4. Carnegie Report 2010
4
Challenges Recommendations
Not outcome based Standardize learning outcome through
assessment of competencies
Inflexible & overly too long Individualize learning process, allow opportunity
to progress within and across levels when
competencies are achieved
Not learner-centered Offer elective programs to support the
development skills for inquiry and improvement
Irby DM, Cooke M, O’Brien BC. Calls for Reform of Medical Education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Academic
Medicine 2010;85:220. doi:10.1097/ACM.0b013e3181c88449
7. Professional Competence (勝任)
Competence
•is the array of abilities across multiple domains or
aspects of physician performance in a certain
context
•is multi-dimensional and dynamic
• changes over time, experience, and setting
Frank JR, Snell L, ten Cate O, Holmboe ES, Carraccio C, Swing SR, et al. Competency-based medical education: theory to practice. Med Teacher. 2010;32:638-45.
7
9. Competency (勝任能力)
• “An observable ability of a health professional, integrating
multiple components such as knowledge, skills, values and attitudes.
• Since competencies are observable, they can be measured and
assessed to ensure their acquisition.”
9Frank JR, Snell L, ten Cate O, Holmboe ES, Carraccio C, Swing SR, et al. Competency-based medical education: theory to
practice. Med Teacher. 2010;32:638-45.
14. 14
ACGME Outcome Project 1999 CanMEDS 2005
What you do What you know
How you get betterHow you interact with others
How you act How you work within
the system
Who you are
20. Milestones
• competency-based developmental outcomes
• demonstrated progressively by residents
• from the beginning of their education through graduation
to the unsupervised practice of their specialties
20
http://www.acgme.org/What-We-Do/Accreditation/Milestones/Overview
21. Why milestones
For program
• Provide a rich descriptive,
developmental framework for
clinical competency committees
• Guide curriculum development of
the residency or fellowship
• Support better assessment
practices
• Enhance opportunities for early
identification of struggling
residents and fellows
For residents
• Provide more explicit and
transparent expectations of
performance
• Support better self-directed
assessment and learning
• Facilitate better feedback for
professional development
21
http://www.acgme.org/What-We-Do/Accreditation/Milestones/Overview
23. Medical
competence
Patient care
Medical knowledge
Practice-based learning
& improvement
Interpersonal &
communication skills
Professionalism
System-based practice
23
PC 1
MK 1
PBLI 1
C 1
PRO 1
SBP 1
PC 2 PC 3 PC 4 PC 5
MK 2
PBLI 2 PBLI 3
C 2 C 3 C 4
PRO 2 PRO 3 PRO 4
SBP 4SBP 3SBP 2
30. Entrustable Professional Activity
A unit of professional practice that can be
entrusted to a sufficiently competent learner
• Entrustable: 可以獨立執行的,不需要監督
• Professional activity:可以單獨執行的臨床工作
Ten Cate 2005 36
31. Competencies versus EPAs
Competencies EPAs
Person-descriptors Work-descriptors
Knowledge, skills, attitudes,
values
Essential parts of
professional practice
• Content expertise
• Collaboration ability
• Communication ability
• Management ability
• Professional attitude
• Scholarly habits
• Discharge patients
• Counsel patients
• Design treatment plans
• Lead family meetings
• Perform paracenteses
• Resuscitate if needed
37
34. EPAs for Fam Med End of Residency Training 1
1. Provide a usual source of comprehensive, longitudinal medical care for people of all
ages.
持續提供所有年齡的民眾周全性、連續性的醫療照護。
2. Care for patients and families in multiple settings.
在多種場域中照顧病患及家屬。
3. Provide first-contact access to care for health issues and medical problems.
提供民眾關於健康議題及醫療問題的初步照護。
4. Provide preventive care that improves wellness, modifies risk factors for illness and
injury, and detects illness in early, treatable stages.
提供預防性照護以改善健康、減少疾病及傷害的風險、早期發現疾病。
5. Provide care that speeds recovery from illness and improves function.
提供照護以加速疾病恢復與改善功能。
40
http://www.stfm.org/NewsJournals/STFMNews/NewsSep302015
35. EPAs for Fam Med End of Residency Training 2
6. Evaluate and manage undifferentiated symptoms and complex conditions.
評估並處置未分化的症狀及複雜狀況。
7. Diagnose and manage chronic medical conditions and multiple co-morbidities.
診斷並處置慢性病況及多重共病。
8. Diagnose and manage mental health conditions.
診斷並處置心理健康狀況。
9. Diagnose and manage acute illness and injury.
診斷並處置急性病及傷害。
10. Perform common procedures in the outpatient or inpatient setting.
在門診或住院場域中施行一般性的手術。
41
http://www.stfm.org/NewsJournals/STFMNews/NewsSep302015
36. EPAs for Fam Med End of Residency Training 3
11. Manage prenatal, labor, delivery and post-partum care.
提供懷孕、生產及產後的照護。
12. Manage end-of-life and palliative care.
提供生命末期及緩和照護。
13. Manage inpatient care, discharge planning, transitions of care.
提供住院照護、出院準備、過渡照護。
14. Manage care for patients with medical emergencies.
提供緊急醫療照護。
15. Develop trusting relationships and sustained partnerships with patients,
families and communities.
與病人、家屬及社區發展互信關係與持續性夥伴關係。
42
http://www.stfm.org/NewsJournals/STFMNews/NewsSep302015
37. EPAs for Fam Med End of Residency Training 4
16. Use data to optimize the care of individuals, families and populations.
使用數據來優化個人、家庭及大眾的照護。
17. In the context of culture and health beliefs of patients and families, use the best science to set
mutual health goals and provide services most likely to benefit health.
在符合病人及家庭的文化與健康信念下,使用最佳的科學證據來設定健康目標並提供最
有益健康的服務。
18. Advocate for patients, families and communities to optimize health care equity and minimize
health outcome disparities.
維護病人、家庭及社區的健康照護平等並減少健康的差距。
19. Provide leadership within interprofessional health care teams.
領導跨領域的健康照護團隊。
20. Coordinate care and evaluate specialty consultation as the condition of the patient requires.
依照病人的需要來協調照護並評估專科會診意見。
43
http://www.stfm.org/NewsJournals/STFMNews/NewsSep302015
38. 45
Domain of Clinical Care Entrustable Professional Activities
Maternity and Newborn Care Care of the Prenatal Patient
Care of the Intrapartum Patient
Care of the Postpartum Patient
Care of the Newborn
Care of Children and Adolescents Care of the Well Baby and Child
Care of a Child or Adolescent with a Minor Episodic Problem
Care of a Child or Adolescent with Acute Serious Presentation
Care of the Adolescent Patient
Care of a Child or Adolescent with a Chronic Condition
Care of Adults Performing a Periodic Health Review of an Adult Patient
Care of the Adult with a Minor Episodic Problem
Care of the Adult with a Chronic Condition
Care of the Adult with Multiple Medical Problems
Care of the Adult with an Acute Serious Presentation
Care of the Elderly Patient Performing a Periodic Health Review of an Elderly Patient
Care of an Elderly Patient with a Minor Episodic Problem
Care of an Elderly Patient with a Chronic Condition
Care of an Elderly Patient with Multiple Medical Problems
Care of an Elderly Patient with an Acute Serious Presentation
End of Life Care Symptom Control Care for a Palliative Patient
Determining Goals of Care / Facilitating a Family Meeting
Caring for the Complex or Palliative Patient at Home
Behavioural Medicine Breaking Bad News
Providing Lifestyle or Behaviour Modification Counselling
Care of a Patient with a Mental Health Issue
Global Health and Care of the
Vulnerable and Underserved
Care of a Patient from another Culture
Care of a Patient Living in Poverty
Care of a Patient with an Intellectual/ Developmental Disability
Surgical and Procedural Skills Care of the Perioperative Patient
Performing an Acute Care Procedure
Performing a Minor Office Procedure
Physicianship Being a Professional
Managing a Practice
Being a Leader
Being a Teacher
Being Self-Reflective and a Self-Directed Learner
https://www.mededportal.org/icollaborative/resource/3993
36 EPAs
for a
postgraduate
Canadian
family
medicine
training
program
40. Entrustment decisions as assessment
• Discard artificial grades and scales (1-9; A-F)
• Focus on required supervision (linked to patient safety)
• Ask yourself:
• Can I leave the room?
• Do I need to return to check?
• Can the trainee finish without me?
• Can the trainee manage the admission of a patient without proactive
assistance?
• Look into the future and take a calculated risk
49
ten Cate 2015
45. How is this Different from Traditional Model?
Traditional time-based Competency-based
Focus, structure
and content
Content: knowledge, skills,
attitudes
Rotations
Outcomes demonstration of
competence
Relevant, paced learning
opportunities
Goal Knowledge acquisition Knowledge application
Actors Teacher to Learner Teacher and Learner
Relevant role models
Assessment Evaluation form
Norm-referenced
Summative
Evaluation portfolio
Criterion referenced
Formative
Program
completion
Fixed time Variable time
Tannenbaum D, Kerr J, Konkin J, Organek A, Parsons E, Saucier D, Shaw L, Walsh A. Triple C competency-based
curriculum. Report of the Working Group on Postgraduate Curriculum Review-Part 1. Mississauga ON: College of
Family Physicians of Canada; 2011 63
47. Becoming a Family Physician
A Lifelong Journey
UNDERGRADUATE
MEDICAL
EDUCATION
65
48. Becoming a Family Physician
A Lifelong Journey
UNDERGRADUATE
MEDICAL
EDUCATION
FAMILY MEDICINE
RESIDENCY TRAINING
BOARDEXAM
Beginning Specialist in Family Medicine 66
49. Becoming a Family Physician
A Lifelong Journey
UNDERGRADUATE
MEDICAL
EDUCATION
FAMILY MEDICINE
RESIDENCY TRAINING
BOARDEXAM
Beginning Specialist in Family Medicine
CONTINUING
PROFESSIONAL
DEVELOPMENT
IncludesFormalEnhancedSkillsTraining
CONTINUING
PROFESSIONAL
DEVELOPMENT
IncludesFormalEnhancedSkillsTraining
67