Secrets of Master Clinicians unraveled through the use of CBME.

2. Competency-based
Medical Education

3. ‫الطبيب‬‫المتميز‬
Super Physicians
Highly-Skilled &
Competent
Clinicians

4. How to Achieve Excellence?

5. ‫والعالم‬ ‫والفيلسوف‬ ‫الطبيب‬
‫الحسن‬ ‫بن‬ ‫هللا‬ ‫عبد‬ ‫بن‬ ‫الحسين‬ ‫علي‬
‫سينا‬ ‫بن‬ ‫علي‬ ‫ابن‬
Who is the Best?

6. How to Achieve Excellence?
Rests on Pillars!

7. The 2 Pillars of Master Clinicians
Cognitive Dimension
Ability to correctly
Diagnose & Treat
Human & Interpersonal
Dimension
Focusing on “WHAT MATTERS” to
the patient rather than only on ‘WHAT
IS THE MATTER” with them!

10. The 2 Pillars of Master Clinicians
Cognitive Dimension
Ability to correctly
Diagnose & Treat

11. Making the
Diagnosis: The
Diagnostic
Routes
Pattern-recognition: Spot Diagnosis/ Syndromic e.g. Shingles, Acromegaly,
ECG of ACS etc.
Smart Heuristic “Rules of Thumb” Short-cuts: early morning headache and
vomiting=Increased intracranial pressure.
Red Flags (serious pathology present-urgent intervention is needed): rest
pain, weight loss, neurological deficits etc. in a patient with low back pain.
Rule-Out Worst Scenario-ROWS (A vital ER Skill): Severe Hypertension,
Meningitis, SAH, CVA, Temporal Arteritis etc. in a patient with headache.
Hypothetico-deductive Strategies (from H&P).
Scoring Tools: Well’s, CAGE etc.
PubMed Search: enter key clinical features in the search box for ?similar case
reports.
Therapeutic trial.

12. Cognitive
Mastery:
Lessons from
the Literature
Excellence
in Decision-
Making:-
Time-
Efficient
and Spot-
on!
Their Secret: Hooked to a
Habit!
• They “LEARN” more on-the-
job than their colleagues by
diverting their “surplus”
mental energy to their
domain of interest!

13. Cognitive
Mastery:
Lessons from
the Literature
Their
GEARS
Case-based “Progressive
problem-solving skills”
• Regularly acquire NEW knowledge
or skills in anticipation of FUTURE
clinical patient needs: ‘Microfeeds’
for possible future scenarios!
• For example-on-line knowledge
access during the ward round!

14. Cognitive
Mastery:
Lessons from
the Literature
Their
GEARS
Systematic/Proactive
Feedback on their patient’s
management decisions
•Follow-up is crucial!
•Feedback is the
best CME!

15. Cognitive
Mastery:
Lessons from
the Literature
Their
GEARS
Reading Regular “Simulator”
Case Scenarios
• Clinical “Flight-simulator” but
“READING & LIVING” the case in a
“critical cognitive reasoning domain”!
• Creating a “cognitive mental scheme”
for future retrieval!

16. Cognitive
Mastery:
Lessons from
the Literature
Their
GEARS
• Diligently focusing, Pursuing & Regularly
practicing their ‘dream’ Expert Skill e.g.
auscultating numerous cardiac patients tto

17. The 2 Pillars of Master Clinicians
Human & Interpersonal Dimension
Focusing on “WHAT MATTERS” to the patient rather than only on ‘WHAT IS
THE MATTER” with them!

18. WHAT
MATTERS” to
the patient?
Master
Physicians-
are experts in
dealing with
the 3 major
concerns of
their
patients!
The Disease
• Right Diagnosis
• Right Treatment
The Illness
(Impact)
• Physical
Component: Pain,
insomnia etc.
• Social
Component: ADL-
Self-care, Work,
Study, Prayers,
Finance etc.
• Psychological:
Anxiety, Fear etc.
Clinician’s Personal
Attributes
(More than 30!)
• Professional
• Builds Rapport
• Empathetic
• Gives Hope
• Focuses on Good
News
• Good Listener
• Approachable
• Non-judgmental
• Motivates
• Etc.

19. How is the world making better doctors?
‘Scottish Doctor’
‘Tomorrow’s Doctor’
CanMEDS 2000
World Federation for Medical Education
‘Good Medical Practice’
Accreditation Council for Graduate Medical Education
WHO/EMRO
Gulf Cooperation Council
Association of American Medical Colleges
Institute for International Medical Education
‘Saudimeds’

20. CBME is a new Paradigm
We must know that the trainee has demonstrated
competence and is ready to progress to the next
stage of their career:
 Requires clear definition of expected competencies (i.e.
thing they need to do)
 Requires assessment to determine whether these
things are done consistently and within the contextual
needs of the clinical environment

21. Importance of a Holistic Professional development not
only Clinical Skills Training

22. 22
What Does CanMEDS stand for?
CanMEDS 2005 Framework
“Canadian Medical Education
Directions for Specialists”…
Better standards. Better physicians. Better care.

23. 23
CanMEDS Project Goal
To identify the core competencies generic to
all specialists to meet the needs of society.

25. Learning Objectives
• Describe the concepts and meaning of
the terminology used in CBME.
• Enumerate the important reasons for
applying a CBME in Modern Healthcare.
• Identify the basic principles of CBME.
• Know the CanMEDS Framework
for CBME.

26. The Need for a NEW Training Strategy
Healthcare is a
high-risk
Profession.
Societal Needs.
Legislative
(accrediting)
requirements

27. Competency-Based Medical Education
CBME is an outcomes-based approach to the
design, implementation, assessment and
evaluation of a medical education program using
an organizing framework of competencies.
The International CBME Collaborators, 2009

28. Note!
Competent
Competence
Competency

29. Competency
An observable ability of a health professional,
integrating multiple components such as
knowledge, skills, values and attitudes.
The International CBME Collaborators, 2009

30. Is a standardized
requirement for an
individual to properly
perform a specific job.
What is
Competency?
It encompasses a
combination of knowledge,
skills and attitude
(behavior) utilized to improve
performance.
More generally, competency
is the state or quality of
being adequately or well
qualified, having the ability
to perform a specific role.

31. Competent
Possessing the required abilities in all domains in
a certain context at a defined stage of medical
education or practice.
The International CBME Collaborators, 2009

32. Competence
Competence entails more than the possession of knowledge, skills
and attitudes; it requires you … to apply these [abilities] in the clinical
environment to achieve optimal results.
Doing
• the right thing
• at the right time
• in the right way
• in complex situations.
Ten Cate, Med Teach, 2010

33. Learning to Drive:

34. Does all of the
things
consistently,
adapting to
contextual and
situational needs:
Drives safely on
interstate or
during bad
weather, avoids
accidents, no
traffic tickets.
(Dad gives him the
keys and walks
away).
Competence
Can do all of
the things:
Passes driver’s
education
classes &
driver’s exam
to get the
license!
Competent
The thing(s)
they need to
do: Can
accelerate and
brake
smoothly.
Competency

36. When do your Trainee (Fellow) get the keys to
the car?
•Lots of good evaluations …
•Absence of bad evaluations …
•Survived a year of fellowship…
•Didn’t commit any crimes …
•Your program director followed the rules…

37. Entrustable Professional Activity

38. Entrustable Professional Activities
• To bridge the gap between the theory of competency-based
education and clinical practice, the concept of ‘entrustable
professional activities (EPAs)’ has been introduced.
• EPAs, when taken collectively, are “the essential professional
activities that describe a specialty.”

40. How are EPAs useful?
• Helps Curriculum builders to identify and select the important,
representative or critical tasks that should be mastered, thus
starting from clinical practice and focusing on the desired
outcomes of training.
• As Tasks require specific Competencies to fulfil, EPAs help create a
base for observation and assessment of competencies as they
manifest themselves in clinical practice.

43. Tip for the Curriculum Builder
•The set of EPAs identified when building a
workplace curriculum should be a valid
coverage of the profession and all domains
of competence should receive attention in a
well-balanced way.

45. Milestones of Competency

47. How are Milestones useful?
 Milestones will be used to design the
curriculum
 Demonstrating “competence” in all of
these milestone “sub-competencies” is
required for graduation into unsupervised
practice.

48. How are Milestones useful?
 If a resident is struggling with an EPA,
the milestones can be examined to see
which individual abilities the resident is
lacking and thus determine where
focused training and support are needed.

50. EPAs &
Milestones:
The key difference between EPAs
and Milestones is that EPAs are the
tasks or activities that must be
accomplished, whereas Milestones
are the abilities of the individual or
the stages in the attainment of the
EPA i.e. the abilities & stages in an
EPA.

51. EPAs &
Competences:
The key differences between EPAs
and Competencies:
 EPAs are not an alternative for
competencies, but a means to
translate competencies into clinical
practice.
 Competencies are descriptors of
physicians, EPAs are descriptors
of work.
 EPAs usually require multiple
competencies in an integrative,
holistic nature.

52. EPA: Ability to
care for a patient
with an Acute
Medical
Condition
The Milestones
 Focused patient-centered and hypothesis driven
history and physical examination.
 Comprehensive Technical Summary
 Comprehensive diagnostic labeling and severity
assessment.
 Articulate a Differential Diagnosis with their Pros
and Cons!
 Order Tests Rationally-based on Sensitivity,
Specificity and Likelihood Ratios.
 Decide on the site of care and any need for higher-
level referral and input.
 Order your “Immediate” Therapeutic Interventions.
 Patient Education, Self-management, Prevention
etc.

54. Inter-
relationships

55. Inter-
relationships

56. Case Scenario
 A 19-year old, newly married, university student with a
background of Type 1 DM, visits her Internist because of
amenorrhea of 3 months duration. She had a pregnancy
kit test from a nearby pharmacy which was positive. She
requested help for termination of pregnancy as she is
“mentally not ready yet”, is feeling depressed and out of
“worry about its impact on her education”. She indicated to
her doctor that she doesn’t want her husband to know.

57. Problem List/Issues
1. Pregnancy issue
2. Unborn baby Rights!
3. Type 1 DM (with Pregnancy)
4. Depression/Anxiety
5. Ethical Issue: Patient Autonomy
6. Family issue/Marital Disharmony
7. Awareness of Family Planning issues/
Contraception
8. Education/University issue-Personal
mental model, University Regulations
etc.

58. EPAs & Skills that are Essential for a High-Quality
Encounter
Knowledge and skills in dealing with a primigravida, Type 1 DM with
pregnancy, Depression.
Knowledge and skills in counseling-Patient, Family etc.
Knowledge about the ethical and legal issues relevant to the case.
Knowledge and skills for the consultation and involvement of other
specialties.
Knowledge & skills in Family Planning, Education etc.
Knowledge about University regulations etc.

59. Explicitly Naming the Skills
Clinical issues= Medical Expert
Counseling= Communicator
Seeking Specialist Help= Collaborator
Looking after the baby/Education/University= Advocate
Ethical and Legal Issues=Professional

60. 10
15
20
25
EPAs IN ONE45 Evaluation ITER System

61. EPAs IN ONE45 Evaluation ITER System
10
15
20
25

62. The Essential Entrustable Professional Activities:
Medical Expert as per the SCHS One45
Able to complete a
comprehensive, Hypothesis-
driven (ACS vs Esophageal
Spasm) and Patient centered
(Psychosocial Impact) H & P.
Able to select the most
appropriate test(s) based on
indications and sensitivity,
Specificity or Likelihood
Ratios (CXR vs BNP in CHF).
Able to formulate
appropriate differential
diagnosis e.g. Anatomic,
Physiologic, Aetio-Pathologic
etc. relevant to the clinical
presentation.
Able to analyze, integrate,
and formulate effective
management strategies e.g.
using the 5S scheme.
Able to discuss relevant
knowledge to a wide variety
of medical problems and
develops a plan of
secondary prevention.

63. The Essential Entrustable Professional Activities:
Medical Expert as per the SCHS One45
Able to identify (Generic &
Specific Severity Indicators)
and respond appropriately to
urgent cases.
Able to use evidence in
clinical decision-making e.g.
calculators (BMI, ABG
interpretation), Scoring Tools
e.g. CURB-65.
Able to apply relevant
information in problem-
solving e.g. proficiently
discuss the pros and cons for
the various differential
diagnosis, avoid Cognitive
Biases etc.
Able to articulate the
important pharmacodynamics
and pharmacokinetics as well
as the indications, adverse
events and serious
interactions of medications.
Able to perform diagnostic &
therapeutic procedures,
understands indications,
limitations & complications e.g.
Can demonstrate the use of a
Peak Flow meter or how a
metered-dose inhaler should be
used via a spacer device.

64. The Essential Entrustable Professional Activities:
Communicator as per the SCHS One45
Able to communicate
effectively with
patients, their
families, and HCPs.
Can use the various
communication styles-both
verbal and non-verbal as
appropriate:
• Therapeutic Communication
• Motivational Communication
• Handing-over
• Breaking Bad News
• Disclosure of Error
• Dealing with Angry Patient or
Relative
• Professional Communication
Able to maintain clear,
accurate &
appropriate records.
Able to write well
organized & legible
orders and progress
notes.
Able to write
Discharge Summaries
that are concise &
completed promptly.

65. The Essential Entrustable Professional Activities:
Collaborator as per the SCHS One45
Works effectively in a team
environment with attending,
juniors & nursing staff.
Coaches
Shows How
Says “We”
Says “Thanks”
“Asks politely”
Says “Let’s go”
Committed to one Goal
Democratic etc.
Not in One45:
Resolution of Interpersonal Conflicts
Community Collaboration: Patient Support Groups, Government Bodies
Collaboration etc. Community Service Rotation.
International Collaboration: Research Collaboration, Quality of Care
Collaboration etc. International Exchange Programs.

66. The Essential Entrustable Professional
Activities: Scholar as per the SCHS One45
Able to regularly attend e.g.
80% of MM and contribute to
rounds, seminars, and other
learning events.
Able to positively react in
response to constructive
feedback.
Able to educate patients,
junior residents, house staff,
and students (Teaching Skills).
Able to successfully complete
a Research Project.
Not in One45
CPD

67. The Essential Entrustable Professional
Activities: Leader as per the SCHS One45
Able to serve in administration
and leadership roles as
appropriate e.g. Clinical Roles:
Consultant, Senior Resident,
Junior Resident etc.
Able to appropriately &
efficiently use health care
resources.
Not in One45
Quality Improvement
Career Management (CV Writing,
Job Search/Application,
Interviewing Skills etc.)

68. The Essential Entrustable Professional
Activities: Advocate as per the SCHS One45
Able to identify the
psychosocial, economic,
environmental & biological
factors which influence the
health of patients and society.
Able to offers advocacy on
behalf of patients at practice
and general population levels.
Can speak and act on behalf
of patients to promote their
well-being mentally, physically
and socially.
Can initiate educational,
screening and preventative
action for patients, their
families and communities.
Social Determinants of
Health

69. The Essential Entrustable Professional Activities:
Professional as per the SCHS One45
Able to deliver the
highest quality of care
with integrity &
compassion.
Recognizes limitations
and seeks advice and
consultations when
necessary.
Able to abide to the
highest standards of
excellence in clinical
care and ethical
conduct.
Not in One45
Self-care
* Can act professionally upholding and applying
the Code of Conduct)/Islamic Cultural Values &
Legislative Regulations.
* Can identify the important domains of quality
and apply them in practice.
• Can articulate and explain the important Ethical
Principles governing patient care e.g.
confidentiality, autonomy etc.
• Can proficiently and successfully deal with
common ethical dilemmas in practice e.g. refusing
medications or “No Code/Not for Resuscitation,
unprofessional colleagues etc.

71. "This means more than just “putting more pressure on
the gas pedal”. It requires a shifting of gears"

72. "This means more than just “putting more pressure on
the gas pedal”. It requires a shifting of gears"
 Re-vitalizing the CanMEDS Subcommittee
 New Lead Members and Champions
 Updated curriculum
 TOT Program
 Webpage
 Innovative educational and training actions
 Emphasis on assessment and research.

74. Clinical Reasoning: Good to Great
https://www.youtube.com/watch?v=Qhayc-bRH5g