MedEd 2.0: Competency Based Medical Education, by Eric Holmboe, MD : Chapter 3 of 6



in over the last several years there's been tremendous interest in developing milestones and something called entrust about professional activities or epa's to help us bridge the gap between these conceptual general competencies and how we might look at them in behavioral terms to make sure that we're able to identify accurately and validly a trainees progression through their program so this is the Dreyfus model and this is an adaptation from David leach and Tom nasca and so you'll probably recognize a number of your trainees are at these various levels a novice is simply somebody who doesn't know what they don't know right that's the person coming in to medical school on day one they really don't know what they don't know they're excited they're energized become a medical student but they have no idea about what their journey are about to begin we've all been there the advanced beginner is there but you need to know what they don't know so think about that graduating medical student you know I've learned a lot of stuff I want to go into surgery but boy there's a lot I don't know about surgery that's the reason I'm doing a residency but they're beginning to recognize what it is they've picked up and what it is they need to acquire over time competent is somebody who's able to perform the tasks and roles within their discipline but they have restricted breadth and depth these are the people that are just good enough in the Dreyfus model they can function as an internist as a surgeon but they don't have a wide breadth and depth of skills proficient is somebody who's not consistent and efficient performance of these tasks and roles of their discipline they know what they know and don't know so these are where these are the kind of people that really have a good sense of where they are developmentally and this is actually for most of us in residency where we want to see our trainees in most of the competencies particularly patient care medical knowledge you would hope that they're proficient by the end of training so if they're now on a trajectory that will enable them to acquire additional expertise once they enter unsupervised practice terminology is also important and this also comes from the International CBM II collaborators and I just want to share these with you because you'll hear these terms used and so this is an opportunity for you to kind of get a sense of kind of what the field is using what it thinks about assessment competent is possessing the required abilities in all domains at a specified stage of medical education or practice now you notice this is a little bit different than the Dreyfus definition in this definition competent is stage dependent and we think that's important because we want to know if people along each stage or where they need to be at a minimum and that's what competence should look like dis competent is someone who's relatively lacking in one or more domains of acquired abilities at a specified stage of medical education of practice so they may be good for example in medical knowledge and professionalism but they're lacking maybe in those communication skills so their dis competent communication and you would want to know that so that you can kind of intervene and remediate make sure they catch up and fill that gap and then finally the folks who worry the most about are those who are incompetent these lack the required abilities in all domains in a certain context regardless of stage of medical education of practice and again it's important to identify these people as early as possible because the likelihood is they probably shouldn't be a physician and we don't want to pass them through the system if they're truly incompetent but again remove them from the system but also importantly to help them identify a career path that's a much better fit for them so with this kind of background in some language let's move now to talk about milestones milestones as you can see here again are just a significant point in development they help us to determine if somebody's on the right path or the right trajectory okay another way that a milestone is in a scheduled event signifying the completion of a major deliverable or set of deliverables in this case we tend to think of this in terms of process in the past but we're really more interested in whether or not somebody's made that significant point in development now milestones if they work well should enable the trainee the program and the regulatory bodies to know an individual's trajectory of kompis acquisition here like to drive this model the focus is developmental we want to make sure they're on the right path and this simple diagram just helps to illustrate that so you can see that the resident in the eighty prime the farthest to the left if somebody actually is on a seller rated trajectory and the milestones will be able to pick up that they've acquired skills earlier than expected and so you might want to adjust their curriculum and their educational experiences to help them continue on the accelerated path conversely the individual who's denoted by the dotted line mark C is somebody who's simply not going to make it they've started behind and they've never caught up in the milestones again would identify that this person is substantially behind the acceptable – jack – Reed as shown in the a box in the middle there that this individual really needs to be identified early and probably removed from the system now the person labeled B in the dash line is somebody that is off to a slower slope but if given some additional time something that's completely acceptable in the compass of a system will make it they will become fully competent they're just going to need more time and again milestones potentially provide the mechanisms by which to identify which of the trajectories your trainees is on now this comes directly from the internal medicine milestones project and this is just an example of a milestone and this is in the AC gb compensate of patient care it's denoted up top and then within each of these broad categories of competencies are sub competencies in this case we're looking at clinical skills and reasoning it's one of the sub competencies now what's important is that you'll notice in the middle column there it gives some benchmarks around when people should reach this level of performance this is considered competence and by when they should reach it so they haven't reached this particular level of skill in this particular constancy of managing patient using clinical skills of interviewing a physical examination you would be very concerned and you would want to make sure you intervened and in this case we can look at the 18-month box and so for somebody in Internal Medicine by 18 months they should be able to obtain the relevant historical subtleties that inform a prioritized both the differential diagnosis and the diagnostic plans including sensitive complicated and detailed information that may not be often volunteered by the patient so this is a higher level of skill this is working with more complex patients being able to really tease out those important key features are subtle differences that can lead to a more accurate diagnosis how would you know you would look so you might use a standardized patient for example on the intern in their first six months but by 18 months you ought to be using a lot of direct observation this is where faculty by observing a trainee in their second year can they actually do this would know whether or not they've actually met this milestone by 18 months so what are the benefits then well they provide the learner with a clear path of progression there are no surprises in fact we put these milestones out for review by the educational community including residents the response from the residents was overwhelmingly positive the reason they liked them so much is that for them they felt like this is one of the first time they actually were given a blueprint or a roadmap about what was expected them along the way during all three years of training so again for them this creates a transparent blueprint and there are no surprises the Moslems also allow for rich formative feedback because of behaviorally described you can tell a trainee what is they are doing well and where they need to improve and so learners will know where they are and where they need to go and again because they define specific behaviors you can focus your assessments in sample behaviors so you get a good sense of what the overall confidence of the trainee actually is what are some of the criticism and they are legitimate milestones tend to be reductionistic in nature successfully checking off a list of milestones doesn't necessarily predict confident practice in a highly complex healthcare environment so just a bunch of checks on a checkbox or a check list doesn't necessarily equate to the whole or that in fact somebody is overall competent and we don't know yet whether or not assessment of competence what a learner can do under controlled situations predicts performance well in actual practice in other words what do they do eventually when they're not observed that work needs to be done and as we point out they're 141 the internal medicine milestones and programs cannot assess them all but they are a blueprint a roadmap to help design curriculum and I think the challenge for programs is to pick those milestones that make the most sense to assess that are more representative of overall competence and I'm going to come back to that in just a minute

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