Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_112_библиотеки_им_акад_М_И_Перельмана
.pdf
models has been very challenging for many programs across
the educational continuum.
37
One reason has been the
difficulty in translating the language and concepts of
competencies into educational practices and assessments. As
a result, two new approaches, Competency milestones and
Entrustable Professional Activities (EPAs), are being used in
various health professions educational programs around the
world. Both approaches continue to evolve as mechanisms to
potentially facilitate more effective implementation of
outcomes-based education using competency frameworks.
While both of these newer approaches are grounded in
robust educational theory, it is important for the reader to
recognize that we are still in the early days of determining
the utility, including validity, and impact of both Milestones
and EPAs on educational and clinical outcomes. While early
research is encouraging, much work remains to be done.
However, given both competency milestones and EPAs are
now part of multiple national systems of assessment across
the globe, we provide some background in this chapter to
help guide the reader in evaluating and exploring these
concepts in their own assessment program.
Competency Milestones
The ACGME competency framework was inspired by the
five “Dreyfus stages of development of skill,” including
Novice, Advanced Beginner, Competent, Proficient, and
Expert, first described in 1986.
24
Competency milestones
were adopted to promote shared mental models of the
competencies, support the developmental assessment of
learners in the workplace, and facilitate curricular
change.
65,66
They are narrative, behavioral descriptions
https://t.me/med1917
aligned with the five developmental steps to assist faculty in
the assessment of medical trainees using a logical trajectory
of professional development within competencies and
subcompetencies. Developed as narrative benchmarks for
effective assessment, ACGME Milestones were written for all
US postgraduate medical disciplines and first published in
the Journal of Graduate Medical Education in March 2013 and
March 2014.
122
All specialties and subspecialties have now
created “Milestones 2.0” based on qualitative and
quantitative research on the experience with Milestones 1.0.
Specialty Milestones are the framework programs used for
semiannual review by clinical competency committees on
resident progress. Fig. 1.7
shows, as an example, one of the 21
Milestone sets of the pediatric competencies.
123
Early
research using US national data for a number of specialties
has now demonstrated multiple elements of validity,
including correlations with early career outcomes of
graduates.
124–131
Milestones have also been reported to be
helpful for earlier identification of residents in difficulty,
better feedback to residents and fellows, and development of
better assessment approaches and as a useful framework for
faculty development.
130,65
https://t.me/med1917
FIG. 1.7 Example of a Milestone for the US competency of
Systems-based Practice.
In the 2015 edition of CanMEDS, Milestones are also
introduced and defined as “descriptions of the abilities
expected of a trainee or physician at a defined stage of
professional development” of each of the “enabling
competencies” under the seven CanMEDS competency roles,
to guide learners and educators in determining whether
learners are “on track.”
106
Entrustable Professional Activities
The concept of EPAs was introduced in 2005.92 Since an
article about EPAs was published in Academic Medicine in
2007,
132,133
the concept has attracted substantial attention
among postgraduate programs in the United States, Canada,
and other countries. For example, EPAs are a core element of
the RCPSC’s Competence By Design initiative.
134,135
In the
United States, the American Boards of Surgery and Pediatrics
are implementing end-of-training EPAs as the mechanism
program directors will use to attest to eligibility for
https://t.me/med1917
certification. Finally, the Ministry of Health in Singapore is
instituting EPAs for determination of readiness for practice.
EPAs have also been used by several US and all Canadian
medical schools as a basis for judging readiness for entry into
residency.
136,137
An EPA is a unit of professional practice that can be fully
entrusted to a trainee as soon as they have demonstrated the
necessary competence to execute this activity unsupervised.
In contrast with competencies, EPAs are not a quality of a
trainee, but a part of the work that must be done. Fig. 1.7
shows a typical competency domain (patient safety) with its
Milestones, reflecting specific competencies such as awareness
of patient safety issues and causes, ability to communicate with
patients and families, and ability to initiate improvement
projects. EPAs, in contrast, are concrete tasks that require that
learners (and for that matter, professionals) possess such
competencies, usually several, in an integrated and
interdependent fashion, before they are allowed to perform
the task on their own. In this example, a learner would be
asked to be the one to disclose a medical error to a patient
and their family (a task that could be an EPA) only if the
learner’s supervisors have become convinced that the learner
is truly ready to do this unsupervised. This may be an ad hoc
entrustment decision if it happens the first time, or a summative
entrustment decision that qualifies the learner to act
unsupervised from then on, requiring extensive and careful
prior assessment and a decision of a competency committee.
We will come back to this terminology. More specifically
defined, EPAs are part of essential professional work in a
given context. They (1) require that trainees possess adequate
knowledge, skills, and attitudes in the pertinent
https://t.me/med1917
competencies, and are generally acquired through training;
(2) must lead to recognized output of professional labor; (3)
should usually be confined to qualified personnel; (4) should
be independently executable; (5) should be executable within
a time frame; (6) should be observable and measurable in
their process and their outcome, leading to a conclusion
(“done well” or “not done well”); and (7) should reflect one
or more of the competencies to be acquired (see Appendix
1.1).
133
Much of the work in healthcare can be captured by tasks or
responsibilities that must be entrusted to individuals. EPAs
require a practitioner to possess and integrate multiple
competencies simultaneously from several domains, such as
content expertise, skills in collaboration, communication,
management, et cetera. Conversely, each competency domain
is relevant to many different activities. Combining
competencies (or competency domains) and EPAs in a matrix
reveals which competencies a trainee must achieve before
being trusted to perform an EPA.
133
The two-dimensional
matrix in Fig. 1.8 provides specifications that are helpful for
assessment and feedback, for individual development, and to
ground entrustment decisions. This makes assessment based
on EPAs a holistic or synthetic approach, rather than the
analytic wish to evaluate competencies analyzed in great
detail as stand-alone qualities of learners.
138
EPAs are not an
alternative to competencies; they constitute a different
dimension, with the purpose of grounding competencies in
clinical practice.
https://t.me/med1917
FIG. 1.8 Overview of EPAs: competencies matrix.
EPAs have now been identified for most graduate medical
education programs in multiple jurisdictions across the
globe.
139–145
An example of an EPA is conducting an
uncomplicated delivery. This activity, performed by family
physicians and obstetrics-gynecology specialists, needs to be
entrusted to a trainee at some point in their training, as the
trainee eventually will need to conduct it without
supervision. It requires specific knowledge, skills, and
behaviors; proficiency is acquired through training; and it is
directly observable and involves specific competencies. As
this activity reflects the CanMEDS roles of medical expert,
communicator, and collaborator, it exemplifies how EPAs
integrate competencies. Other examples of EPAs are
providing preoperative assessment, managing care of
patients with acute common diseases across multiple care
settings, providing palliative care, managing common
infections in nonimmunosuppressed and immunecompromised populations, conducting a family education
session about schizophrenia, conducting a risk assessment,
serving as the primary admitting pediatrician for previously
well children suffering from common acute problems,
pharmacological management of an anxiety disorder,
https://t.me/med1917
providing end-of-life care for older adults, and office-based
counseling in developmental and behavioral paediatrics. A
comprehensive set of EPAs should cover the core of a
profession. Each EPA should be described well and include,
next to an informative title, specification and limitations; an
indication of risks when not performed well; a list of required
competencies; elaboration of required experience,
knowledge, and skills; suggestions for assessment; and an
expiration date after the EPA has last been done
136
,146
(see
Appendix 1.1
).
Linked to the EPA construct is the purpose of entrustment
decision-making. This process serves to acknowledge ability, to
provide permission to act with limited supervision, and to
enable duties in healthcare practice. True competency-based
medical education grants certification as soon as competence
is adequately demonstrated, irrespective of the time in
training, and this requires a personalized and flexible
approach to training programs. EPAs allow for making
entrustment decisions for separate units of professional
practice, resulting in more gradual, legitimate participation in
professional communities of practice
147
rather than a full
license to practice on the last day of training. Certification for
EPAs is not a dichotomous process. As trust increases, the
level of supervision can decrease. A model of five levels of
supervision, entrustment, and permission has been proposed
for postgraduate training and is shown in Fig. 1.9.
148
https://t.me/med1917
FIG. 1.9 Using Milestones to determine an appropriate level of
supervision for an EPA.
Combining Competency
Milestones and EPAs
While the implementation of competency milestones and
EPAs, on top of using a competency framework, may feel to
critics as another burden for programs and individual
teachers, the competency milestones and EPAs are
complementary. Eric Warm, program director of the
University of Cincinnati Internal Medicine residency training,
converted his assessments to entrustment scales and crosswalked the five Milestone developmental levels of
competencies with the five supervision levels of EPAs (Table
1.5). Faced with the need to regularly report on Milestones
for all residents, he asks clinicians to estimate trainees’
readiness for direct supervision, indirect supervision, or
unsupervised practice. This serves efficiency and conceptual
https://t.me/med1917
elegance and allows faculty to use a more construct-aligned
entrustment ratings scale (see Chapter 4). To take this
approach one step further, the Dreyfus stage model of
development, the broadly used RIME model (Reporter-
Interpreter-Manager-Educator;
149
see Chapter 4), the
competency milestones approach,
107
and levels of
supervision can all be aligned as shown in Table 1.6. The
model can be extended with more detailed representations of
behavior and supervision,
150
but the core idea is that of
alignment of frameworks. Moving from Milestone or
supervision level 3 to 4 can be viewed as passing the
threshold that allows for clinical oversight only or
unsupervised practice at the end of training. It does not
qualify a trainee to stop developing, as the journey to
expertise and mastery must continue (Fig. 1.6), but would
allow for a formal recognition of ability, permission, and
duty to enact the EPA, sometimes called a STAR (statement
of awarded responsibility) or a summative entrustment
decision (discussed later in the chapter). As with many
conceptual models, they are useful but have limitations.
Nevertheless, Table 1.6 connects several developmental
approaches together to help see the forest for the trees.
Table 1.5
Five levels of Supervision and Permission
1. Be present and observe, but not permitted to perform the EPA
2. Permitted to act under direct, proactive supervision, present in the room
3. Permitted to act under indirect, reactive supervision, readily available to enter the
room
4. Permitted to act without qualified supervision in the vicinity; with distant
supervision or clinical oversight; basically acting unsupervised
5. Permitted to supervise junior trainees regarding the EPA
Given this alignment, an example may be given. Suppose a
https://t.me/med1917
pediatric residency program has an EPA called “Provide
telephone advice and management of patient” (taken from
Jones et al.
150–152
). In the EPAs-Competencies Matrix, it has
been determined that the most important domains of
competence, from an assessment perspective, are Medical
Knowledge, Interpersonal and Communication Skills, and
Practice-based Learning and Improvement. Let us assume
that for each of these domains Milestones have been
described. A trainee must be assessed to determine whether
indirect supervision—that is, not with a supervisor in the
room or on the telephone or on a virtual visit—is justified. If
the trainee meets the expected behavior at Milestone level 3
in all three domains, that decision seems justified. If the
trainee does not yet show the behavior or skill expected at
level 3 in either one of the competencies, additional close
supervision will be necessary.
It is also important to note, however, that in reality all the
general competencies are needed for effective provision of
telemedicine visits, and this realization should be part of any
curriculum for telemedicine. In the terminology of the RIME
model, the learner would be evaluated as an adequate
interpreter and beginning manager (see Chapter 4
). Fig. 1.9
shows this relationship. Carraccio and colleagues performed
a crosswalk of the competency milestones with the pediatric
EPAs (see Appendix 1.2). Here you can see how the narrative
descriptors of the competency milestones can be combined
down to a competency milestone level to create a brief
vignette, or story, of what the learner would actually be
about to do at that level of development and entrustment.
The model can also be used in reverse order. Clinical
educators may start with a holistic assessment that a trainee
https://t.me/med1917
Соседние файлы в папке Библиотека им академика М.И. Перельмана