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Workshop Preparing the Implementation of EPAs in Undergraduate Medical Education

RobertEnglander(USA)ClaireTouchie(Canada)OlletenCate(Netherlands)IndraPosthumus(Netherlands)

WorkshopImplemenHngEPAsinUME.SummitonCBME,Barcelona,August28,2016

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OVERVIEW !1.  Welcome, acquaintance, what do you want to take home?2.  Bob Englander: Implementing the Core EPAs for Entering Residency

in Undergraduate Medical Education

3.  Claire Touchie: State of the art in Canadian EPAs and what can schools expect to be doing?

4.  Indra Posthumus / Olle ten Cate: Curriculum development for UME at Utrecht

5.  Small groups: Plan your Curriculum Committee work!6.  Plenary discussion and wrap-up

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ACQUAINTANCE AND PERSONAL GOALS !

•  Who are we?•  Who are you?•  What are your wishes for this session?

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REMIND ME ABOUT DEFINITION AND PURPOSE OF EPAS !•  Definition: core units of professional practice that can be fully

entrusted to a trainee as soon as he or she has demonstrated the necessary competence to execute the activity unsupervised

•  Purpose: to frame medical training and assessment around core activities health care requires doctors to do, and to focus the development of competence and competencies toward increasing entrustability and responsibility of learners

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Implementing the Core EPAs for Entering Residency in Undergraduate Medical

Education

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THE CORE ENTRUSTABLE PROFESSIONAL ACTIVITIES FOR ENTERING RESIDENCY

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Rationale

•  Graduate Medical Education Competencies well established

•  Gaps identified between:

─  Expectations of programs directors and entering resident skills

─  What residents do without supervision and what they have been documented as competent doing without supervision

•  International focus on transitions

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WHY EPAS?

•  Make sense to faculty, trainees and the public•  Make assessment more practical by clustering competencies and their milestones

into meaningful professional activities

•  Add meaning to assessment by focusing on integration of competencies in the context of care delivery

•  Add “trust” to the assessment conversations

•  Align what we assess with what we do•  Align education across the continuum

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EPA

DoC

DoC

DoC

M1 Mx

M1 Mx

M1 Mx

M1 Mx

M1 Mx

M1 Mx

EPA: Entrustable Professional Activity DOC: Domain of Competence C: Competency M: Milestone

C2

C3

C1

C4

C2

C5

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M1 Mx

M1 Mx

M1 Mx

M1 Mx

M1 Mx

M1 Mx

Narrative description of an early (novice) learner

Narrative description of a learner at “x” level

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EXAMPLE OF THE LINKS BETWEEN EPAS, COMPETENCIES AND MILESTONES !

•  Core EPAs for Entering Residency

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CORE EPAS FOR ENTERING RESIDENCY

1)  Gather a history and perform a physical examination

2)  Prioritize a differential diagnosis following a clinical encounter

3)  Recommend and interpret common diagnostic and screening tests

4)  Enter and discuss orders/prescriptions

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

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CORE EPAS FOR ENTERING RESIDENCY

8)  Give or receive a patient handover to transition care responsibility

9)  Collaborate as a member of an interprofessional team

10)  Recognize a patient requiring urgent or emergent care, and initiate evaluation and management

11)  Obtain informed consent for tests and/or procedures

12)  Perform general procedures of a physician

13)  Identify system failures and contribute to a culture of safety and improvement

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A MODEL OF COMPETENCY-BASED ADVANCEMENT !USING AN EPA FRAMEWORK: EPAC !

!

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EPAC !

•  New approach to curriculum and assessment

•  Early entry into specialty training pathway with alignment across UME/GME (pediatrics as model)

•  Create “true” competency-based advancement system using EPA (and Milestone) framework

•  Transitions based on demonstration of competence, not only time

•  Emphasis on longitudinal relationships

•  Lessons learned could be applied to other specialties

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AREAS OF FOCUS FOR IMPLEMENTING EPAS !

•  Curriculum•  Assessment•  Entrustment pathways

•  Faculty Development

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CURRICULUM !

•  Gaps•  Sequence•  Content

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ASSESSMENT !

•  Assessment Working Group (lead by Alan Schwartz from UIC)•  “deep dive” assessments for 5/13 Core EPAs for Entering Residency,

based on the literature

•  Holistic/global approach to all EPAs but as primary approach to the other 8

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ASSESSMENT: GLOBAL ASSESSMENT OF LEVEL OF SUPERVISION (MODIFIED FROM CHEN ET AL) !

–  Level 1: Observe only–  Level 2: Allowed to practice under direct supervision

•  A. As coactivity with supervisor•  B. With supervisor in room and ready to step in

–  Level 3: Allowed to practice EPA under indirect supervision•  A. with supervisor immediately available, all findings checked•  B. with supervisor immediately available, key findings checked•  C. With supervisor distantly available, findings reviewed

–  Level 4: Allowed to practice without supervision

–  Level 5: Allowed to supervise others

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ASSESSMENT !

•  EPA Assessment Data

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ENTRUSTMENT !

•  Clinical Competency Committees:–  Make-up

–  Frequency–  Supportive data

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FACULTY DEVELOPMENT !

•  Focused group of preceptors•  Use of the Core EPA vignettes•  Student-led faculty development in assessment

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UGME EPAs: the Canadian Perspective!ClaireTouchie,MD,MHPE,FRCPC

onbehalfoftheAFMCEPAworkinggroup

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AFMC WORKING GROUP ON EPAS !

Future of Medical Education in Canada – PG: •  Develop smoother and more effective transitions from medical

school to residency. •  Necessity to create closer links between the learner

competencies developed in the MD training with the educational objectives set for the resident.

•  Map to CanMEDS roles

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EPAS AT THE TRANSITION: 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

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METHODOLOGY TO SELECT EPAS !

•  Pan-Canadian working groupUME, PME, students, residents, medical educators

•  Started with AAMC core EPAs (13)WG survey

•  Other documents used as reference•  Preliminary list•  Feedback UME/PME/schools

Consensus reached on a total of 12 “themes” for Canadian (AFMC) EPAs

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AFMC EPAS !

AFMC EPAs (1-6) EPA1-ObtainahistoryandperformaphysicalexaminaHonadaptedtothepaHent’sclinicalsituaHonEPA2-FormulateandjusHfyaprioriHzeddifferenHaldiagnosisEPA3-FormulateaniniHalplanofinvesHgaHonbasedonthediagnosHchypothesesEPA4-InterpretandcommunicateresultsofcommondiagnosHcandscreeningtestsEPA5-Formulate,communicateandimplementmanagementplansEPA6-Presentoralandwri`enreportsthatdocumentaclinicalencounter

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AFMC EPAS !

AFMC EPAs (7-12) EPA7-ProvideandreceivethehandoverintransiHonsofcareEPA8-RecognizeapaHentrequiringurgentoremergentcare,provideiniHalmanagementand seekhelpEPA9-CommunicateindifficultsituaHonsEPA10-ParHcipateinhealthqualityimprovementiniHaHvesEPA11-PerformgeneralproceduresofaphysicianEPA12-EducatepaHentsondiseasemanagement,healthpromoHonandpreventaHvemedicine

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EXAMPLE: FORMULATE AN INITIAL PLAN OF INVESTIGATION BASED ON THE DIAGNOSTIC HYPOTHESES !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 Expert Leader Professional Health 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.

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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

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CHALLENGES AHEAD: IMPLEMENTATION •  Centrally developed but locally implemented

–  2 schools implemented (Fall 2015 and Fall 2016) –  7 schools are working on implementation plan –  3 schools will start implementation plan in 2017

•  Different implementation plan –  Curricular focus vs Assessment focus

•  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?

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KEEPING THE PROJECT ALIVE !

•  UME taking ownership–  Survey which Entrustable behaviours are being taught and assessed already

–  Early adopters “paving the way”–  Monthly teleconferences

•  Sharing of experiences: what works and what does not

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ACKNOWLEDGEMENTS !

•  FMEC-PG project•  AFMC EPA working group•  UME Deans

•  AFMC Staff/Board of Directors•  MCC

Curriculum development for UME at Utrecht

IndraPosthumus,OlletenCate,UniversityMedicalCenterUtrecht,

TheNetherlands

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Curriculum Development history at Utrecht UME

•  2011: Accreditation review triggered thinking of curricular change •  2011-12 Review of publications and document, many discussions •  2012: Curriculum Committee established •  2013: Blueprint for new curriculum. Several major innovations; relevant are: Integration and lengthening of clerkships,

introduction of e-portfolio, EPAs a core principle for teaching and assessment

•  2014-16: implementation, refining, preparation of materials, informing stakeholders

•  And the program for a cohort of 300 starts… .... August 2016!

Identifying the EPAs – what path was followed? Resources •  Dutch national Framework of Objectives for UME (legally binding)

•  AAMC Core EPAs for entering residency (13)

Iterative construction of EPA framework •  July 2014: 10 EPAs

•  September 2014: 9 EPAs + 2 integrative Ma3 EPAs

•  June 2015: 2 Ba-EPAs, 8 Ma1/Ma2 EPAs, 2 Ma3 EPAs

•  August 2015: 2 Ba3 EPAs; 5 graduation core EPAs

•  March 2016: 5 Core EPAs + 36 small, nested EPAs

•  August 2016: further refinements on detailed scale

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1 Checkingbasicvitalfunc3onsofastableadultpa3ent2 Gatheringandrepor3ngbasicgeneralpa3entinforma3onthatdoesnotrequire

inves3ga3ons3 Reques3ngandcollec3ngbasicbodilymaterials4 Conduc3ngsimpletherapeu3cacts5 Gatheringandrepor3ngbasicspecialty-specificpa3entinforma3onthatdoesnotrequire

inves3ga3ons6 Reques3ng,interpre3ngandsharingbasicdiagnos3cinves3ga3ons7 Designandini3a3ngatreatmentplanforcommondisorders8 Breakingbadnewstopa3entsandfamilyaboutnon-terminalcondi3ons9 Conduc3ngbasicspecialty-specificprocedures10 Ac3ngasprimary-responsiblecaregiverforasmallward

UME EPAs first iteration

1 Checkingandrepor3ngbasicvitalfunc3onsofastableadultpa3ent2 Gatheringandrepor3ngbasicgeneralpa3entinforma3onofastableadultpa3ent3 Reques3ngandcollec3ngbasicbodilymaterialsofstableadults4 Conduc3ngsimpletherapeu3cactsonastablepa3ent5 Reques3ng,interpre3ngandsharingresultsofbasicdiagnos3cinves3ga3ons6 Designingandini3a3ngatreatmentplanforcommondisorders7 Breakingbadnewstopa3entsandfamilyaboutnon-terminal,nonchroniccondi3ons8 Recognizingandac3ngonanemergencysitua3oninthehospital9 Caringforapa3entaroundend-of-lifedecisions 10 Managinganinpa3entward(integrates1-9)11 Managinganoutpa3entclinic(integrates1-9)

UME EPAs - second iteration

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1 BA3 Vitalparameters2 BA3 Basicmedicalprocedures3 MA1/2 Historyandgeneralphysicalexamina3on4 MA1/2 Commonproceduresofthephysician5 MA1/2 Conduc3ngsimpletherapeu3cactsonastablepa3ent6 MA1/2 Reques3ng,interpre3ngandsharingresultsofbasicdiagnos3c

inves3ga3ons7 MA1/2 Designingandini3a3ngatreatmentplanforcommondisorders8 MA1/2 Breakingbadnewstopa3entsandfamilyaboutnon-terminal,non-

chroniccondi3ons9 MA1/2 Recognizingandac3ngonanemergencysitua3oninthehospital10 MA1/2 Caringforapa3entaroundend-of-lifedecisions11 MA3 Managinganinpa3entward12 MA3 Managinganoutpa3entclinic

UME EPAs - third iteration

1 The Clinical Consultation

2 General Medical Procedures;

3 Informing, Advising & Guiding Patients and Families

4 Communicating & Collaborating with Colleagues

5 Extraordinary Patient Care

[Optional: elective EPAs]

UME EPAs - fourth iteration

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.. 5 Core EPAs Specifications

The Clinical Consultation

History, physical examination, measuring vital signs, creating a differential diagnosis, ordering and interpreting diagnostic tests, designing a management plan and basic documentation

General Medical Procedures

Preparing and executing 13 medical procedures including the necessary communication with patients

Informing, Advising & Guiding Patients and Families

General guidance of patients, including discussing diagnostic options, obtaining informed consent, discussing test results and management plan, and discharge conversation

Communicating & Collaborating with Colleagues

Writing a discharge summary/letter, oral patient hand-overs, patient documentation and presentations, research documentation and presentations, collaborating with other health care workers and contributing to interprofessional teams

Extraordinary Patient Care

Basic Life Support, Establishing death

UNIT year

LINK GREEN

BA 3

LINK RED MA 1

LINK BLUE MA 1

LINK YELLOW

MA 2

LINK PURPLE

MA 2

TRANSITIONAL YEAR MA 3

Disci-plines

Int.med.; surgery; fam.med

Pediatrics; obgyn; clin.

genetics

Neurology; psychiatry; geriatrics

Fam.med; ENT; ophth; derm;pubH

Int.med; surgery; anaesth.

All major disciplines as elective options

EPA 1 ✪ ✪ ✪ ✪ ✪

The Clinical Consultation

EPA 2 ✪ ✪ ✪ ✪

General Medical Procedures

EPA 3 ✪ ✪

Guiding, Informing and Advising

Patients & Families

EPA 4 ✪ ✪

Communicating and Collaborating with

Colleagues

EPA 5 ✪

Extraordinary Patient Care

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Example of one integrated clerkship: “LINK Red”Disciplines: Pediatrics, Obstetrics/Gynaecology, Clinical Genetics

Summative entrustment of specific core EPAs required: 1.2 Gynaecology clinical consultation 1.3 Clinical consultation of pregnant woman 1.3 Clinical consultation of neonate and infant 1.4 Pediatric clinical consultation 1.6 Clinical genetics consultation 2.7 Insertion of urinary catheter 2.8 Speculum exam

Summative entrustment of general core EPAs optional (or in other clerkship): 3.1 Discussing diagnostic options and obtaining informed consent 3.2 Discussing test results, management plan 4.1 Documentation and presentation 4.2 Acting in interprofessional teams 5.1 Establishing death 5.2 Basic life support

UMCU: EPA1

EPA2 EPA3 EPA4 EPA5CEPAER

EPA1:GatherahistoryandperformaphysicalexaminaHon X

EPA2:PrioriHzeadifferenHaldiagnosis X

EPA3:RecommendandinterpretcommondiagnosHcandscreeningtests X

EPA4:EnteranddiscussordersandprescripHons X

EPA5:DocumentaclinicalencounterinthepaHentrecord X X

EPA6:GiveanoralpresentaHonofaclinicalencounter X X

EPA7:FormclinicalquesHonsandretrieveevidence X X

EPA8:GiveorreceiveapaHënthandover X

EPA9:Collaborateasamemberofaninterprofessionalteam X

EPA10:Giveurgentoremergentcare X X

EPA11:Obtaininformedconsent X

EPA12:Performgeneralproceduresofaphysician X X

EPA13:IdenHfysystemfailures&contributetoacultureofsafetyandimprovement

[NotrepresentedinEPAsbutinothertasks]

UtrechtCoreEPAsversusAAMCCoreEPAs

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BREAK-OUT GROUP ACTIVITY [30 MINS]. ASSIGN A REPORTER. !Imagine being members of a new Curriculum Committee, charged with revising the clinical UME curriculum (with classes of 150) that is planned to start September 2018. The Dean wants an EPA-based curriculum. This is your first meeting. What do you want to achieve with the committee before January 2017 and before the summer of 2017 and how will you do that? Think of the following topics and prioritize. There is sufficient funding.

–  Creation of an EPA framework–  Informing and training of faculty–  Creating management and administrative infrastructure–  Revising assessment procedures–  Implementing an E-Portfolio system–  Reorganization of all clerkships–  Setting up a program evaluation system

Thank You!