CBME의 공통 용어를 향하여(Med Teach, 2017)

CBME의 공통 용어를 향하여(Med Teach, 2017)

Toward a shared language for competency-based medical education

Robert Englandera, Jason R. Frankb,c, Carol Carracciod, Jonathan Sherbinoe, Shelley Rossf , and Linda Snellb,g; on behalf of the ICBME Collaborators

도입

Introduction

공유 언어는 적응적 변화를 이끄는 데 중요하다. 사람들이 같은 의미로 같은 단어를 사용하기 시작하면, (심지어 이 문제에 대한 중요한 차이가 있을 때조차) 더 효과적으로 의사소통하고, 오해를 최소화하고, 같은 페이지에 있다는 느낌을 갖게 된다.(Heifetz et al., 2009).

Shared language is important in leading adaptive change. When people begin to use the same words with the same meaning, they communicate more effectively, minimize misunderstandings, and gain the sense of being on the same page, even while grappling with significant differences on the issues (Heifetz et al. 2009, p. 9).

적응형 도전adaptive challenge의 특징. 이러한 유형의 도전은 다음과 같은 방식으로 기술적 도전technical challenge과 구별된다. 

the hallmarks of an adaptive challenge. This type of challenge is distinct from a technical challenge in the following ways: 

• (1) 경로가 명확하지 않다. 

• (2) 목적지는 교육 및 훈련 프로그램에 대한 신분 변경을 요구한다. 

• (3) 여정은 교육자, 임상 교수, 훈련생 모두에게 새로운 역량과 실험이 필요하다. 

• (4) 과정은 불안정하고 종종 상실감을 발생시킨다. 

• (5) 과정은 기술적인 작업보다 해결하는 데 더 오래 걸립니다(Heifetz et al. 2009). 

• (1) the path is not clear; 

• (2) the destination requires a change of identity for education and training programs; 

• (3) the journey requires new competencies and experimentation for educators, clinical faculty, and trainees alike; 

• (4) the process generates disequilibrium and often a sense of loss; and 

• (5) the process takes longer to resolve than technical work (Heifetz et al. 2009). 

이러한 종류의 근본적인 변화는 관련 용어의 공유 언어에 의해 크게 촉진된다.

This kind of fundamental change is greatly facilitated by a shared language of related terms.

CBME 언어에 대한 모호성은 새로운 패러다임의 채택에 대한 중요한 장벽으로 강조되었다. (Fernandez et al. 2012; 부모 외 2013; Whitehead et al. 2015; Hautz).

Ambiguity around the language of CBME has been highlighted as an important barrier to the adoption of the new paradigm (Fernandez et al. 2012; Parent et al. 2013; Whitehead et al. 2013; Hautz et al. 2015).

마일스톤 

Defining milestones

이정표의 개념은 처음에는 대학원 의학 교육 위원회(ACGME)의 이정표 프로젝트의 결과로 주목을 받았다. 이 프로젝트는 각 전문 분야별로 global unsupervised practice(ACGME 2013)의 달성에 필요한 역량 개발을 대학원 교육 과정 중에 명확히 규정해야 했습니다.

The concept of milestones has gained significant attention, initially as a result of the Milestones Project of the Accreditation Council for Graduate Medical Education (ACGME). This project required each of the specialties to define the “milestones” that during the course of graduate training marked advancement toward the competencies required for achievement of the global unsupervised practice (ACGME 2013).

그러나 유럽 의학 교육에서 이정표의 개념은 미국이나 캐나다의 현재 담론에서 보다 다양하고 "광범위한" 용어로 자주 설명된다.

However, in European medical education the notion of a milestone is frequently described in different and “larger” terms than in current discourse in the United States or Canada.

이정표: 개인의 능력을 발달 연속체를 따라 정의되고 관찰 가능한 마커.

Milestone: A defined, observable marker of an individual’s ability along a developmental continuum.

이 정의는 [관찰가능하고 평가가능한 전문지식의 단계적 진보]에 대한 명시적 진술로서 교육 이정표의 개념을 설명한다.

This definition articulates the concept of an educational milestone as an explicit statement of the stepwise progression of expertise that can be observed and assessed.

EPA

Defining EPAs

EPA의 정의에 중요한 특징은:

Critical to the definition of EPAs are the following features, An EPA:

•   주어진 맥락에서 필수적인 전문적인 업무의 일부이다.

•   적절한 지식, 기술, 태도를 필요로 한다.

•   전문직업적 노동에 대한 recognized output을 내게 한다.

  is part of essential professional work in a given context

  requires adequate knowledge, skills, and attitude

  leads to recognized output of professional labor

또한 ten Cate와 Schelle은 EPAs의 이상적이지만 필수적이지는 않은 특징들을 기술했다. EPA는..

In addition, ten Cate and Scheele delineated features of EPAs that are ideal but not required. These include that EPAs should:

• 자격을 갖춘 사람에게만 국한되어야 한다.

• 비의존적으로 실행 가능하능해야 한다

• 특정 time frame 내에 실행 가능해야 한다

• 과정 및 결과에서 관측 가능하고 측정 가능(완전하거나 잘 수행되지 않음)해야 한다.

• 하나 이상의 역량을 반영해야 한다(아래 "EPA, 역량 및 이정표 간의 관계" 참조).

   be confined to qualified personnel

   be independently executable

   be executable within a time frame

   be observable and measurable in its process and outcome (done well or not done well)

   reflect one or more competencies (see “The relationship between EPAs, competencies and milestones,” below)

의학교육의 맥락에서 다음과 같은 합의된 정의:

the following consensus definition in the context of medical training:

EPA(독점적 전문 활동): 충분한 역량이 갖춰지면, 특정 의료 환경에서 직접적인 감독 없이 수행할 수 있는 한 분야(전문직)의 필수 업무입니다.

Entrustable professional activity (EPA): An essential task of a discipline (profession, that an specialty, or subspecialty) individual can be trusted to perform without direct supervision in a given health care context, once sufficient competence has been demonstrated.

그러면, 전공, 전문과, 보건의료전문직은 관련된 업무 범위를 반영하는 일련의 EPA를 갖게 될 것이다.

then, that a discipline, specialty, or health care profession would have a set of EPAs that reflects the relevant scope of practice.

EPA 개념의 결과로 "Nested EPA"와 "공인 책임 진술(STAR)"이라는 두 가지 추가 용어가 문헌에 등장하고 있다.

Two additional terms are emerging in the literature as a result of the EPA concept: “nested EPA” and “statement of awarded responsibility (STAR).”

내포된 EPA: 광범위한 EPA에 필요한 지식, 기술 및 태도의 subset에 대한 숙련도가 필요한 작업. 중첩된 작업의 성능에 대한 기대는 전체 작업에 관여하는 것보다 개발 경로의 초기 단계에서 발생합니다. 

내포된 EPA에는 "상위" EPA의 요소가 있다. 즉, 다음과 같다. 

• 지식, 기술 및 태도의 통합이 필요하다. 

• 지정된 기간 내에 독립적으로 실행 가능합니다. 

• 관측 가능하고 측정 가능한 결과물로 이어집니다. 

내포된 EPA의 예로는 "제왕절개의 적응증을 이해하고 수행할 수 있다"가 있으며, 이것의 "상위" EPA는 "복잡한 출산을 관리할 수 있다"가 된다. (van Loon et al. 2014).

Nested EPA: A task that requires proficiency in a subset of the knowledge, skills, and attitudes required for the broader EPA. The expectation for entrustment with the performance of a nested task occurs at an earlier stage of the developmental trajectory than entrustment with the entire task. 

A nested EPA possesses the elements of its “parent” EPA; that is, 

• it requires the integration of knowledge, skills, and attitudes; 

• it is by independently executable within a given time frame qualified personnel; and 

• it leads to observable and measurable outputs. 

An example of a nested EPA might be “understanding the indications for and performing a caesarian section,” which is a nested in the “parent” EPA “managing complicated childbirth”. (van Loon et al. 2014).

책임 부여명세서(STAR): EPA에 대한 기여granted가 허가되는 특정 지점에 대한 공식 인정. STAR는 관리자가 해당 EPA에 대한 모든 중요 활동을 수행할 수 있는 교육자의 능력에 대해 시간이 지남에 따라 신중한 결정을 내릴 것을 요구한다. STAR의 구체적이고 형식적인 의미는 (지금까지 trainee 성과 문서의 근간이 되어온) 어떤 평가와도 다르다. 즉, STAR는 학습자가 감독 없이 해당 EPA를 수행할 수 있음을 보여준다. 결과적으로, 그것은 assessment 또는 evaluation보다는 인증과 유사하다.

Statement of awarded responsibility (STAR): A formal recognition of the specific point at which entrustment for an EPA is granted. STARs require supervisors to make deliberate decisions over time about their trainees’ competence to perform all critical activities for that EPA. The specific and formal implications of a STAR differ from those of any evaluations that have been the backbone of trainee performance documentation to date, in that a STAR allows the learner to perform the corresponding EPA without supervision. As a result, it bears a closer resemblance to a certification than an assessment or evaluation.

다른 떠오르는 용어들

Other emerging terms in CBME

Competency

Competence

The array of abilities (knowledge, skills, and attitudes) across multiple domains or aspects of performance in a certain context. Statements about competence require descriptive qualifiers to define the relevant abilities, context, and stage of training. Competence is multi-dimensional and dynamic. It changes with time, experience, and setting. (Frank et al. 2010)

Competency

An observable ability of a health professional related to a specific activity that integrates knowledge, skills, values, and attitudes. Since competencies are observable, they can be measured and assessed to ensure their acquisition. Competencies can be assembled like building blocks to facilitate progressive development. (Frank et al. 2010)

Competency-based medical education

An outcomes-based approach to the design, implementation, assessment, and evaluation of medical education programs, using an organizing framework of competencies. (Frank et al. 2010)

Competency benchmark

Expected performance level for a cohort of learners at a given point in education, training, or practice. (Willet 2012)

Competency framework

An organized and structured representation of a set of interrelated and purposeful competencies. (Willet 2012)

Competent

Possessing the minimum required abilities in all domains in a certain context at a defined stage of medical education, training, or practice. (Frank et al. 2010)

Domains of competence

Broad, distinguishable areas of competence that in the aggregate constitute a general descriptive framework for a profession, such as the six domains of competence described by the ACGME (Patient Care, Medical Knowledge, Professionalism, Interpersonal and Communication Skills, Systems-Based Practice, and Practice-Based Learning and Improvement) or the seven CanMEDS roles (Medical Expert, Professional, Communicator, Collaborator, Leader, Health Advocate, and Scholar). (Englander et al. 2013)

Dyscompetence

Possessing relatively less ability in one or more domains of health professional competence in a certain context and at a defined stage of education or practice. (Frank et al. 2010)

Incompetent

Lacking the required abilities to carry out a context-specific task at the predetermined performance level for a defined stage of medical education, training, or practice.

Entrustable professional activities

Entrustable professional activity: An essential task of a discipline (profession, specialty, or subspecialty) that a learner can be trusted to perform without direct supervision and an individual entering practice can perform unsupervised in a given health care context, once sufficient competence has been demonstrated.

Nested EPA: A nested EPA is a task unit that represents a foundational subset of the KSA required for the broader EPA. As a building block for the broader EPA, the expectation for entrustment occurs at an earlier stage of the developmental trajectory. A nested EPA possesses the elements of its “parent” EPA

(requires the integration of knowledge, skills and attitudes; is independently executable within a given timeframe by qualified personnel; and leads to observable and measurable outputs).

Statement of Awarded Responsibility (STAR): A STAR is a formal recognition of the specific point at which entrustment for an EPA has been granted. STARs require supervisors to make deliberate decisions over time about their trainees’ competence to perform all critical activities for that EPA.

Milestones

Milestone: A defined, observable marker of an individual’s ability along a developmental continuum.

EPA, 역량 및 이정표 간의 관계

The relationship between EPAs, competencies, and milestones

EPA는 일의 단위인 반면, 역량은 개인의 능력이다. EPA를 특징짓는 지표 중 하나는 일반적으로 여러 역량 영역에 걸쳐 다양한 역량의 통합이 필요하다는 것이다.

EPAs are units of work, whereas competencies are the abilities of individuals. One of the defining markers of an EPA is that it requires the integration of multiple competencies, usually across domains of competence.

저자들은 EPA와 역량 사이의 구별이 항상 명확한 것은 아니라는 것을 인정한다. 이러한 구분은 EPA의 "크기"에 관한 의견의 불일치로 인해 더 복잡해졌다. 문헌에는 "작은" EPA로는 lumbar puncture 수행을, "큰" EPA로는 외래환자 환경에서 일반적인 만성 질환을 관리를 언급하고 있다(10 Cate 2013).

The authors recognize that the distinctions between EPAs and competencies are not always sharp. The distinction is further muddied by the lack of consensus regarding the “sizing” of EPAs. The literature has included EPAs as “small” as performing a lumbar puncture and as “large” as managing a common chronic disease in the outpatient setting (ten Cate 2013).

그럼에도 불구하고, EPA와 역량은 서로를 보완한다. 이 두가지가 모였을 때 의사에 대한 보다 전체적인 관점을 제공한다.

Nevertheless, EPAs and competencies complement each other. Together, they provide a more holistic view of a physician

역량만으로는, 의사의 역할이 실세계에서는 감독자와 학습자에게 의미가 없을 정도로 추상적이거나 너무 원자화된 형태로 이루어질 수 있다. 또한, 역량에만 기반한 평가 시스템은 graded responsibilities에 관해 다소 인위적인 렌즈를 제공한다. 

Applied alone, constructs of competency can result in definitions of the physician’s role that are either so abstract or so atomized as to become meaningless to supervisors and learners in the real-world contexts of care delivery. Further,assessment systems based solely on competencies can provide a somewhat artificial lens through which to view graded responsibilities. 

EPA는 [의료 전문가의 실제 작업의 범위]를 높은 안면타당도로 outlining함으로써 역량 모델의 한계를 균형잡아준다. 그것들은 학습자에게 점점 더 많은 책임을 부여하는 과정과 업무 기반 평가에 유용한 구조를 제공한다. 

EPAs balance this limitation of the competency model by outlining, with high face validity, the spectrum of the health professional’s actual work. They provide a useful structure for work-based assessment and for the progression by which increasing responsibility is given to the learner. 

그러나 역량 프레임워크는 여전히 필수적이다. Entrustment에 필요한 역량의 매핑이 없다면, 평가자는 EPA의 준비 상태를 구성하는 것이 무엇인가에 대한 shared mental model을 갖지 못할 것이다. 게다가, 의사에게 필요한 역량의 전체 범위를 설명해주는 역량 프레임워크가 없다면, 그 결과는 의사에 대한 uneven하거나 지나치게 기술적인 관점일 것이다. 즉, 의사에 대해 작업 또는 산출물에 대해서만 정의할 뿐, 전문성이나 advocacy와 같은 21세기 의사에게 필요한 특정 능력들을 잠재적으로 무시한다.

However, a competency framework remains essential; without a mapping of the competencies required for entrustment, assessors will lack a shared mental model of what constitutes readiness for an EPA. Moreover, without a competency framework to describe the complete spectrum of necessary physician abilities, the result might be an uneven or overly technical view of the physician – that is, a definition based solely on his or her work or output – and thus potentially ignore many of the specific abilities required of the twenty-first century physician, such as professionalism and advocacy.

최소한 두 개의 모델이 있다: 주로 미국 모델과 유럽 모델 중 하나

 at least two models – one primarily in the US and one in Europe – are in use. Figure 1

미국의 프레임워크에서, 이정표는 역량보다 더 작은 구성 요소이며, 해당 역량에 대한 특정 수준의 성취도를 나타낸다. 

Therefore, in the US framework, a milestone is a smaller construct associated than a competency and represents behavior swith a specific level of achievement for that competency. 

유럽에서는 이정표가 EPA 또는 역량보다 상당히 "더 큰 것"으로 개념화된다. 따라서 이정표는 주니어에서 시니어 전공의가 되면서 밟아나가는 역량이나 EPA의 성취를 보여주는 지표가 된다.

In Europe, milestones are conceptualized in some settings as considerably “bigger” than the EPAs or competencies, such that a milestone is a marker of the achievement of a cluster of competencies or EPAs that allows one to move, for example, from junior to senior residency.

그림 2는 이 모델에서 이정표와 EPA 사이의 관계를 나타내고, 그림 3은 이 모델의 이정표와 역량 사이의 관계를 나타낸다.

Figure 2 depicts the relationship between milestones and EPAs in this model, and Figure 3 depicts the relationship between milestones and competencies in this model.

그러한 하이브리드 모델의 존재는 EPA, 이정표 및 역량을 위한 명확한 정의와 공유 언어의 필요성을 강화한다. 일부 인증 기관에서는 이미 문서에 이정표 용어를 포함했습니다(ACGME 2013). 곧 EPA도 그럴 것이다.

The existence of such hybrid models reinforces the need for clear definitions and a shared language for EPAs,milestones, and competencies. some accreditation bodies have already included milestones terminology in their documents (ACGME 2013); EPAs are likely coming soon.

Conclusion and next steps

CBME의 다음 단계에는 그러한 결과를 달성하는 데 필요한 개발 진행 또는 이정표를 정의하고, 학부 및 대학원 의학 교육에서 역량 평가 및 구현을 위한 EPA와 같은 프레임워크를 개발하는 것이 포함된다.

 the next phase of CBME involves defining the developmental progression, or milestones, required to achieve those outcomes and developing frameworks such as EPAs for implementing the teaching and assessment of competencies in both undergraduate and graduate medical education

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Med Teach. 2017 Jun;39(6):582-587. doi: 10.1080/0142159X.2017.1315066.

Toward a shared language for competency-based medical education.

Englander R1, Frank JR2,3, Carraccio C4, Sherbino J5, Ross S6, Snell L2,7; ICBME Collaborators.

Author information

1

a School of Medicine, University of Minnesota , Minneapolis , MN , USA.

2

b Royal College of Physicians and Surgeons of Canada , Ottawa , Canada.

3

c Department of Emergency Medicine , University of Ottawa , Ottawa , Canada.

4

d American Board of Pediatrics , Chapel Hill , NC , USA.

5

e Division of Emergency Medicine, Department of Medicine , McMaster University , Hamilton , Canada.

6

f Department of Family Medicine , University of Alberta , Edmonton , Canada.

7

g Centre for Medical and Department of General Internal Medicine , McGill University , Montreal, Quebec , Canada.

Abstract

The paradigm shift brought about by the advent of competency-based medical education (CBME) can be characterized as an adaptive change. Currently, its development and implementation suffer from the lack of a lingua franca. A shared language is needed to support collaboration and dissemination across the world community of medical educators. The International CBME Collaborators held a second summit in 2013 to explore this and other contemporary CBME issues. We present the resulting International CBME Collaborator's glossary of CBME terms. Particular attention is given to the terms competency, entrustable professional activity (EPA), and milestone and their interrelationships. Medical education scholars and enthusiasts of the competency-based approach are encouraged to adopt these terms and definitions, although no doubt the vocabulary of CBME will continue to evolve.

PMID:

 

28598739

 

DOI:

 

10.1080/0142159X.2017.1315066

[Indexed for MEDLINE]