans Can define the participants necessary to address important health problems for both individuals and communities Milestone
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To retell the major ideas or events in a text in your own words in a much shorter way than the original
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Six Family Medicine Competencies 22 Components
Patient Care and Procedures PC1 Urgent and Emergent PC2 Chronic illness PC3 Health prevention promotion PC4 Undiffer-entiated patients PC5 Proced-ures Medical Knowledge MK1 Breadth and depth MK2 Critical thinking Professionalism Prof1 Fully integrate Prof2 Action awareness Prof3 Humanism Cultural Prof4 Self care growth Systems Based Practice SBP1 Cost conscious SBP2 Safety SBP3 Advocate SBP4 Coordinate team care Practice Based Learning & Improvement PBLI1 Find & use evidence PBLI2 Self directed learning PBLI3 Improves system Interpersonal & Communication Skills ICS1 Relation-ships ICS2 Effective ICS3 With team, with others ICS4 Improve with tech
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--Not about new forms or perfect form
--It is about doing high quality, high level feedback and evaluation --3 DO > 6 survey
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http://www. coderfriendly
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Important concept foundational to the Milestones
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Apply the Dreyfus model to driving
5 minutes
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Family Medicine Milestones
5 Developmental Levels Personal physician Graduating resident Senior resident Junior resident Beginning resident Look familiar Do NOT turn the bubbles in numbers!!
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Implementation Approach
CBE emphasis will primarily be: Assessment Feedback Evaluation Honing and refining teaching skills NOT on instituting new programs Work in progress Pause and let them digest the slide. What do you think of this approach?
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Competencies vs. Milestones vs. EPAs
- Competencies are descriptors of physicians - Milestones are about progress in attaining comps - EPAs are descriptions of work
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