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Time Consult PatientCare M edical Knowledge Communication Professionalism Ability Milestones on the Road to Competency: Advancing Competency-based Graduate Medical Education INTRODUCTION • Accreditation Council for Graduate Medical Education (ACGME) accredited Graduate Medical Education (GME) programs began the transition to competency-based medical education (CBME) in 2001 with the launch of the Outcomes Project. • Almost ten years into this project, programs continue to struggle with the transition from a time and process based training model to a competency-based framework. • In 2008, Tom Nasca, CEO of the ACGME, and the Internal Medicine Residency Review Committee identified that advancing CBME will require development of milestones of competency development and implementation of common evaluation tools to document achievement of those milestones. • In 2009, the ACGME charged each medical discipline to develop milestones and common evaluation tools. William F. Iobst MD 1 , Eric S. Holmboe MD 1 , Richard H. Bell, Jr. MD 2 , Sarah C. Hood MS 1 American Board of Internal Medicine 1 American Board of Surgery 2 INTERNAL MEDICINE MILESTONES Internal Medicine initially defined discrete developmental and behaviorally based milestones for each general competency (see Table 1) and is now piloting assessment strategies that bundle these milestones to allow evaluation of key developmental points in training called “landmarks” (see Figure 1). These landmarks represent critical stages in residency development that anticipate what have been described as entrustable professional activities (EPA) of the profession 1 . EPAs are activities that the public trusts all physicians are capable of performing. In the example shown in Figure 1, the ability to supervise a resident team is a critical stage in residency that anticipates the ultimate EPA of leading a health care team. CONCLUSIONS • Developing specialty specific milestones for the ACGME general competencies has focused the Graduate Medical Education community on developing descriptors of competence that can enhance the assessment and evaluation of competency • Milestones development has created opportunities to develop shared approaches to assessment and evaluation in competency- based medical education For additional information please contact: William F. Iobst, MD and Sarah C. Hood, MS Academic Affairs American Board of Internal Medicine [email protected] SUMMARY OF WORK The Internal Medicine and General Surgery GME communities have developed initial milestones draft documents and are currently working on implementation strategies. The work of both of these groups has generated a number of shared learnings: • Milestones should be developmental in nature • Milestones should describe discrete behaviors but can be bundled around the assessment and evaluation of learners at critical points or skills (landmarks or domains of practice) that ultimately demonstrate the development of those knowledge, skills and attitudes that define the discipline • Assessment and evaluation systems based upon milestones should be learner-centered and should generate rich formative feedback and ultimately summative feedback so that all stakeholders know an individual’s trajectory of competency acquisition • Articulation of milestones of competency development should ensure that learners acquire the knowledge, skills and attitudes for advancing in the program and for entering the next phase of their careers PatientC are Standardized patient D irect Observation Sim ulation 6 m onths 9 m onths 18 m onths H istoricalD ata G athering 1. Acquire accurate and relevant history from the patientin an efficiently custom ized,prioritized, and hypothesis driven fashion 2. Seek and obtain appropriate, verified,and prioritized data from secondary sources (e.g.fam ily, records,pharm acy) 3. O btain relevanthistorical subtleties thatinform and prioritize both differential diagnoses and diagnostic plans,including sensitive,com plicated,and detailed inform ation thatm ay notoften be volunteered by the patient C linicalskills and reasoning M anages patients using clinical skills of interviewing and physical examination A ssessm ent Methods/Tools A pproxim ate Tim e Fram e Trainee to A chieve Stage DevelopmentalMilestones Inform ing ACG M E Com petencies ACGME C om petency EPA Landm ark A Landm ark B Landm ark C Milestones S,T and U Milestones V and W Milestone X,Y and Z Com petency Com m ittee Focused assessm ent/evaluation system PBLI PC ICS H ealth care team leader Supervising a residentteam Table 1: Example of Internal Medicine Milestone in the Patient Care General Competency 2 Figure 1: Example of Resident Team Supervision as an Entrustable Professional Activity (EPA) GENERAL SURGERY MILESTONES General Surgery elected to first identify critical domains of practice and then determine which of the broad ACGME general competencies were required in each domain. Within each domain, discreet milestones defining competency were subsequently developed. Ultimately, nine domains of practice were chosen (see Table 2). A domain like “consultation” for example requires demonstration of competency in medical knowledge, patient care, communications, and professionalism (see Figure 2). This construct is based on the fact that the professionalism required for consultation is related to, but not the same as the professionalism required to complete administrative tasks. By evaluating competence in context, as in the consultation example, the assessment and evaluation of the general competencies can be focused on discrete milestones. Table 2: The Nine Domains of Practice for General Surgery Figure 2: Competence in the Context of Providing Consultation CHALLENGES • Defining common milestones and assessment tools that potentially apply across all medical disciplines • General competencies potentially amenable to this approach include •Professionalism •Interpersonal and Communication Skills •Practice-based Learning and Improvement •Systems-based Practice • Utilizing milestones-based competency evaluation for both the accreditation of GME programs and the certification of individual physicians • Training faculty to complete valid and reliable milestones based assessment and evaluation REFERENCES 1. Competency-Based Postgraduate Training: Can We Bridge the Gap between Theory and Clinical Practice? Olle ten Cate, Fedde Scheele. Academic Medicine, Vol. 82, No. 6 / June 2007, p 542-7 2. Charting the Road to Competence: Developmental Milestones for Internal Medicine Residency Training Green ML, Aagaard EM, Caverzagie KJ, Chick DA, Holmboe ES, Kane G, Smith CD, Iobst W. Journal of Graduate Medical Education. 2009;1(1): 5 – 20. Domains of Practice Domains of Competency Required Care for diseases and conditions MK, PC, PROF, COMM, SBP, PBL Perform operations and procedures MK, PC, PROF, COMM, SBP, PBL Provide consultation MK, PC, PROF, COMM, Coordinate care MK, PC, COMM, SBP Engages in self directed learning MK, PROF, PBL Improves care PC, COMM, SBP, PBL Educates PC, PROF, COMM Maintains personal health PROF Does administrative tasks PC, PROF, COMM, SBP
