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OlletenCate,PhDCenterforResearchandDevelopmentofEduca9on
UniversityMedicalCenterUtrechtTheNetherlands
WorldSummitonCBME,August28,2016,Barcelona
Disclosurestatement
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SomeofthecurrentworkisbeingsponsoredbyanEU-FP7fundedproject
CreaNveCommonsLicense.ThisworkislicensedunderaCreaNveCommonsASribuNon-NonCommercial-ShareAlike4.0InternaNonalLicense.hSp://creaNvecommons.org/licenses/by/4.0/
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Overview
• Howitstartedandwhathappenedsince• Coreprinciples• Newdevelopments
• HesitaNonsintheliterature• WrappinguptheessenceofEPAs
WhattriggeredEPAthinkingin2005?• MyroleinintroducingCanMEDScompetencyrolesframeworkinPGMEintheNetherlands
• UproarinDutchpoliNcsabout“disasters”of“newlearning”and“competency-based”educaNonleadingtoaparliamentaryinvesNgaNon
• AchatwithUMCU’sCEO:“Nursesarenowbeingeducatedcompetency-basedbutcannotcalculatethedripsofanIVanymore”
• Achatwithoneoftheclinicians:“IfindmostimportantwhetherIcantrustthetrainee”
• InvitaNontogiveaEUPhDcourseonCBE(May2005)
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Long,AcadMed2000
2005,MedicalEduca+on
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Increaseofpublica9onsaboutEPAs
0
10
20
30
40
50
60
70
80
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Ar9cles/yrreferringtoEPAsaccordingtoGoogleScholar
"Entrustable"inNtle "EntrustableprofessionalacNvity"anywhere
ExamplesofprogramsandcountriesseriouslyconsideringtoapplyEPAs
Knowncountries
Knowndisciplines
NetherlandsUnitedStatesCanadaSingaporeIrelandScotland/UKSwitzerlandGermanyDenmarkAustralia/NZ
Obstetrics&GynaecPsychiatryPediatricsInternalMedicineRadiologyFamilymedicineEmergencyMedicineSurgeryGastro-enterology
Pulmonary&crit.careAnesthesiologyHaematologyENT-surgeryPhysicianAssistanted.NursingVeterinarymedicineMidwifery
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Hasitsdefini9onchanged?2005circumscripNonand2016definiNon
EPA: A unit of professional practice that can be fully entrusted to a trainee, as soon as he or she has demonstrated the necessary com-petence to execute this activity unsupervised
2005/6 2016
NotessenNallychanged
person-descriptors
knowledge, skills, attitudes, values
• content expertise • health system knowledge • communication ability • management ability • professional attitude • scholarly skills
Competencies
work-descriptors
Essential units of professional practice
• discharge patient • counsel patient • lead family meeting • design treatment plan • Insert central line • Resuscitate patient
EPAs
CompetenciesversusEPAsCoreprinciples
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Onecanpossesscompetencies;
onecannotpossessEPAs
CoreprinciplesCompetenciesversusEPAs
Analy9ccompetenciesframework
Withnursingstaff
Withfamily
WithpaNents
Withcolleagues
Withtrainees
…
ConsultaNon
Breakingbadnews
ExplainmedicaNon
Withchildren
Withelderly
…
Thedo
ctor
Medicalexpert
Communicator
Collaborator
Manager
Healthadvocate
Scholar
Professional
Pangaro&tenCate2013
Coreprinciples
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Medicalexpert
Communicator
Collaborator
Manager
Healthadvocate
Scholar
Professional
Synthe9cEPAframeworkapproachEPA1
EPA2
EPA3
EPA4
EPA5
Coreprinciples
Medicalexpert
CommunicatorCollaborator
LeaderHealthadvocateScholarProfessional
++
++
+++
++
+++
+
++
++++
+
++
+++
++
+
++
EPA1 EPA2 EPA3 EPA4 EPA5
com
petenciesinferred
AssessmentfocusedonEPAs
Thematrix:EPAsrequiremul9plecompetencies
Coreprinciples
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Growthofcompetenceover9me
Coreprinciples
Growthofcompetenceover9me
4proficient
5expert
3competent
2advanced
1novice
EPA
training deliberateprofessionalprac9ce
Shadesofdecreasingsupervision
ReadyforunsupervisedpracNce
Coreprinciples
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Individualized5-EPAworkplacecurriculumforaphysicianassistant(level4=fullentrustment)
Mulderetal2010
Coreprinciples
Accomoda9ngflexibilityCoreprinciples
XEPAs
X+YEPAs
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Somenewdevelopments
• FromEPAsforcomple+onofresidencytoincludeEPAs(“unsupervised”)forenteringresidency(“indirectsupervision”)
• FromjustEPAstoCoreEPAs(foralltrainess)andElec+veEPAs(notforall)
• From“Entrustable”asadjec+veforac+vi+es,tooneforlearnerbehaviortoo(+pre-entrustable)
• FromEPAsasallindependent,tosmallEPAsnestedwithinbroadEPAslater.
• LinkingsupervisionlevelswithmilestonesandDreyfus
EPAscanbesuitableforUME,butthispictureisamisunderstanding
AcadMed2015LastPage
EPAscanbemasteredthroughallstagesoftrainingandcareerandshouldreflectcurrentability,rightanddutytoact
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Yr6Yr5Yr4Yr3Yr½
Thenes9ngprinciple:example-UMEsmallEPAsnestedwithinbroadEPAsforenteringresidency
Connec9ngDreyfusstages,EPAs,competencies,milestones,supervision
direct supervision
aspirational /provide
supervision
oversight only
observe only indirect supervision
Dreyfusstagesofdevelopment(1986):1=novice2=advancedbeginner3=competent4=proficient5=expert
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Somenewdevelopments
• From5-stepsupervisionscale(from“observeonly”to“superviseothers”)tomoredetailsformedicalschool
• Trustmayexpireapernon-pracNceortransiNontoothercontextàfrom“unsupervised”to“requiresindirectsupervision”àimplicaNonsforMOC?
• Newconcepts:Entrustmentdecision-making,ad-hocversussumma+veentrustment(STAR),entrustabilityscales,presump+ve,ini+alandgroundedtrust,factorsandfeaturesenablingtrust(ability,integrity,reliability,humility)
• Technologytosupportentrustmentdecisions
Expira9onacerinac9veperiod
training prac9ce
EPA
Compe-tence
thres-hold
JusNfiedentrustmentdecisions
Lossoftrust
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OBSERVER:
TRAINEE:
EPA:
TRAINEE:
TRAINEE:
DrJohnSmith
SPECIFY
Basedonmyobserva9on(s),IsuggestforthisEPAthetraineemaybereadyacerthenextreviewto:2.Actunderdirectsupervision3.Actunderindirectsupervision4.Actwithonlypost-hocreport5.Supervisejuniors
NO Hesitate YES
DATE: TRAINEE:
OBSERVER:
TRAINEE:
EPA:
TRAINEE:
TRAINEE:
DrJohnSmith
SPECIFY
DATE: TRAINEE:
Providefeedbackoneachofthefollowingdomainsofcompetence,relevanttothisthisEPA
*MedicalExpert*Communicator
*Collaborator*Scholar*Leader
*Healthadvocate*Professional
OBSERVER:
TRAINEE:
EPA:
TRAINEE:
TRAINEE:
DrJohnSmith
CONFIRMANDSEND
COMMUNICATORProvidespecificfeedback.Trytoincludestrengthsandaspectsthatmaybenefitfromimprovement.
Orrecordafeedbackmessage
DATE: TRAINEE:
Towardtechnologyenhancedassessment1>2>3
Hesita9onsintheliterature
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Bokomline:• Mastery-learninginK-12andArmydoesnotwork;outcome-
basededucaNonhasa“historyoffailure”.• Toomucheffortinindividualassessmentsisneededtobe
pracNcal.+1000pagesmilitarydoctrinetasksturnedoutunmanageable.
• RequiredobservaNonsforCBMEandEPAsbyclinicianswillnothappen;unreliableanduselessdelayedraNngswillresult.
Bokomline:• Competenciesandmilestones[andEPAs?]sufferfromconceptual,psychometricandlogisNcalproblems
• Learningcurvesaremorecomplexthansuggested.• PotenNalforcurriculum,assessment,licensureandcerNficaNonbutno‘‘wonderdrug’’
• Focustowardachievementofcompetency,ratherthaninNme,islikelytohavedemonstrablebenefits.
• Thechallengeistoreallocateresources.
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BoSomline:• Whydidyourtrust?5139jusNficaNonsofentrustmentdecisions
forEPAsinObGynanalyzed.• Mostimportantreasons:Experiencewiththetask(59%),
Technicalperformance(20%),Skillstrainingdone(9%),Genericcompetencies(0.5%)
• Cliniciansdon’tconsidergenericcompetencieswhenentrusNngresidentswithEPAs.
Wrappinguptheessence• Physiciansmustbetrainedtodophysicianwork
• Competencies:indirectfeaturesoflearnersenablingperformance.EffecNvecomple+onofac+vi+es(EPAs)iskey.
• “AcNviNes”:frominfinitelysmall(handingoveratooltoanurse)tohuge(runningahospital).Searchthemiddleground.
• EPAscanbeappliedfromUMCthroughPGMEandfellowship
• EPAsreflectexpectaNonsattheendoftraining,i.e.breadthofresponsibilityatstartofsubsequenttrainingorcareer.
• SmallEPAsbecomenestedwithinlargerEPAsinfurthertraining,henceareholisNc;notachecklistofsmallacNviNes.
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Wrappinguptheessence• Measurementusingstandardsofcompetenceislimited
• WaysacNviNescanbesuccessfullyexecutedlegiNmatelyvary
• Entrustmentdecisionsinclude,nexttoassessingability,permissionanddutytoactataspecifiedlevelofsupervision
• Twoindividualsmaybothbeexcellentbutworkdifferently;bothmaybetrusted,butfordifferentreasons
• TrustineffecNveperformanceisagestalt,incompletelyinformedbyobservaNon-itincludestakinganacceptablerisk
Wrappinguptheessence• Learnersinhealthprofessionsmustbetrustedwith
responsibiliNesassoontheyarecompetenttodoso;gradualincreaseinresponsibilitysNmulatesmoNvaNon
• FullresponsibilitywhilesNllintrainingisbeSerforpaNentsafetythanworkingsuddenlyunsupervisedaperlicensing
• AporxolioofcerNfiedEPAsreflectscurrentcompetenceandshouldbeaccessiblebythirdparNes
• InacNvityapercerNficaNonforanEPAshouldleadtolossoftrustandincreaseofrequiredsupervision
• UlNmately:allisaboutbringingbacktrustintheequaNonoflearners,healthcarestaff,paNentsandsociety
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Selectedreferences• tenCate,O.,2016.Competency-basedmedicaleducaNonanditscompetencyframeworks.InM.Mulder,ed.Competence-basedVoca+onaland
ProfessionalEduca+on:BridgingtheWorldsofWorkandEduca+on.Dordrecht,theNetherlands:SpringerScience+BusinessMediaBV.• TenCate,O.etal.,2015.CurriculumdevelopmentfortheworkplaceusingEntrustableProfessionalAcNviNes(EPAs):AMEEGuideNo.99.Medical
teacher,37(11),pp.983–1002.• tenCate,O.,2005.EntrustabilityofprofessionalacNviNesandcompetency-basedtraining.Medicaleduca+on,39(12),pp.1176–7.• tenCate,O.etal.,2016.EntrustmentDecisionMakinginClinicalTraining.AcademicMedicine,91(2),pp.191–198.• tenCate,O.,2006.Trust,competence,andthesupervisor’sroleinpostgraduatetraining.BMJ(Clinicalresearched.),333(7571),pp.748–51.• TenCate,O.,Snell,L.&Carraccio,C.,2010.Medicalcompetence:theinterplaybetweenindividualabilityandthehealthcareenvironment.
MedicalTeacher,32(8),pp.669–75.• Chen,H.C.,vandenBroek,W.E.S.&tenCate,O.,2015.TheCaseforUseofEntrustableProfessionalAcNviNesinUndergraduateMedical
EducaNon.AcademicMedicine,90(4),pp.431–436.• Englander,R.etal.,2014.CoreEntrustableProfessionalAc+vi+esforEnteringResidency-CurriculumDevelopersGuide,WashingtonDC.Available
at:www.aamc.org.• Hauer,K.E.,2015.Evalua+ngClinicalTraineesintheWorkplace:OnSupervision,TrustandtheRoleofCompetencyCommiUees[DoctoralThesis],
SanFrancisco/Utrecht:KarenHauerandUtrechtUniversity.• Klamen,D.L.etal.,2016.Competencies,milestones,andEPAs–Arethosewhoignorethepastcondemnedtorepeatit?MedicalTeacher,
(January),pp.1–7.Availableat:hSp://www.tandfonline.com/doi/full/10.3109/0142159X.2015.1132831.• Long,D.M.,2000.Competencybasedresidencytraining:thenextadvanceingraduatemedicaleducaNon.AcademicMedicine,75,pp.1178–1183.• Loon,K.A.Van,2016.TheRoleofGenericCompetenciesintheEntrustmentofProfessionalAcNviNes :ANaNonwideCompetency-Based
CurriculumAssessed.• McGaghie,W.C.,Barsuk,J.H.&Wayne,D.B.,2015.MasteryLearningWithDeliberatePracNceinMedicalEducaNon.AcademicMedicine,90(11)1.• Norman,G.,Norcini,J.&Bordage,G.,2014.Competency-BasedEducaNon:MilestonesorMillstones?JournalofGraduateMedicalEduca+on,
6(March),pp.1–6.• Pangaro,L.&tenCate,O.,2013.Frameworksforlearnerassessmentinmedicine:AMEEGuideNo.78.Medicalteacher,35(6),pp.e1197–210.• Touchie,C.&tenCate,O.,2016.Thepromise,perils,problemsandprogressofcompetency-basedmedicaleducaNon.MedicalEduca+on,50(1),
pp.93–100.
