1. Competencies, Milestones & EPAs: What Does It All Mean?
Susan B. Promes, MD, FACEP
Professor and Program Director
Department of Emergency Medicine
Director, Curricular Affairs
Office of GME

2. Historical Perspective
ACGME Outcomes Project
Initiative to increase emphasis on educational outcomes
In 1999, Advisory committee identified six competencies and programs
The previous model of accreditation captured the potential of a GME program to educate residents by focusing on structure and process components.
Programs are expected to show evidence of how they use educational outcomes data to improve individual resident and overall program performance.
With funding in part by a grant from the Robert Wood Johnson Foundation, the ACGME Outcome Project is changing the focus of GME accreditation.
As of July 2002, programs are responsible for requirements related to the competencies.

3. Why Outcomes? Accountability Process vs. Product
Department of Education Requirements
Political Need
The impetus to emphasize educational outcomes assessment in GME accreditation is based on the following factors.
Accountability: Our system of medical education relies heavily on considerable public funding. We therefore need to be accountable to the public in terms of both meeting public needs and preparing well-qualified new physicians in the most cost-effective way possible.
Process vs. Product: Measuring program quality by examining structure and process is not a direct or complete measure of the quality of the educational outcomes of a program.
Dept of Education: The U.S. Department of Education spearheaded a movement in the 1980s aimed at greater inclusion of outcomes assessment in the accreditation process.
Political Need: Availability of educational outcomes-based data is necessary to inform discussions with policymakers and others who have become increasingly focused on issues related to funding for medical education, and, most recently, on patient safety.

4. Criticism of Modern Medical Education
Our medical education systems of the 20th century are no longer “good enough”. We need to do better.
How can we ensure the public that our graduates are competent?

5. Criticism of Modern Medical Education
Is there a better way to ensure competence than just time spent in a training program?

6. We believe that in the future, expertise rather than experience will underlie competency-based practice and…certification.
Aggarwal & Darzi, NEJM 2006
Competency based medical education is being discussed worldwide…even in major journals like the New England Journal of Medicine.

7. Competency Based Medical Education
Flexibility for individuals
Efficiency
Less time-oriented
Public accountability
Relevance assured
Transparent standards
Logical progression

8. Six ACGME Competencies
Medical Knowledge
Patient Care
Practice Based Learning and Improvement
System Based Practice
Professionalism
Interpersonal and Communication Skills

9. Medical Knowledge
Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and how to apply this knowledge to patient care.
Acquisition
Analysis
Application

10. Patient Care
Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.
Gathering information
Synthesis
Partnering with patients/families

11. Professionalism
Residents must demonstrate professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.
Professional behavior
Ethical principles
Cultural competence

12. Systems-based Practice
Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide optimal health care.
Health care delivery system
Cost effective practice
Patient safety and advocacy/Systems causes of error

13. Interpersonal and Communication Skills
Residents must be able to demonstrate interpersonal and communication skills that result in effective information
exchange and teaming with patients, their patients families, and professional associates.
Communicating with patients and families
Communicating with team members
Scholarly Communication

14. Practice-based Learning and Improvement
Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices.
Life-long learning
Evidence based medicine
Quality improvement
Teaching skills

15. Measuring the unmeasurable
“Domain
independent”
skills
Does
Shows how
Miller’s pyramid
Knows how
Knows
“Domain specific” skills
Cees van der Vleuten
Maastricht University

16. Measuring the unmeasurable
Importance of domain-independent skills
If things go wrong in practice, these skills are often involved (Papadakis et 2005; 2008)
Success in labor market is associated with these skills (Meng 2006)
Cees van der Vleuten
Maastricht University

17. Measuring the unmeasurable
Self assessment
Peer assessment
Patient assessment
Multisource feedback
Journals or logs
Simulation
Portfolio assessment
Cees van der Vleuten
Maastricht University

18. Competency defined
An observable ability of a health professional, integrating multiple components such as knowledge, skills, values and attitudes.
KSA – knowledge skills and abilities
Med Teach. 2010;32(8):
Competency-based medical education: theory to practice.
Frank JR, Snell LS, Cate OT, Holmboe ES, Carraccio C, Swing SR, Harris P, Glasgow NJ, Campbell C, Dath D, Harden RM, Iobst W, Long DM, Mungroo R, Richardson DL, Sherbino J, Silver I, Taber S, Talbot M, Harris KA.
The International CBME Collaborators 2009
Special thanks to Drs. Hauer, Chen, Young, O’Sullivan and ten Cate

19. Competent defined
Possesses the required abilities in all domains in a certain context at a defined stage of medical education or practice.
The International CBME Collaborators 2009
Special thanks to Drs. Hauer, Chen, Young, O’Sullivan and ten Cate

20. Competence defined
Entails more than the possession of knowledge, skills and attitudes; it requires you to apply them in the clinical environment to achieve optimal results
Medical competence: The interplay between individual ability and the health care environment
TJO ten Cate, L Snell, C Carraccio
Medical Teacher 32 (8),
Example of driving a car:
Competency
Can accelerate and brake smoothly
Can approach an intersection and can turn left
Competent
Passes driver’s education classes
Passes driver’s exam to get the license
Competence
Drives safely on interstate or during bad weather, avoids accidents, no traffic tickets
Parents hand over the keys and walk away
Ten Cate, Medical Teacher, 2010
Special thanks to Drs. Hauer, Chen, Young, O’Sullivan and ten Cate

21. Competency Competent Competence Competency
Can identify the various key cooking utensils
Demonstrates appropriate hygeine and understanding of infection control in the kitchen
Competent (Required KSA in that particular context)
Passes each of the cooking exams
Receives qualifications in each of their areas of distinction
Competence
Drives safely on interstate or during bad weather, avoids accidents, no traffic tickets
Parents hand over the keys and walk away
Competent
Competence

22. Recent Events MedPac, IOM and Macy Foundation call for GME Reform
Concern for Gov’t regulation of GME
2011 Macy Report: Ensuring an Effective Physician
Workforce
• IOM new initiative: Governance and Financing of
Graduate Medical Education

23. New ACGME Program Requirement V.A.
The specialty-specific Milestones must be used as one of the tools to ensure residents are able to practice core professional activities without supervision upon completion of the program. (Core)
ACGME Program Requirement V.A.

24. Supervision Direct Indirect Oversight
With Supervision Immediately Available
With Supervision Available
Telephonic or electronically
Oversight
Provide review after care is delivered

25. New ACGME Program Requirement V.A.
The specialty-specific Milestones must be used as one of the tools to ensure residents are able to practice core professional activities without supervision upon completion of the program. (Core)
ACGME Program Requirement V.A.

26. Seven ACGME Specialties Roll Out Milestones
Diagnostic Radiology
Emergency Medicine
Internal Medicine
Neurosurgery
Orthopedics
Pediatrics
Urology

27. Milestones defined
Meaningful, measurable markers of progression of competence
What abilities does the trainee possess at a given stage?
What can the trainee be entrusted with?
Special thanks to Drs. Hauer, Chen, Young, O’Sullivan and ten Cate

28. © Copyright 2012 ACGME and American Board of Emergency Medicine

29. When Do You Trust the Trainee?
When is a professional activity mastered?
Set thresholds / minimum standards
Allow unsupervised practice
Direct vs.. Indirect Supervision
Full entrustment
ACGME requires Program Directors to attest to a trainee’s competence.
Verify that the resident has demonstrated sufficient competence to enter practice without direct supervision.
Programs must set guidelines for circumstances and events in which residents must communicate with appropriate supervising faculty members

30. ACGME requires Program Directors to attest to a trainee’s competence.

31. Dreyfus Model
Dreyfus Model of Skill Acquisition (2004)

32. Entrustable Professional Activities (EPAs)
Define important clinical activities
Link competencies / milestones
Include professional judgment of competence by clinicians
EPAs together constitute the core of the profession
Make “decisions of entrustment” for “entrustable activity”
Special thanks to Drs. Hauer, Chen, Young, O’Sullivan and ten Cate

33. EPA defined
A core unit of work reflecting a responsibility that should only be entrusted upon someone with adequate competencies
Ole ten Cate
Medical Teacher 1010;32:
CONTEXT is key!
More specific:
Part of essential professional work in a given context
Independently executable, within a time frame
Leads to recognized output of professional labor
Observable and measurable in process and outcome, leading to a conclusion (“well done” or “not well done”)
Must require sufficient, specific knowledge, skill and attitude, generally acquired through training
Should reflect competencies, important to be acquired
Usually confined to qualified personnel only

34. Building a Competency Based Workplace Curriculum around EPAs:
The Case of PA Training
Mulder, ten Cate, Daalder and Berkvens
Medical Teacher 2010; 32: e

35. Competency vs.. EPA Work Descriptors Person Descriptors
Knowledge Skills, Attitudes and Values
Content expertise
Collaboration ability
Communication ability
Management Ability
Professional Attitude
Scholarly Approach
Work Descriptors
Essential Parts of Professional Practice
Discharge Patient
Counsel Patient
Lead Family Discussion
Design Treatment Plan
Perform Paracentesis
Resuscitate if needed
Special thanks to Drs. Hauer, Chen, Young, O’Sullivan and ten Cate

36. Next Steps Refinement of Milestones Identify Assessment Methods
Collection and Reporting Out on Data

37. Conclusion
Competency Based Education is here to stay for the foreseeable future
Wolf in sheep’s clothes