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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.