EM Milestones andResource Development

CORD 2013

EM Milestones andResource Development

• Putting Competency Based Education into Practice – Doug

• Intro to the EM Milestones Wiki – Joint Milestones Task Force

• When you get home, get on the Wiki and see what works for you

• Not a finished product but a starting point

Douglas Char, MD FACEP FAAEMCORD Academic Assembly

March 2013

We are at a tipping point in competency-based medical education (CBME) — and it’s only taken 40 years since the competency conversation first appeared in the medical literature!

In case you were not aboard the CBME train as it left the station, this concept is an integrated framework for education, in which specific behavioral outcomes (competencies) drive both medical school curricula and individual advancement, rather than the current driving forces of time (four years of medical school) and process (clerkships of specific length). Carol Aschenbrener – Chief Medical Officer, AAMC

http://wingofzock.org/2012/09/25/competency-based-medical-education-the-time-is-now/

Traditional medical education presumes that all students are ready to graduate once they have completed a set number of years of study and passed the required assessments, There is a growing interest in tailoring the length as

well as the content of medical education to individual aptitudes.

“People learn in different ways and at different speeds,”

“As early as 1932, reports emerged saying that it is not enough to stuff students’ heads with information

Stakeholder no longer accepting residents as independent actors, they expect physicians to function as leaders and participants in team-oriented care.

https://www.aamc.org/newsroom/reporter/april11/184286/competency-based_medical_education.html

It is a curricular concept designed to provide the skills physicians need, rather than solely a large, prefabricated collection of knowledge.

A medical school or residency program using competency-based medical education defines a set of skills or competencies based on societal and patient needs, such as medical knowledge, patient care, or communications approaches, and then develops ways to teach that content across a range of courses and settings.

https://www.aamc.org/newsroom/reporter/april11/184286/competency-based_medical_education.html

The competency-based approach still includes scientific knowledge, but in the broader context of a physician’s

tasks as a healer.

We are wrestling with it just like everyone else. The challenge is not so much accepting the concept, which we think is great, but figuring out how to make it work. Where do we teach? How do we evaluate performance? How do we remediate students who have not met requirements?” Thomas Pellegrino - EVMS

How to define competencies, and how to assess performance are perhaps the two most significant concerns about competency-based medical education. Peter Katsufrakis – NBME

“we’ve been wrestling with this question for decades,” M. Brownell Anderson - AAMC

Implementing competency-based training in postgraduate medical education poses many challenges. Making this transition requires change at virtually all levels of postgraduate training.

Key components of this change include; Development of valid and reliable assessment tools

such as work-based assessment using direct observation,

Frequent formative feedbackLearner self-directed assessment; Active involvement of the learner in the educational

process; Intensive faculty development that addresses

curricular design and the assessment of competencyIobst. Teach Med 2010; 32: 651–656

Bloom’s Taxonomy 1956 Anderson’s revision 2000

Remembering: can the student recall or remember the information?

define, duplicate, list, memorize, recall, repeat, reproduce state

Understanding: can the student explain ideas or concepts?

classify, describe, discuss, explain, identify, locate, recognize, report, select, translate, paraphrase

Applying: can the student use the information in a new way?

choose, demonstrate, dramatize, employ, illustrate, interpret, operate, schedule, sketch, solve, use, write.

Analyzing: can the student distinguish between the different parts?

appraise, compare, contrast, criticize, differentiate, discriminate, distinguish, examine, experiment, question, test.

Evaluating: can the student justify a stand or decision?

appraise, argue, defend, judge, select, support, value, evaluate

Creating: can the student create new product or point of view?

assemble, construct, create, design, develop, formulate, write

Cognitive (Knowledge) Affective (Attitude)

Psychomotor (Skills)

• Final milestones will provide meaningful data on the performance that graduates must achieve before entering unsupervised practice (graduate)

• Initial milestones for entering residents will add a performance- based vocabulary to conversations with medical schools about graduates’ preparedness for supervised practice (residency)

Norcini BMJ 2003:326(5):753-755Miller GE. The assessment of clinical skills/competence/performance. Acad Med 1990:S63-7.

Many people argue that this statement is incorrect and that the curriculum is the key in any clinical course.

In reality, students feel overloaded by work and respond by studying only for the parts of the course that are assessed.

To promote learning, assessment should be educational and formative—students should learn from tests and receive feedback on which to build their knowledge and skills

Pragmatically, assessment is the most appropriate engine on which to harness the curriculum.

V Wass. Lancet 2001; 357: 945–49

Trained ObserversCommon understanding of expectationsSensitive “eye” to key elementsConsistent evaluation of a given level of

performanceMinimum number of quality observations

Assessment based on 7-9 observations felt to be valid and reliable

Interpreter/Synthesizer ExpertsClinical Competency Committee

Numbers produce range restrictionNarratives are easily understood by faculty

and produce data without range restriction Natural to how we teach and provide feedback

Goalis to create verbal pictures 4 cm laceration right arm vs

Danger here is that rather than engaging a total practicum to which other forms of learning discourse bring their insights, a limited professional education is based upon an inappropriate epistemology of competency

Tendency to limit the reflection, intuition, experience and higher order competence necessary for expert, holistic or well developed practice

Martin Talbot, Med Educ 2004; 38: 587–592

If your are feeling overwhelmed and confused by all this new jargon – you are not aloneYour faculty are looking to you for answers!

Nobody has all the answers so stop waiting for the Holy Grail?Better to join the legion of PDs working to define

itThere is no way to sort out the milestones

without getting “dirty” – expect to make mistakesAssessment is suppose to drive curriculum (this is

a game changer)Resistance if futile, give in and drink the kool aid

Reduce your stress, it’s going to happen!

Intro to EM Milestones Wiki

Kevin Biese, MD, MAT

EM Milestones Wiki

JMTF – Work so far

• Intro to the Wiki – Christina• Care Based Milestones – Moshe• Systems Based Milestones – Mary Jo• Procedural Milestones – Jenna• Milestones Workbook - Rodney

Intro to Wiki Resources

Christina Shenvi, MD, PhD

WiiFM

But ultimately, check back to…

Accessing the wiki

• Emmilestones.pbworks.org• You do not need a login

• We hope this will be a helpful resource

JMTF – Care-Based Milestones

Moshe Weizberg, MD, FACEP

THANK YOU

• Committee• Nestor Rodriguez• Jason Seamon

EVALUATIONS

• How do you want to divide your milestones• What do you want your evaluation questions

to look like• How do you label each level• Where do you want your comment boxes

HOW DO YOU WANT TO DIVIDE YOUR MILESTONES

• All milestones on every evaluation• Divide among various rotations• Divide among faculty• Divide by day of the month

• Hit all core competencies• CCCs evaluate all milestones based on evals

PRO’S AND CON’SPRO’s CON’s

All milestones on every evaluation

Lots of dataMost information

Very long evaluationsFaculty compliance?Realistic?

Divide among various rotations

Select milestones that relate to that rotation

Have to match up the right milestones to the right rotations/evaluators

Divide among faculty Different faculty members become experts in evaluating their milestones

Those faculty won’t have input on other milestones

Divide by day of the month Hit every milestone every blockAvoid lengthy evals

Logistically challengingHit or miss

WHAT DO YOU WANT YOUR EVALS TO LOOK LIKE

• Yes/No/N/A• Mix up elements from various milestones• Mirror the milestone pages

PRO’S AND CON’S

PRO’s CON’s

Yes/No/N/A More accurateBetter info on each element

Many more questionsHarder to feed into CCCs

Mix up elements from various milestones

Probably most accurate Very difficult to set upVery difficult to analyzeMay be confusing for faculty

Mirror the milestone pages

EasierLess questionsFeeds cleanly into CCCs

Resident hits some elements and not othersVery wordy for faculty to read?less accurate

LESSONS LEARNED

• Many faculty gave all residents level 5• Faculty bias based on label of each level (PGY)• Faculty education• Resident education

JMTF - Systems-Based Milestones

Mary Jo Wagner, MD

JMTF: Procedural Milestones

Jenna Fredette, MDChristiana Health Care Systemjfredette@christianacare.org

Progress So Far

• Early Stages: Emails exchanged, surveys completed, one conference call good position for new members!

• None the less we have created an agenda for moving forward in 2013

Challenges with Procedural Milestones

• Achieving a Level 4/5 in a Procedural Milestone does not necessarily prove procedural proficiency

Challenges with Procedural Milestones

• Milestones addresses the following– General Approach to Procedures– Airway Management– Vascular Access– Focused Ultrasound– Wound Management– Anesthesia/Sedation

• We perform and require proficiency in many more areas than this

Current Agenda Moving Forward

• Collect institutional checklists and come up with set of standardized procedural checklists

• Add milestone language to the checklists when appropriate

• Determine the best way to evaluate each of the milestones (?procedural shift cards, SDOTs, SIM labs…)

• Welcome new ideas and input!!

• JMTF Procedural Milestones Wiki

JMTF - Milestone Workbook

Rodney Omron, MD, MPH

Structure: 2011 ABEM Model Content• SIGNS, SYMPTOMS, AND PRESENTATIONS• ABDOMINAL AND GASTROINTESTINAL DISORDERS• CARDIOVASCULAR DISORDERS• CUTANEOUS DISORDERS• ENDOCRINE, METABOLIC, AND NUTRITIONAL DISORDERS• ENVIRONMENTAL DISORDERS• HEAD, EAR, EYE, NOSE, THROAT DISORDERS• HEMATOLOGIC DISORDERS• IMMUNE SYSTEM DISORDERS• SYSTEMIC INFECTIOUS DISORDERS• MUSCULOSKELETAL DISORDERS (NONTRAUMATIC)• NERVOUS SYSTEM DISORDERS• OBSTETRICS AND GYNECOLOGY• PSYCHOBEHAVIORAL DISORDERS• RENAL AND UROGENITAL DISORDERS• THORACIC-RESPIRATORY DISORDERS• TOICOLOGIC DISORDERS• TRAUMATIC DISORDERS • Procedures and skills integral to the practice of EMergency medicine• other core competencies of the Practice of Emergency Medicine

Validated Education Tools

Contribute your validated

educational research

Thank you!!!!

• Just a start• Joint Milestones Task Force

– 11:30 – 1:00 Today Spruce Room – Keep the great work coming