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 readRequires 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 itObservable 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 togetherConsider these criteria when reviewing some examples of what I think are EPA’s.
Milestones and EPAsThe definition of expectedoutcomes 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 Novice Time, Practice, Experience Dreyfus SE and Dreyfus HL. A 1980 Carraccio CL et al. Acad Med 2008;83:761-7
Progression Varies by Trainee & Context PGY1 MS4 PGY3 PGY3 Expert/ PGY1 Master PGY1 Proficient MS4 MS4 Competent MS3 Advanced Beginner Novice Time, Practice, Experience Dreyfus SE and Dreyfus HL. A 1980 Carraccio CL et al. Acad Med 2008;83:761-7
The Internal Medicine Milestones 142 milestones organized by competency and competency sub-divisions Framed in behavioral terms (Competence is observed in practice!) that define knowledge, skills, attitudes and behaviors Linked with potential assessment tools Published in 2009
Patient CareACGME Developmental Milestones Approximate AssessmentCompetency Informing Time Frame Methods/Tools ACGME Competencies Trainee to Achieve StageClinical skills and Historical Data Gathering Standardized reasoning 1. Acquire accurate and relevant history 6 months patient Manages from the patient in an efficiently Direct Observation patients using customized, prioritized, and hypothesis Simulation clinical skills of driven fashion interviewing and 2. Seek and obtain appropriate, verified, 9 months physical and prioritized data from secondary examination sources (e.g. family, records, pharmacy) 3. Obtain relevant historical subtleties that inform and prioritize both differential 18 months diagnoses and diagnostic plans, including sensitive, complicated, and detailed information that may not often be volunteered by the patient RRC sub-bullet
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 reductionistic Checking off a milestones list does not equal competent practice in a highly complex health care environment There are 142 curricular milestones Programs can not assess them all • Even over three years!
Milestone Challenges Utilize the milestones to develop meaningful assessment and evaluation. • Generate data that enables attestation of desired competence. • What the government, public and the profession trust physicians are capable of doing Evolve the milestones to be more manageable that allows attestation of competence in desired outcomes.
ACGME Accreditation Milestones Will serve as one of nine sets of data that ACGME will use when accrediting programs Will allow ACGME to track the development of desired competence at the program level Milestones reporting will occur twice per year and will begin in 2013
ACGME Accreditation Internal Medicine Milestones Discrete developmental narratives describing the development of competence in the learner in each of the six ACGME general competencies Define stages of development (informed by assessment data) that provide the framework for making judgment/attestation of competence 23 narrative milestones streams
Assessment/Evaluation Challenges Ensure that assessment documents competence in those activities required to achieve the desired outcome of training • Assessment that is meaningful! • Assessment that is manageable!
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 professionten Cate et al.Acad Med 2007 16
Training and Safe Patient Care Trainee performance* X Appropriate level of supervision** Must = Safe, effective patient-centered care* a function of level of competence in context**a function of attending competence in context
“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.