A Competency-Based Education Model. George C. Mejicano, MD, MS Professor of Medicine Senior Associate Dean for Education

Transcription

1 A Competency-Based Education Model George C. Mejicano, MD, MS Professor of Medicine Senior Associate Dean for Education

2 Disclosure Slide Dr. Mejicano has no personal financial relationships with commercial interests

3 The Four Horsemen of the Medical Education Apocalypse Teaching patient shortages Shortage of instructors Conflicting systems Financial problems [Academic Medicine 2008; 83(12): ]

4 Some Possible Solutions to the Four Horsemen Employ and utilize technology as faculty, clinical, and patient extenders Develop a national bank of learning objects and curriculum materials shared by many/all Give the learners more control over education Adopt standard, competency-based systems [Academic Medicine 2008; 83(12): ]

5 Philosophical Concepts Driving Force for Curriculum Driving Force for Process Structure Process Content and Knowledge Acquisition Teacher Competencybased Outcome and Knowledge Applications Learner(s) Path of Learning Hierarchy No Hierarchy Responsibility for Learning Teacher Student and Teacher Partnership [Courtesy of Bob Englander]

6 Assessment Concepts Typical Assessment Context Typical Assessment Tool Timing of Assessment Type of Evaluation Structure Process Proxy / Removed Single or Few, Often Multiple Choice Questions Emphasis on Summative Norm- referenced Competency-based Authentic / Directly Observed Multiple, Subjective as well as Objective Portfolios Emphasis on Formative Criterion-referenced [Courtesy of Bob Englander]

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8 ACGME/ABMS Domains of Competency Patient Care and Procedural Skills Medical Knowledge Practice Based Learning & Improvement Interpersonal and Communications Skills Professionalism Systems-based Practice

9 Family Medicine Milestone Project (An Example from ABFM and ACGME) September

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11 Going to a competency based framework will flip the instructional paradigm on its head. Carol Aschenbrener, MD Former Chief Medical Education Officer Association of American Medical Colleges

12 The Profound Implications of a Competency Based Curriculum All six domains of competency are considered equivalent Time is irrelevant Disciplines don t matter Assessment is key

13 [Can J Nursing Informatics; 2011; 5(4):967]

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16 Spider / Radar Charts

17 Learner Trajectories

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20 The Gap between expectations and residents performance on the first day of their internship.

21 1. Gather a history and perform a physical examination GQ 4 o 5 Program Directors All or most 94.9% 88.4% 2. Prioritize a differential diagnosis following a clinical encounter Sample text here for a 3. Recommend and interpret common diagnostic and screening tests transition slide 88.3% 66.2% 83.9% 66.0% 4. Enter and discuss orders/prescriptions 54.9% 59.7% 5. Document a clinical encounter in the patient record 6. Provide an oral presentation of a clinical encounter 7. Form clinical questions and retrieve evidence to advance patient care 89.4% 80.2% 88.6% 81.2% 87.9% 63.8%

22 GQ 4 or 5 Program Directors All or most 8. Give or receive a patient handover to transition care responsibility 9. Collaborate as a member of an interprofessional team Sample text here for a transition slide 10. Recognize a patient requiring urgent or emergent care, and initiate evaluation and management 11. Obtain informed consent for tests and/or procedures 77.3% 54.8% 91.9% 78.3% 82.9% 55.5% 79.9% 49.6% 13. Identify system failures and contribute to a culture of safety and improvement 67.1% 30.7%

23 12. Perform general procedures of a physician (IV line insertion, Phlebotomy, BVM ventilation, CPR) Sample text here for a transition slide GQ 4 or 5 IV line insertion 39.8% Phlebotomy 43.6% Program Director s All or most 24.2% Bag-valve-make ventilation (BVM) 67.8% Cardiopulmonary resuscitation (CPR) 62.9%

24 Goal of OHSU s New Your MD Curriculum Effectively prepare the MD graduate for residency training and professional practice to best serve and meet the needs of society in the 21 st century

25 Ensuring Learners are Prepared to Transition to GME

26 CEPAER Project Charge Develop a clear, concise list of what graduating medical students should be entrusted to do without direct supervision on DAY ONE of residency

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28 EPA Entrustment refers to the ability to effectively perform a professional activity unsupervised Brings trust and supervision into assessment which are intuitive for faculty working with trainees Entrustment decisions allow inference about a learner s competence

29 Entrustment is Based On: Ability or level of knowledge, skills and attitudes Conscientiousness Telling the truth absence of deception (truthfulness) Knowing one s limits (discernment) Kennedy et al., Acad Med. 2008;83(10 Suppl):S89 92

30 Levels of Supervision Direct Care Responsive Oversight Routine Oversight Backstage Supervision Kennedy E, et al. Clinical oversight: Conceptualizing the relationship between supervision and safety. JGIM, 2007;22:

31 EPA Professional is a modifier of activities that refers specifically to: Area of practice (e.g., specialty) Scope of practice (e.g., profession)

32 EPA The Activities: Represent the essential work that defines a discipline (in aggregate) Lead to a recognized outcome Should be independently executable within a given time frame Are observable and measurable units of work in both process and outcome Require integration of critical competencies and milestones

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34 DOC C 2 M 1 M 2 C 3 M 1 M 2 EPA DOC C 1 C 4 M 1 M 2 M 1 M 2 EPA: Entrustable Professional Activity DOC: Domain of Competence C: Competency M: Milestone DOC C 2 C 5 M 1 M 2 M 1 M 2

35 M 1 M 2 M 1 M 2 Narrative description of a pre-entrustable learner M 1 M 2 M 1 M 2 Narrative description of the entrustable learner M 1 M 2 M 1 M 2

36 13 DOC C 2 C M 1 M 2 M 1 M 2 EPA DOC C 1 C 4 M 1 M 2 M 1 M 2 129? EPA: Entrustable Professional Activity DOC: Domain of Competence C: Competency M: Milestone DOC C 2 C 5 M 1 M 2 M 1 M 2

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39 Vision of EPA Competency Curve EPA4 EPA2 EPA3 EPA1 Competence Threshold EPA5 Advancement (entrustment) decisions training deliberate professional practice Modified from Olle Ten Cate

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41 Rationale for the CEPAER Project GME competencies have been established Until CEPAER, the desired product from UME had not been well-articulated Gaps identified between: Expectations of GME Program Directors and the skills of their entering residents What residents are called upon to do without supervision and what they have been certified as competent to do International attention focusing on transitions

42 CEPAER Pilot Project Studying the implementation of EPAs via four key areas:

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44 The Scavenger Hunt Analogy 43 Needed MK = 5 PCP = 6 SBPIC = 5 PBLI = 8 PPPD = 11 ICS = 8 Experiences Where the 43 can be Found Threads, Blocks, Enrichment Exercises, Intersessions, and Scholarly Project Both Required and Elective Clinical Experiences

45 Students Must Find all 43 Each of the 43 competencies matter Where each is found does not matter Seven core disciplines Each rotation will offer at > 4 competencies Students can take rotations over and over in order to obtain the needed experiences When learner is ready and enough data is accrued, entrustment decisions are made

46 18 month Foundations of Medicine curriculum Transition to Clinical Experiences Course Core Clinical Experiences in: Family medicine Internal medicine Neurology Obstetrics/Gynecology Pediatrics Psychiatry Surgery Rural & Continuity Experiences Intersessions & electives

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50 Student Assessment Grades relevant to discipline are tiered e.g., Honors (A), Near Honors (B), etc.) Awarded by supervising clinicians Grades relevant to the 43 competencies and the 13 EPAs required to graduate Pass / Not Yet Passed for each competency Pre-entrustment / Entrustment based upon multimodal assessments for each EPA Awarded by Entrustment Committees

51 Student Affairs: Three Distinct Functions Student support and advocacy Career advising / role modeling Coaching

52 We want to create master adaptive learners! [Courtesy of Bill Cutrer, Don Moore and the AMA ACE Consortium]

53 Research and Evaluation Data for Educational Improvement (REDEI)

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56 The OHSU EPA Badges

57 Acknowledgements Bob Englander Carol Carraccio Joe Gilhooly Tim Brigham Maryellen Gusic Mike Ryan Kim Lomis Bill Cutrer Don Moore Patty Carney Rich Hawkins And many others!

58 Thank You!!