canadian entrustable professional activities (epas) for the transition
TRANSCRIPT
Canadian Entrustable Professional Activities (EPAs) for the Transition
Claire Touchie, MD, MHPE, FRCPC
MCC Annual General Meeting 2016September 11, 2016
Conflict of interest
• None for this talk• Co-investigator for HIV related studies
Objectives
• Discuss why EPAs for the transition of UGME to PGME
• Describe the development of the AFMC EPAs• Demonstrate how EPAs can be used at the
transition to guide learning and assessment strategies
Why focus on the transition?
• First year residents are expected to perform certain clinical activities without direct supervision on the first day of residency
• Increased morbidity/mortality has been reported in the trainee changeover period– The July Effect
Why focus on the transition?
Conclusion: Mortality increases and efficiency decreases in hospitals because of year-end Changeovers, although heterogeneity in the existing literature does not permit firm conclusionsAbout the degree of risk posed, how changeover affects morbidity and rates of medicalErrors, or whether particular models are more or less problematic.
Young et al, Annals of Intern Med, 2011
Why focus on the transition?
Raymond et al, Acad Med, 2011Touchie et al, Med Educ, 2014
FMEC-PG recommendation #5
• The FMEC-PG project: set of recommendations
• Recommendation #5: Develop smoother and more effective transitions from medical school to residency.
• Necessity to create links the learner competencies developed in the MD training with the educational objectives set for the resident.
Need for a new approach
Frenk J, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010
CanMEDS 2015
Assessing competencies
• Relative ease to assess Medical Expert and Communicator roles
• Less obvious to assess other intrinsic roles• Olle ten Cate and EPAs
EPAs: An outcomes-based approach
Entrustable Professional Activities:• An essential task of a discipline that an individual can be trusted
to perform without “supervision” in a given context – Unit of work that clinicians do in their practice that is directly
observable– Ultimate aim is to do it unsupervised– Can assess in the workplace– Can map competencies to EPAs– Development through 5 different levels of trust
• Intuitive• Making the implicit explicit
Entrustable professional activities
• PGME: – Conducting an uncomplicated delivery (OB-GYN)
– Provide peri-operative assessment and care (IM)
– Breaking bad news (FM)
• UGME:– Performing a history and physical exam (AAMC)
– Give or receive patient handover to transition care responsibility (ten Cate and Young, BMJ Qual Saf 2012)
12
CBME, EPAs and milestones
How do they all relate?– EPAs: what we do
– Competencies: KSAs we need to be competent – person-descriptors
– Milestones: how we get there
Ten Cate et al., Med Teach AMEE guide 99, 2015
Entrustable and entrustment
Trust and supervision at the transition
Level 1
Not allowed to practice EPA a. Inadequate knowledge/skill; not allowed to observeb. Adequate knowledge, some skill; allowed to observe
Undergraduate Medical Education
Postgraduate Medical Education
Level 2
May act under proactive, ongoing, full supervision (direct)a. As coactivity with supervisorb. With supervisor in room ready to step in as needed
Level 3
May act under reactive supervision (indirect)a. With supervisor immediately available, all findings
double checkedb. With supervisor immediately available, key findings
double checkedc. With supervisor distantly available, findings reviewed
Level 4
May act unsupervised
Level 5
Allowed to supervise others in practice of EPA
Touchie and ten Cate, Med Educ, 2016Adapted from Chen et al., Acad Med, 2015
Other entrustment scales
• O-SCORE and OCAT– I had to do – I had to talk them through– I had to prompt them from time to time– I needed to be in the room just in case– I did not have to be there
• University of Alberta – Family Medicine– Stop: important correction– In progress– Carry-on/Got it!
AFMC Entrustable Activities
AFMC EPA development and outcome
The Charge came from:• The FMEC PG Implementation Project
– Transition from Medical School to Residency Working Group
• The UGME Deans
AFMC EPAs : Ensure that…
• Students have been observed performing core activities necessary prior to residency training
• Residents will be ready to perform certain core activities on day one
• These “generic” EPAs define expectations for residents entering residency programs regardless of
• school of MD training• residency training program site • chosen specialty
Methodology to select EPAs
• Pan-Canadian working groupUME, PME, students, residents, medical educators
• Started with the 13 AAMC core EPAs • WG survey• Other documents used as references• Distributed preliminary list
– Feedback UME/PME/schoolsConsensus reached on a total of 12 “themes” for
Canadian (AFMC) EPAs
AFMC EPAs
AFMC EPAs (1-6)EPA 1 - Obtain a history and perform a physical examination adapted to the patient’s clinical situationEPA 2 - Formulate and justify a prioritized differential diagnosis EPA 3 - Formulate an initial plan of investigation based on the diagnostic hypothesesEPA 4 - Interpret and communicate results of common diagnostic and screening testsEPA 5 - Formulate, communicate and implement management plansEPA 6 - Present oral and written reports that document a clinical encounter
AFMC EPAs
AFMC EPAs (7-12)EPA 7 - Provide and receive the handover in transitions of careEPA 8 - Recognize a patient requiring urgent or emergent care, provide initial management and seek help EPA 9 - Communicate in difficult situationsEPA 10 - Participate in health quality improvement initiativesEPA 11 - Perform general procedures of a physicianEPA 12 - Educate patients on disease management, health promotion and preventive medicine
An example
Short description
The graduate selects a series of tests to help refine the differential diagnosis for a clinical presentation and enable him/her to make appropriate management decisions. The plan of investigation should be limited to common clinical situations expected for this level of training.
Most relevant CanMEDS roles
Medical ExpertLeaderProfessionalHealth Advocate
Entrustable Behaviours
The learner Orders (or decides not to order) tests considering their features and limitations (e.g., reliability, sensitivity,
specificity), availability, acceptability for the patient, inherent risks and contribution to a management decision In case of social implications of a positive results, discusses the selection of the tests with patients / families
ordering them (e.g. HIV, pregnancy in an adolescent) Identifies levels of uncertainty at each step of the diagnostic process and do not over-investigate or under-
investigate Chooses diagnostic interventions using evidence or best practice/guidelines according to costs and availability
of resources taking into consideration the way in which care is organized Identifies who will be responsible for the follow-up of the test results.
Assessment suggestions
This EPA should be assessed by direct observation of the learner at rounds, during review of a patient encounter, with case reviews or chart simulated recall.
Formulate an initial plan of investigation based on the diagnostic hypotheses
Mapping EPAs with CanMEDS roles
Med Expert
Collab Comm Health Adv
Leader Prof Scholar
EPA 1 x x x x
EPA 2 x x x x
EPA 3 x x x x
EPA 4 x x x x
EPA 5 x x x x
EPA 6 x x x x
EPA 7 x x x x x
EPA 8 x x x x
EPA 9 x x x x
EPA 10 x x x x
EPA 11 x x x x
EPA 12 x x x x
EPA implementation: curriculum vs. assessment
• Preliminary results of MD program survey– 8 schools out of 17 to date– EPA 1 (Hx and PE) is being taught and assessed by
all schools that have responded – Behaviours of EPAs 2, 4 and 12 are being taught
and mostly assessed– Major gaps in EPAs 7 (Handover), 10 (QI)
Based on the new approach
Frenk J, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010
Implementation plans of UGME EPAs
• In Canada:– Memorial University Assessment– Queens University Curriculum
• In USA– Vanderbilt Curriculum and Assessment
• In The Netherlands– Utrecht Curriculum and Assessment
Implementation and implications
• Lessons learned– Faculty buy-in and development
• Mandatory training for all vs. specifically trained teachers• One observation pass/fail decision
– Student preparedness• Growth curves• Learner handover
– Need for Assessment committees– Need for an assessment office
Implementation: where are we?
• Centrally developed but locally implemented– 2 schools implemented/ing (Fall 2015 and Fall 2016)– 7 schools are working on implementation plan– 3 schools will start implementation plan in 2017
• Decision making– How/When to decide that leaners are entrusted?– How many observations?– What entrustment scale to use? Language important– How many different settings/contexts?
Ongoing concerns
• EPAs totality of “becoming” a doctor– A framework to assess in the workplace and to
reflect competencies• Cost• Staff involvement• Opportunity for clinical exposure
Summary
• There is a need to ensure that the transition between medical school and residency is safe
• Entrustable professional activities provide a frame to directly observe activities that must be performed by residents early in their training
• Canadian schools are looking at implementing 12 core EPAs
Acknowledgments
• Andrée Boucher as the project co-lead• AFMC for all the project support• MCC • Working Group Members• UGME deans, PGME deans, AFMC Board of
Directors• Student and Resident associations
THANK YOU!