1. CBD – What you need to know
Nicky Kraus, Lindsay Melvin and Rupal Shah

2. CBD Overview
Implications on learning and assessment

3. EPAs and assessment EPA Assess Example
Key tasks that a trainee can be entrusted to perform
Context and level specific
EPAs and assessment
Assess
Snapshot in time
“Can I entrust this resident to perform this specific task without supervision?”
Depends on context, time in training, case complexity etc.
Example
EPA: Performing histories and physical exams, documenting and presenting findings, across clinical settings for initial and subsequent care (TTD, EPA 1)
EPA-based assessment: History for new patient with COPD
You will be receiving a ton of information about CBD, EPA assessment, direct observation from Dr. Goguen as well as during meetings with your academic advisors. We will use examples to illustrate some of this terminology so that it makes sense.
Slide: Introduce EPA concept and related EPA based assessment (emphasize that assessment answers the question “can I entrust this resident with this specific task at this point in time?”) based on an entrustment scale

4. EPAs and assessment Varying points in time Different contexts
Collated assessments (per EPA) = map of competence over time
Multiple assessors
Different contexts
Varying points in time
An individual EPA based assessment is an opportunity to get feedback and coaching directly from your supervisor. This is LOW STAKES meant to highlight areas in need of improvement and help trainee progress towards becoming competent to complete an EPA independently.
Residents are not expected to be entrustable each time an EPA is completed, this normally takes repeated effort to achieve.
Assessments collated across multiple assessors (i.e. different attendings), across contexts (i.e. different rotations), across time (i.e. early versus later blocks) provide a picture of whether or not a trainee is achieving a greater level of independence for a given EPA over time.
A single assessment = opportunity for feedback + coaching

5. EPAs and assessment Clinical Supervisor Competence Committee
Coaching and feedback to trainee
Low-stakes observations
Synthesize data from many sources
Promotion decisions
Emphasize the new relationship between supervisor and trainee – one of COACHING and FEEDBACK that is LOW-stakes
Decisions around promotion and sufficient competence is now made by the competence committee – and a single EPA-based assessment will feed into that promotion decision, in combination with a number of other sources of assessment (i.e. OSCE, simulation etc.)

6. EPAs and assessment Expected trajectory
Residents are not expected to be entrustable each time an EPA is completed, this normally takes repeated effort to achieve.
The purpose of EPA based assessments across contexts, supervisors and time is to document trajectory and identify residents in need of help earlier in training than with traditional educational models.

7. EPAs and assessment Academic Advisors Trainee Clinical Supervisors
Competence Committee
EPAs and assessment
Academic Advisors
Each trainee has an academic advisor that will help them understand their trajectory, formulate individual learning plans to move along the competence continuum and guide the trainee with questions re CBD and EPA achievement.

8. Where are you at now?
Level specific EPAs

9. Where are you at?
* We will review which EPA-based assessments should be completed on CTU for PGY1-PGY3, and on GIM Ambulatory Clinics for PGY3
PGY2 – PGY3
* Disclaimer --> there may be other EPAs that you will see on Medsquares for your stage of training but we are specifically highlighting those that are relevant to CTU for PGY1-3 and clinics for PGY3. Other EPA’s may be completed, but this is a streamlined guideline.
PGY1 (Blocks 1 -4)

10. Where are you at? PGY1 (Blocks 1-4) – EPAs relevant to CTU
EPA TTD-1: Performing histories & physical exams, documenting & presenting findings, across clinical settings for initial & subsequent care
EPA TTD-2: Identifying and assessing unstable patients, providing initial management, and obtaining help.
EPA COD-5:** Performing the procedures of Internal Medicine.
Paracentesis, thoracentesis, lumbar puncture, knee aspiration
**2 comments: COD5 is usually completed in PGY2-3 years; however, PGY1’s often have exposure to procedures early in training and opportunities to have these directly observed should be taken advantage of. We only included the procedures that PGY1’s are likely to see on CTU – but there are other procedures included in this EPA.
***TTD Resident Primers include details about the number of successful EPA assessments, requirement for direct observation, number of faculty that need to complete an assessment and clinical settings in which these EPAs need to be observed. Please review this primer at the start of each block, and refer back to it periodically to ensure you are on track for EPA assessment.
*** Please review the TTD Resident Primer sent by Dr. Goguen for details!

11. Where are you at? PGY2-3 – EPAs relevant to CTU and ED Admit
EPA COD-1: Assessing, diagnosing, and managing patients with complex or atypical acute medical presentations.
EPA COD-4: Assessing, resuscitating, and managing unstable and critically ill patients.
EPA COD-5: Performing the procedures of Internal Medicine.
Paracentesis, thoracentesis, lumbar puncture, knee aspiration, Code Blue
COD5 - Added CODE BLUES to procedures for senior levels.
*** Please review the COD Resident Primer sent by Dr. Goguen for details!

12. Where are you at? PGY3 – EPAs relevant to GIM Ambulatory Clinic
EPA COD-1: Assessing, diagnosing, and managing patients with complex or atypical acute medical presentations.
Patient who presents to clinic unwell
EPA COD-2: Assessing and managing patients with complex chronic conditions.
** EPA – COD 1 – requires at least 6 EPA’s to be done in the ambulatory setting so I included it here
In block 5, there will be the option to do many more EPAs – get yourself familiar with which ones you may need to be doing and which ones you have had several assessments in!
*** Please review the COD Resident Primer sent by Dr. Goguen for details!

13. But how?
Guidelines to completing EPA assessments

14. But how? Plan Meet your supervisor and identify EPAs to complete
Review ‘Resident Primer’ sheet
Meet your supervisor and identify EPAs to complete
Plan
- 1-2 clinical EPAs per week
- procedural EPA opportunistically
Make a plan. Make it regular  e.g. Complete an EPA for the first admission on every post-call day, or have an EPA observation on Wednesdays at 1pm

15. But how? Type of assessment Direct observation Indirect observation
Simulation
‘Partial’ tasks
E.g. focused respiratory exam for COPD
But how?
Direct observation – not practical to watch a full history and physical (for example) so should be focused on partial tasks
Indirect observation – case review, team round discussion, chart review, discharge summary review etc.
Simulation – skills labs

16. But how? Filling out forms In the moment With supervisor Coaching
Not a secret!
Fill out the forms shortly after the clinical assessment – in the moment Opportunity for the supervisor to provide immediate feedback and coaching
The feedback is formative and encouraged – ‘not a secret’

17. Practical tips
What you need to know to get started

18. Practical tips https://cbme.usquaresoft.com/
Medsquares website
Check login and password and make sure It works

19. Practical tips Add to home screen
Add medsquares to your home screen (for iPhone):
Open safari
Enter medsuqares website

20. Practical tips Add to home screen
Add medsquares to your home screen (for iPhone):
Click Share icon
Click Add to Home Screen

21. Practical tips Add to home screen
Add medsquares to your home screen (for iPhone):
Name new icon and click Add
Icon should now appear on your home screen

22. Practical tips
Fill out a form

23. Practical tips
Fill out a form

24. Practical tips
Fill out a form
Point out type of assessment

25. Practical tips Fill out a form
Point out that only 2-3 milestones need to be assessed using the entrustment scale and w/ subsequent comments

26. Practical tips Fill out a form
All assessments require completion of the overall entrustment scale for the EPA

27. Practical tips Fill out a form
All assessments require completion of the overall entrustment scale for the EPA

28. Practical tips Tracking your progress
To track your progress and see number of EPAs compelted where you were entrusted and overall completed click go back to the first page when you login to medsquares. Click summary instead of new entry.

29. Practical tips Tracking your progress
This shows you the number of entrustable EPAs needed per EPA and your progress so far.
For example, let’s look at EPA TTD1. You need to achieve entrustment on at least 4 of EPA TTD1 assessments and so far this resident has 1 of 4. Remember it is okay to not be entrustable early on and work towards entrustment (this is the expected trajectory).
If you want to review the total number of assessments (entrustable and not entrustable) then click on the Review tab.

30. Practical tips Tracking your progress
Here you see that for EPA TTD1 a total of 3 assessments have been completed. The pink one is the one where this resident achieved entrustable (1 of 4 target seen on the previous page).