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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2823_Библиотеки_им_академика_М_И_Перельмана
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the goal of medical education is growing independence from
supervision, understanding that medicine is a team activity
and that no individual is ever truly independent when caring
for patients. Interns are in supervised practice, but their level
of responsibility is clearly higher than that of students. More
importantly, when residents graduate and move into
practice, their ability to function without supervision must
be documented. These concepts of responsibility,
entrustability, and function are all synthetic, in which a
combination of knowledge, skills, and attitudes is required.
“Independence” does not mean a lack of accountability, or
freedom to function outside the medical care system; in fact,
the opposite is now taught in training programs under the
“Systems-based Practice” competency of the ACGME.
However, growing independence from supervision is one
underlying premise of the synthetic model, and it has this in
common with developmental models (differences will be
discussed later in the chapter).
A useful synthetic framework for evaluating students and
residents in their progress from understanding into action
uses a descriptive, developmental vocabulary: ReporterInterpreter-Manager-Educator (RIME)
11
(see Table 4.1 and
Appendix 4.1).
Table 4.1
RIME Framework: Short Definitions
Reporter: learner takes ownership of collecting and
communicating the patient’s findings and priorities
(symptoms, exam, labs, images, medications).
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Interpreter: learner takes ownership of explaining new,
abnormal, or important findings.
Manager: learner takes ownership of planning with
patients (diagnostic, therapeutic, and patient education).
Educator: learner takes ownership of improving care
through study.
(see Appendix 1 for fuller definitions)
The RIME framework can be used by itself as a tool for
structuring observations of each learner–patient interaction,
for categorizing an overall level achieved in a rotation, or as
a larger framework for teachers to frame more granular
systems such as Milestones, competencies, or EPAs. Since the
underlying rhythm of RIME is observation-reflection-action,
it corresponds to the History & Physical – assessment – plan
sequence that all clinicians have used during their years of
training (see Table 4.2).
Table 4.2
The Analogous Rhythm of the Scientific, Clinical, and RIME
Processes
Classical Scientific Method Clinical
Process
RIME
Scheme
Observation History and
physical
Reporter
Reflection Diagnosis Interpreter
Action Therapy Manager
Reflection/Further
observations Follow-up
Educator
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This supports the framework’s acceptance as a shared mental
model and helps achieve the desired construct alignment9 of
teachers and activities of learners. Each of the more granular
ACGME subcompetencies can be mapped to the RIME
framework (see Appendix 4.2).26 The Patient Care Milestones
of each specialty can be visualized in what Hemmer has
termed “RIME-stones” (see Appendix 4.3) and the 13 Core
Entrustable Professional Activities for Entering Residency
(CEPAERs) proposed by the Association of American
Medical Colleges (AAMC) can be implemented as ready-touse dimensions of performance within the RIME
framework27 (see Table 4.3).
Table 4.3
EPAs within the RIME Framework
Core Entrustable Professional Activity (EPA)
Pregraduation
EPA
#
Reporter
Gather a history and perform a physical exam. 1
Document a clinical encounter in the patient record. 5
Provide an oral presentation of a clinical encounter. 6
Collaborate as a member of an interprofessional team. 9
Interpreter
Prioritize a differential diagnosis following a clinical
encounter.
2
Recognize a patient requiring urgent or emergent care. 10
Recommend and interpret common diagnostic and
screening tests.
3
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Manager
Enter and discuss orders and prescriptions. 4
Give or receive a patient handover to transition care
responsibility.
8
Obtain informed consent for tests and/or procedures. 11
Perform the general procedures of a physician. 12
Educator
Form clinical questions and retrieve evidence to
advance patient care.
7
Identify system failures and contribute to a culture of
safety and improvement.
13
The EPAs and the associated numbers are from the Core
Entrustable Professional Activities for Entering Residency,
Association of American Medical Colleges, 2014.
We can see that different frameworks provide degrees of
granularity that are useful in different settings.
The RIME framework uses these classifications (reporter,
etc.) to describe the ability at which the trainee functions—
either in a single patent encounter or globally. Each RIME
step is a final “common pathway” that requires a synthesis
of skills, knowledge, and attitude. This can be used for
setting minimal expectations for learners in each year of
training, or for describing the level of activity for which the
learner is judged or trusted to be consistent. The RIME
framework does not set the upper bound of what a student
or resident is allowed to do, but rather the minimal standard
of acceptable performance for the learner’s level of training.
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In this respect RIME is a “razor,” helping teachers set a clearcut point below which the learner is classified as not yet
ready for higher responsibility.
In rating an individual learner–patient encounter, the RIME
method can be applied directly to the level of performance
just observed. On the other hand, for an end-of-rotation
evaluation form, it is up to the teacher to be sure that the
overall rating reflects the level the learner has achieved with
consistency, and with the common, core medical issues that
are likely to be encountered at the next level of training or
practice.
Learners may be quite proficient at interpreting chest pain in
a hospitalized patient but complete novices in dealing with
nodular goiter in an outpatient clinic. This content- and
context-based expertise has been demonstrated in both
students and residents. The RIME framework describes how
a learner interacts with a particular patient, and it is up to the
teacher to make a judgment about their overall level of
performance with common, core problems that are expected
to be seen within each educational experience.
The RIME framework is not developmental in the sense that
learners do not sequentially drop prior functions. Residents
and faculty, for instance, continue to perform their roles as
reporter. Advanced learners do not typically separate the
tasks of reporting and interpreting or reporting and
managing. For an expert, the fundamentals of differential
diagnosis underlie the way patients are interviewed and
examined; in other words, the task of interpretation is
contained within the gathering of data, and a good oral case
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presentation typically contains an implicit interpretation.
Like other approaches that describe function, the level of
performance does depend upon context and the patient’s
problem. Learners may be quite proficient at interpreting
chest pain in a hospitalized patient, but complete novices in
dealing with nodular goiter in a referral clinic. Even
residents might function at a reporter level for something
uncommon, like Cushing’s syndrome, but be at a manager
level for community-acquired pneumonia. H owever, a
resident ready for independent practice is not simply a
manger for pneumonia, but also reports and interprets
successfully. In other words, the RIME synthetic framework
has an explicit developmental aspect but is not, strictly
speaking, developmental.
The RIME scheme guides teachers’ observations in looking
for the signs of interpretation or management within the
trainee’s act of reporting. Perhaps more importantly, the
apparent stages of the RIME scheme can be used to establish
a minimally acceptable level of performance for learners at
each level. A clinical clerk must always be an acceptable
reporter, even though interpreting is not yet proficient. A
resident, on the other hand, must always be successful as
reporter, interpreter, and manager.
In the global rating scale below, interpreter is depicted as a
higher level of performance than reporter and manager is
higher than interpreter. Are the distances between the three
equal? There are no empirical data to support this, and since
being an educator is part of the action phase of the process, it
is difficult to assign a visual distance between them.
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EPAs have emerged in both graduate medical education and
undergraduate medical education (UGME). Originally
defined by Olle ten Cate, EPAs represent the routine
professional-life activities of physicians based on their
specialty and subspecialty (see Chapter 1). Entrustable
means a physician has demonstrated the necessary
knowledge, skills, and attitudes (or competencies) to be
trusted to ultimately perform the activity unsupervised.
EPAs logically have led to the development of entrustment
scales that are focused on levels of learner ability and
defined by the actions of the rater regarding supervision of
those actions, as opposed to inference of the competence of
the individual trainee.
28
A central concept of EPAs is that trust is an internal construct
in the teacher that can be relied upon for consistent
assessment of learners. Per ten Cate and colleagues, “Trust
involves the confident expectation that a person (i.e., student
or learner) can be relied on to honour implied or established
commitments to an individual (i.e., faculty and patient) and to
protect [the individual’s] interest. It renders the individual
(i.e., faculty and patient) vulnerable to the extent (s)he cannot
oversee or control the actions of the other, on whose
expertise or integrity (s)he may depend.”29 Teachers decide
when and for what tasks they trust trainees to assume
clinical responsibilities. As units or domains of entrustment,
EPAs are believed to represent the critical activities of the
profession that the learner should be able to achieve
unsupervised (i.e., earned independence) prior to
graduation. EPAs are synthetic as they require multiple
knowledge, skills, and attitudes and encompass multiple
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competency milestones (see Chapter 1). Like RIME, EPAs
enable better construct alignment of the evaluation task and
the activity being assessed and thus may improve
evaluation
9,30
(also see Chapter 9).
For example, managing an upper gastrointestinal
hemorrhage is an EPA. Doing so requires knowledge (e.g.,
anatomy and causes of bleeding), skills (e.g., performing
endoscopy), and attitude/behavior (e.g., confidence to
perform the task in an unstable patient). Like Milestones, it
also encompasses multiple subcompetencies in the ACGME
framework and thus represents a synthetic product.
Two main types of entrustment scales are currently in use.
The first type often uses a 1–5 rating scale based on
improving performance and the nature of supervision
required. Supervision-based entrustment scales are
sometimes referred to as “prospective entrustment scales” as
the rater is judging the performance or encounter in relation
to the amount of supervision that will be required moving
forward. For supervision-based scales, a resident at Level 1
either can only observe others perform the task or cannot
perform the EPA without direct assistance from a teacher.
Level 2 embodies a learner who can perform the EPA under
direct supervision while at Level 3 the learner can perform
the procedure with the teacher standing outside the room or
at a distance (indirect supervision). At Levels 4 and 5 the
learner can perform the task independent of the teacher (they
are entrusted to perform the activity without direct or
indirect supervision). Tables 4.4 and 4.5 provide several
examples of supervision-type entrustment scales directed at
GME and at UME.
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Table 4.4
Entrustment in Postgraduate Education
Based on this single observation, please provide an
overall judgment of this learner.
Level
1. Learner can be present but only as an observer. I
would not let the learner perform this skill the next
time.
2. Learner can practice skill with direct supervision
(supervisor in room). I (or someone else) would need
to watch the learner perform the skill in real time.
3. Learner can practice skill with indirect
supervision (supervision available within minutes). I
(or someone else) do not need to watch the learner in
the room but will need to reassess the
patient/confirm findings with the patient.
4. Unsupervised practice allowed (distant oversight).
I (or someone else) do not need to watch the learner
but I (or someone else) am available if the learner
comes for help or to provide feedback.
From Kogan JR, Dine CJ, Conforti LN, Holmboe ES. can rater
training improve the quality and accuracy of workplacebased assessment narrative comments and entrustment
ratings? A randomized controlled trial. Acad Med. 2023 Feb
1;98(2):237-247. doi:10.1097/ACM.0000000000004819.
The other version of entrustment rating is the coactivity
scale, which defines the level of entrustment by the amount
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of input and contribution required on the part of supervising
faculty. The surgical O-SCORE is a commonly used
coactivity scale (see Fig. 4.4).
Fig. 4.3 Relationships and degree of granularity in
assessment frameworks used in graduate medical
education in the United States. AAMC, Association of
American Medical Colleges; ACGME, Accreditation
Council for Graduate Medical Education; EPAs,
Entrustable Professional Activities; PGY1, postgraduate
year 1.
Fig. 4.4 The Ottawa Surgical Competency Operating
Room (O-Score) Scale: an entrustability-aligned anchor
scale.
Finally, the Zwisch scale (Fig. 4.5) has also gained a
following in the procedural community (see Chapter 9) and
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