Transcript Ten Cate UCFS MedEd GRs October 14 2015x

Med Ed Grand Rounds UCSF, October 14, 2015
EPAs in the undergraduate
medical curriculum
Lessons learned
Experiences from across the pond
Olle ten Cate, PhD
University Medical Center Utrecht, the Netherlands*
*Thanks to Lisanne Welink MD, Margot Weggemans MD, Suzanne van der Velden MD,
Sanne van den Munckhof MD, Marijke van Dijk MD PhD - all UMC Utrecht
No conflict on interest to be reported
Financial support received from EU’s 7th Framework Programme,
under grant agreement 619349 (WATCHME).
Content – lessons from UMC Utrecht
For consideration when developing EPAs for UME:
1. EPAs were not conceived for UME
2. Background: Utrecht UME curriculum development
3. Identifying the EPAs
4. What are adequate levels of supervision
5. Entrustment before entrustment decisions
6. Nesting specific EPAs within general EPAs
7. Translation into examination rules
8. Faculty buy-in
9. When are EPAs EPAs and when not?
EPAs were not conceived for UME
• Essence: bringing trainees to an adequate level for
unsupervised practice
• Serving competency-based medical practice through
competency-based medical education
• CEPAER initiative has given the impression that EPAs
should be mastered before residency;
cf McGaghie et al, AcadMed Nov. 2015:
EPA’s may be used in UME but..
• They are not end stage of summative entrustment
for unsupervised practice
• They require careful consideration regarding a
number of critical issues
• Role of EPAs and entrustment in years before UME
graduation still unclear
• Not all important objectives for UME may be
captured in (only) EPAs
Utrecht UME curriculum development
curriculum
Involved are a Curriculum Committee CRU+
(including junior MD staff of Education Center)
and groups of faculty, established to develop new
courses and clinical clerkships
Features of current UME curriculum
• Two closely connected phases (3yr Bachelor -3yr
Master)
• Integration of basic sciences in 5-week almost full
time ‘blocks’ in first two years (B1+B2)
• Much small group work; limited lectures;
constructivist philosophy, not fully PBL
• Early clinical rotations in B3 year (6 weeks internal
medicine; 6 weeks surgery), intermittent blocks
• PGY 6: transition to residency: longer clerkships,
more responsibility
New features in CRU+ (from 2015)
Bachelor phase
• Qualitative entrance selection; no lottery
• Focus on knowledge retention. Repeated testing of
knowledge. Students must pass block tests and
four “CRUX” tests (each including the content of
one semester)
• B3 will include an integrated clerkship of 12 weeks
(internal medicine, surgery and family medicine)
• Every student adopts a panel of 4 patients or
families for 3 years from one family medicine
practice
New features in CRU+ (from 2016)
Master phase
• M1 & M2: 4 units of 6 block weeks preparing
for 12 consecutive weeks of longitudinally
integrated clerkship (LINKs), each including 24 disciplines
• Every student has own clinical preceptor for
each LINK
• EPAs form central feature in the structure and
assessment in LINKs
• M3 will not change much, but core EPAs for
entering residency will feature too.
Elective
Ma 2
Block
LINK YELLOW
Block
LINK PURPLE
Elective
Block
LINK RED
Block
LINK BLUE
Elective
Block
LINK GREEN
Family medicine, ENT,
Opthalmology, Public
health, Dermatology
Pediatrics
ObGyn
Clinical genetics
Family medicine
Internal medicine
Surgery
Internal medicine
Surgery
EM, Anesthesiology
Neurology
Psychiatry
Geriatrics
Ba 2
Non-clinical blocks and elective
Nonclinical
block
Nonclinical
block
Nonclinical
block
Nonclinical
block
Nonclinical
block
Nonclinical
block
Nonclinical
block
Nonclinical
block
Ba 1
Ba 3
Ma 3
Sub-internship
Ma 1
Research term Elective
START: Supervised Training in
• Attitude
• Research
• Teaching
Nonclinical
block
Nonclinical
block
Nonclinical
block
Nonclinical
block
Nonclinical
block
Nonclinical
block
Nonclinical
block
Nonclinical
block
Identifying the EPAs
Resources
• Dutch national Framework of Objectives for UME (legally
binding)
• AAMC Core EPAs for entering residency (13)
• A proposed German list of EPAs (Charité U Berlin)
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
UME EPAs first iteration
1
Checking basic vital functions of a stable adult patient
2
Gathering and reporting basic general patient information that does not
require investigations
3
Requesting and collecting basic bodily materials
4
Conducting simple therapeutic acts
5
Gathering and reporting basic specialty-specific patient information that
does not require investigations
6
Requesting, interpreting and sharing basic diagnostic investigations
7
Design and initiating a treatment plan for common disorders
8
Breaking bad news to patients and family about non-terminal conditions
9
Conducting basic specialty-specific procedures
10 Acting as primary-responsible caregiver for a small ward
UME EPAs - second iteration
1
Checking and reporting basic vital functions of a stable adult patient
2
Gathering and reporting basic general patient information of a stable adult
patient
3
Requesting and collecting basic bodily materials of stable adults
4
Conducting simple therapeutic acts on a stable patient
5
Requesting, interpreting and sharing results of basic diagnostic
investigations
6
Designing and initiating a treatment plan for common disorders
7
Breaking bad news to patients and family about non-terminal, non chronic
conditions
8
Recognizing and acting on an emergency situation in the hospital
9
Caring for a patient around end-of-life decisions
10 Managing an inpatient ward (integrates 1-9)
11 Managing an outpatient clinic (integrates 1-9)
UME EPAs - third iteration
1
2
3
4
5
6
BA3
BA3
MA1/2
MA1/2
MA1/2
MA1/2
7
8
MA1/2
MA1/2
9
10
11
12
MA1/2
MA1/2
MA3
AM3
Vital parameters
Basic medical procedures
History and general physical examination
Common procedures of the physician
Conducting simple therapeutic acts on a stable patient
Requesting, interpreting and sharing results of basic diagnostic
investigations
Designing and initiating a treatment plan for common disorders
Breaking bad news to patients and family about non-terminal,
non-chronic conditions
Recognizing and acting on an emergency situation in the hospital
Caring for a patient around end-of-life decisions
Managing an inpatient ward
Managing an outpatient clinic
UME EPAs - fourth iteration
1
The Clinical Consultation
2
General Medical Procedures
3
Informing and Advising Patients and their Families
4
Intercollegial Communication
5
Care Under Unsusual Conditions
UME EPAs - fourth iteration
1 The Clinical
Consultation
•
•
•
•
•
•
Taking a medical history
Performing physical examination
Prioritizing a differential diagnosis
Requesting common diagnostic tests
Interpreting diagnostic tests
Designing a treatment plan
2 General Medical
Procedures
•
•
•
•
•
•
•
•
•
•
Capillary blood taking
Venous blood withdrawal and taking a blood culture
Swabs: oral, nasal, ears, skin, anal or wounds
Giving infusions
Ankle brachial index
Administering a simple bandage and scarf bandage
Urethral catheterization
Suturing and injection of local anesthetic to skin
Perform an ECG
Give intracutaneous, subcutaneous
or intramuscular injections
Arterial blood gas
•
UME EPAs - fourth iteration
3 Informing and
Advising Patients
and their Families
• About diagnostic options (incl informed consent)
• About prognosis (incl breaking bad news)
• About therapeutic options (incl compliance and
obtaining informed consent)
4 Intercollegial
Communication
•
•
•
•
•
•
Discharge letter
Oral handover
Consulting other care providers
Refer to other care providers
Report on medical errors
Give oral patient or research presentation
5 Care Under Unsusual • Establishing patient death
• Basic and advanced life support
Conditions
UMCU EPAs versus AAMC Core EPAs
CEPAER
UMCU: EPA
1
EPA 1: Gather a history and perform a physical examination
X
EPA 2: Prioritize a differential diagnosis
X
EPA 3: Recommend and interpret common diagnostic and
screening tests
X
EPA 4: Enter and discuss orders and prescriptions
X
EPA 5: Document a clinical encounter in the patient record
X
EPA EPA
2
3
X
X
EPA 6: Give an oral presentation of a clinical encounter
EPA 7: Form clinical questions and retrieve evidence
EPA EPA
4
5
X
X
X
EPA 8: Give or receive a patiënt handover
X
EPA 9: Collaborate as a member of an interprofessional team
X
EPA 10: Give urgent or emergent care
X
EPA 11: Obtain informed consent
EPA 12: Perform general procedures of a physician
EPA 13: Identify system failures and contribute to a culture of
safety and improvement
X
X
X
What are adequate levels of supervision?
Issue: Existing entrustment and supervision scale
not satisfactory
• Too little gradation in first levels of supervision
• Levels 4 and 5 will not be reached during UME
Existing PGME entrustment and supervision scale
1
2
3
4
5
Not allowed to practice EPA
Allowed to practice EPA only under proactive, full supervision
Allowed to practice EPA only under reactive/on-demand
supervision
Allowed to practice EPA unsupervised
Allowed to supervise others in practice of EPA
But, early 2015, there was Carrie Chen et al.
PGME entrustment & supervision scale UME entrustment & supervision scale
(Chen et al 2015, Academic Medicine)
1. Not allowed to practice EPA
2. Allowed to practice EPA only under
proactive, full supervision (direct)
1a: Not allowed to observe EPA
1b: Allowed to observe EPA
2a: As coactivity with supervisor
2b: With supervisor in room ready to
step in as needed
3. Allowed to practice EPA only under
3a: With supervisor immediately
reactive/on demand supervision
available, all findings double checked
(indirect)
3b: With supervisor immediately
available, key findings double checked
3c: With supervisor distantly available (e.g.
by phone), findings reviewed
4. Allowed to practice EPA unsupervised 4. Allowed to practice EPA unsupervised
5. Allowed to supervise others in practice 5. Allowed to supervise others in practice of
of EPA
EPA
Entrustment before entrustment decisions
Issue
No early full (‘summative’) entrustment possible yet, but
1. Students need to practice with limited supervision
2. Student cannot always be directly supervised
How to justify that students already perform tasks with
limited supervision
Entrustment before entrustment decisions
Approach
Ad hoc entrustment
occasional permission to practice with limited
supervision for educational purposes (to be confirmed
every time)
Summative entrustment
formalised, default permission to act with limited
supervision
Nesting specific EPAs within general EPAs
Issue
‘Perform a physical examination’
‘Prioritize a differential diagnosis’
‘Recommend common diagnostic tests’
Many general skills of a physician require
discipline-specific skills and knowledge
Nesting specific EPAs within general EPAs
Approach
• Training of discipline-specific history,
physical examination and specific
procedures in designated blocks and LINKs
• Integration in to full EPA in final (Ma3) year
Nesting specific EPAs within general EPAs
EPA1: The Clinical Consultation
• medical history
Specifications
Issue
• physical examination
• differential diagnosis
‘Perform a physical examination’
• common diagnostic tests
• treatment
plan
‘Prioritize a differential
diagnosis’
• Medical
Discipine-specific
skillscommon
and
‘Recommend
diagnostic tests’
• Surgical
knowledge
• Pediatric
• Gynaecological
General skills of a physician
require
• Neurological
• Psychiatric
discipline-specific skills
and
knowledge
• Dermatological
• ENT
• Ophthalmologic
Nesting specific EPAs within general EPAs
Procedures
• Capillary blood taking
• Venous blood withdrawal and
taking a blood culture
• Swabs: oral, nasal, ears, skin, anal
or wounds
• Giving infusions
• Ankle brachial index
• Administering a simple bandage
and scarf bandage
• Urethral catheterization
• Suturing and injection of local
anesthetic to skin
• Performing an ECG
• Giving intracutaneous, subcutaneous and intramuscular
injections
• Measuring arterial blood gas
EPA 2: general medical procedures
 5th year students (Ma2)
EPA 2a: basic medical
procedures
 3rd year students (Ba3)
Nesting specific EPAs within general EPAs
Procedures
• Capillary blood taking
• Venous blood withdrawal and
taking a blood culture
• Swabs: oral, nasal, ears, skin, anal
or wounds
• Giving infusions
• Ankle brachial index
• Administering a simple bandage
and scarf bandage
• Urethral catheterization
• Suturing and injection of local
anesthetic to skin
• Performing an ECG
• Giving intracutaneous, subcutaneous and intramuscular
injections
• Measuring arterial blood gas
EPA 2: general medical procedures
 5th year students (Ma2)
EPA 2a: basic medical
procedures
 3rd year students (Ba3)
Translation to assesment rules & procedures
• No numerical final clerkship scores
• End-of LINK qualifications [+expected percentages]:
•
•
•
•
“Fail” [5% or less]
“Requires attention” [10 -15%]
“Good” [75 to 80%]
“Excellent” [10% or less]
• Dominant WBA tools:
•
•
•
•
•
Short practice observations
Case-based discussions
Patient presentations
Written reports on selected patients
Multi source professional behavior observation
Translation to assesment rules & procedures
• EPA summative entrustment decisions in final year,
fed by ‘nested’ small specific ‘EPAs’
• Decision by local director of subinternship + advice
by longitudinal family medicine mentor
Required for graduation:
• All EPAs must be trusted on Level 3a (indirect
supervision, all findings checked); Level 3b (key
findings checked) or 3c (review only) exceeds
standard expectation
• E-portfolio support for feedback and entrustment
decision making is being prepared
Faculty buy-in
• While EPAs usually make ‘intuitive sense’, nailing
down the EPAs and translation to teaching and
assessment, requires explanation and adequate
understanding
• A recommendable procedure appears monitoring
the active role of clinical teachers in development of
procedures in the workplace
• Continuous returning to the definition of EPA
• Focus of discussion: when to leave students alone
When are EPAs EPAs and when not?
•
“Identify system failures and contribute to a culture of safety
and improvement”
• “scientifically active”
• “Intercollegial communication”
Titles are insufficient to determine this, operationalization of the
(set of) acivities is necessary.
Entrustable: Acts requiring trust – by colleagues, patients,
society. Prohibited for unqualified persons.
Professional: Confined to occupations with extra-ordinary legal
qualification.
Activities: Tasks that must be done. May be scheduled, may be
listed in work descriptions.
Thank you