MD학위의 토대 정의: 1년차 전공의를 위한 Core EPA(Acad Med, 2016)

MD학위의 토대 정의: 1년차 전공의를 위한 Core EPA(Acad Med, 2016)

Toward Defining the Foundation of the MD Degree: Core Entrustable Professional Activities for Entering Residency

Robert Englander, MD, MPH, Timothy Flynn, MD, Stephanie Call, MD, MSPH, Carol Carraccio, MD, MA, Lynn Cleary, MD, Tracy B. Fulton, PhD, Maureen J. Garrity, PhD, Steven A. Lieberman, MD, Brenessa Lindeman, MD, MEHP, Monica L. Lypson, MD, MHPE, Rebecca M. Minter, MD, Jay Rosenfield, MD, MEd, Joe Thomas, MD, Mark C. Wilson, MD, MPH, and Carol A. Aschenbrener, MD

LCME (Liaison Committee for Medical Education)에서 정한 표준은 교육 성과보다는 필수 주제와 학생 경험에 더 중점을 둡니다. 모든 학부 과정은 결과 기반 학습 목표를 가져야하지만, LCME 표준은 이러한 "결과"가 무엇이어야하는지에 대한 지침을 제공하지 않습니다 .2

Standards set by the Liaison Committee on Medical Education (LCME) focus more on required subject matter and student experiences than on educational outcomes. Although all undergraduate courses must have outcomes-based learning objectives, the LCME standards do not provide guidance as to what those “outcomes” should be.2

결과적으로 특정 임상 적 능력과 의학 학위 (MD) 졸업 예정자에 대한 acument에 대한 의견 차이가 있습니다. 이러한 명확하고 표준적인 기대치의 결여로 인해 레지던시 프로그램 디렉터의 기대와 새로운 레지던트의 성과 사이에 격차가 생기고, 레지던트의 성과에 (학교마다) 중대한 이질성이 생겼다 .3-6

As a result, there is disagreement about the specific clinical abilities and acumen that should be expected of a medical degree (MD) graduate. This absence of clear, standard expectations has led to a gap between residency program directors’ expectations and new residents’ performance and to significant heterogeneity in entering residents’ performance.3–6

문헌은 레지던트가 종종 감독없이 수련 초기에 임상 업무를 수행하고 있다는 증거로 가득 차 있습니다. 예를 들어 레이몬드 (Raymond)와 동료 7 명은 10 가지 핵심 전문 분야에서 2,500 명 이상의 거주자를 연구하여 일상적인 업무 (보험 회사와의 간호 토론)에서 감정적 인 라덴 (화난 환자 관리), 기술적 인 도전 ) 처음 며칠 동안.

The literature is replete with evidence that residents are trusted to perform clinical tasks early in residency often without supervision. For example, Raymond and colleagues7 studied more than 2,500 residents from 10 core specialties who reported performing activities from the routine (discussing a patient’s care with an insurance company) to the emotionally laden (managing an angry patient) to the technically challenging (performing a thoracentesis) during their first days.

지난 10 년 동안 미국과 캐나다의 의학 교육자들은 의대에서 레지던트로의 전환을 포함하여 교육 및 훈련의 전환에 초점을 맞추기 시작했습니다.

Over the past decade, medical educators in the United States and Canada have begun to focus on the transitions in education and training, including the transition from medical school to residency.8,9

개발 지침

Guiding Principles for Developing the Core EPAs for Entering Residency

Drafting Panel은 몇 가지 지침 원칙을 수립했으며, 첫 번째는 환자 안전이 이 작업의 주요 동기가 될 것이라는 것입니다. "7 월 효과"의 존재 여부에 상관없이, 본 연구에 참여하기위한 우리의 이론적 근거는 주로 두 가지 환자 안전 문제에 기반을두고 있습니다 : 

(1) 새로운 레지던트의 임상 기술은 매우 가변적이며 프로그램의 기대에 항상 부합하지 않습니다 

(2) 레지던트들은 직접적인 감독없이 적절한 지시 나 평가를받지 못한 많은 활동을 수행합니다.

The Drafting Panel established several guiding principles, the first being that patient safety would be the primary motivator for this work. Whether or not the “July effect” exists,12,13 our rationale for engaging in this work was primarily based on two patient safety issues: (1) The clinical skills of new residents are highly variable and do not always meet the expectations of program directors,5,14,15 and (2) residents perform many activities for which they may not have had adequate instruction or assessment without direct supervision.16

두 번째 기본 원칙은 전문과 선택과 상관없이 모든 의사에게 적용되는 공통 기술의 "핵심"을 개발하는 것이 었습니다. 포괄적 인 의과 대학 교육은 모든 의료 학교 졸업생 (예 : 절차 전문 봉합)에 적용하기보다는 전문 분야에 특화된 기술뿐만 아니라 환자 치료 이외의 학교 사명과 관련된 추가 기술 교육을 포함합니다. 우리는 이러한 추가 기술을 다루려고 시도하지 않았습니다.

The second guiding principle was to develop a “core” of common skills that apply to all physicians, regardless of specialty choice. A comprehensive medical school education includes instruction in additional skills linked to the school’s mission beyond patient care as well as in skills that are specific to a specialty rather than applicable to all medical school graduates (e.g., suturing for the procedural specialties). We did not attempt to address these additional skills.

세 번째 기본 원칙은 학습자 평가가 의학 교육의 핵심 요구 사항을 성공적으로 구현하는 데 중요하다는 것입니다. 우리는 잦은 형성적 평가에 기초한 평가 시스템을 계획하여 종합적인 증거에 기반한 위탁 결정을 궁극적으로 완성했습니다.

Our third guiding principle was that learner assessment is critical to the successful implementation of any core requirements in medical education. We envisioned an assessment system based on frequent formative assessments, ultimately culminating in entrustment decisions based on the aggregate evidence.

마지막으로, 우리의 네 번째 기본 원칙은 이러한 핵심 요구 사항의 구현은 교수개발을 위한 강력한 자원과 결합되어야한다는 것입니다. 교수진은 교수, 평가 및 피드백에 대한 새로운 접근법을 배우고 직접 감독없이 특정 업무를 수행 할 준비가되어 있는지에 대한 위탁 결정을 내릴 수있는 기술을 개발해야합니다.

Finally, our fourth guiding principle was that implementation of such core requirements must be coupled with robust resources for faculty development. Faculty will need to learn new approaches to teaching, assessment, and feedback and develop the skills to make entrustment decisions regarding a student’s readiness to perform specific tasks without direct supervision.

개념 프레임워크

Conceptual Framework: Choosing EPAs and Linking Them to Competencies and Milestones

EPAs의 개념은 2005 년에 추상적이고, 맥락에 독립적이며, 세분화 된 역량의 본질에 따르는 한계를 극복하기위한 실질적인 접근법으로서 도입되었습니다. EPA는 care delivery에 중점을 두는 관찰 가능하고 측정 가능한 작업 단위이며, 따라서 평가 프로세스를 학습자가 실제로하는 일과 직장에서 관찰하는 내용과 일치시킵니다. EPAs는 또한 평가 방정식에 대한 다양한 수준의 감독에 대한 신뢰 개념과 그 의미를 소개한다.

The concept of EPAs was introduced in 2005 as a practical approach to overcoming the limitations created by the abstract, context- independent, and granular nature of competencies. EPAs are observable and measurable units of work that focus on care delivery and, as such, align the assessment process with what learners actually do and what faculty observe in the workplace. EPAs also introduce the notion of trust and its implications for variable levels of supervision to the assessment equation.19

• EPA는 교육자가 학습자와 실제 care 전달에 필요한 역량의 통합을 평가할 수있게 해줍니다. 

• 역량은 임상 활동의 성공적인 수행을 뒷받침하는 학습자 능력의 세분화 된 구성 요소에 대한 설명을 용이하게합니다. 

• 역량과 이정표는 주어진 EPA에 대한 위임으로 진행할 수없는 학습자를 "진단"하는 역할을 할 수 있습니다.

• EPAs allow educators to assess a learner’s integration of the competencies needed for actual care delivery into her or his performance. 

• The competencies in turn facilitate the description of the granular components of the learner’s abilities that underpin the successful performance of clinical activities. 

• Competencies and their milestones thus can serve to “diagnose” a learner who is unable to progress to entrustment on a given EPA.

EPAs는 처음에는 수퍼바이저가 연습하지 않고 EPA를 연습 할 수있는 능력에 연계 된 위탁 교육을 통해 레지던트 전환을 위해 설계되었습니다. 우리는 UME-GME 전환을 위해 이 위임 개념을 채택했다 .17,18 신규 레지던트는 항상 직접 감독 (직접 감독관) 또는 간접 감독 (수석 주민 또는 교수진 즉시 지원 가능) 중 하나를가집니다. 따라서 우리는 레지던트에 들어가기위한 핵심 EPA를 "모든 레지던트들이 직접 감독없이 거주 첫날에 수행해야하는 활동"으로 정의했습니다.

EPAs were initially designed for the residency-to-practice transition with entrustment linked to the learner’s ability to practice the EPA unsupervised. We adapted this entrustment concept for the UME-to-GME transition.17,18 New residents always have either direct supervision (supervisor directly in the room) or indirect supervision (senior residents or faculty immediately available to assist). Therefore, we defined the core EPAs for entering residency as “activities that all entering residents should be expected to perform on day one of residency without direct supervision.”11

Getting to the Final 13: Why These EPAs?

List 1 Final 13 Core Entrustable Professional Activities for Entering Residency11

1. Gather a history and perform a physical examination

2. Prioritize a differential diagnosis following a clinical encounter

3. Recommend and interpret common diagnostic and screening tests

4. Enter and discuss orders/prescriptions

5. Document a clinical encounter in the patient record

6. Provide an oral presentation of a clinical encounter

7. Form clinical questions and retrieve evidence to advance patient care

8. Give or receive a patient handover to transition care responsibility

9. Collaborate as a member of an interprofessional team

10. Recognize a patient requiring urgent or emergent care and initiate evaluation and management

11. Obtain informed consent for tests and/or procedures

12. Perform general procedures of a physician

13. Identify system failures and contribute to a culture of safety and improvement

See List 1 for the final 13 EPAs.11

EPA를 핵심 역량에 매핑하기

Mapping the EPAs to Their Critical Competencies

See List 2 for these domains of competence and 

List 3 for examples of the competencies within the domain of patient care.

다음으로 Q-sorting 방법론을 사용하여 각 EPA에 대해 5 ~ 8 가지 가장 중요한 역량에 대한 합의를 이끌어 냈습니다. 이론적으로 각 EPA는 여러 역량에 매핑 될 수 있지만 그 중 소수만이 위탁에 도달해야합니다. 우리는 핵심 역량을 학습자가 직접 감독없이 활동을 수행하기 전에 증명해야하는 역량으로 정의했습니다. 예를 들어 자동차 운전에는 점화, 조향, 제동 및 GPS 관리 역량이 포함됩니다. 이 경우 첫 번째 세 가지 역량은 새 드라이버에 대한 위탁 결정에 중요 할 수 있지만 마지막 것은 그렇지 않습니다. 마찬가지로, 신규 거주자는 수혈, 중추선 또는 예방 접종과 같은 업무에 대한 직접 감독없이 정보에 입각 한 동의를 얻을 수 있어야합니다. 그렇게하려면 관리 계획을 수립하고 실행하고 환자와 그 가족을 상담하고 교육하는 것과 같은 환자 치료 역량이 필요합니다. 비록 그러한 procedure를 수행하는 것(환자 치료 -1)이 정보에 입각 한 동의를 얻는 데 중요 할 수도 있지만, 레지던트는 수혈처럼 그들이 직접 하지 않는 절차에 대한 동의를 얻는 경우도 많으므로 procedure에 관한 역량은 informed consent EPA에 연결하지 않았습니다.

Next, we used a Q-sorting methodology to reach consensus on the five to eight most critical competencies for each EPA. Theoretically, each EPA could be mapped to many competencies, but only a few of those are required to reach entrustment. We defined critical competencies as those that must be demonstrated before a learner may perform the activity without direct supervision. For example, driving a car includes competencies in ignition, steering, braking, and managing a GPS. In this case, the first three competencies would be critical to an entrustment decision for a new driver, while the last is not. Similarly, a new resident should be able to obtain informed consent without direct supervision for tasks such as blood transfusions, central lines, or immunizations. Doing so requires patient care competencies such as developing and carrying out management plans and counseling and educating patients and their families. Although performing the procedure (Patient care-1) might seem critical to obtaining informed consent, residents often obtain consent for procedures they do not do (e.g., blood transfusion), so we did not link procedural competency to the informed consent EPA. 

핵심 역량을 위한 마일스톤 개발

Developing Milestones for the Critical Competencies

위에서 설명한 프로세스를 통해 13 개 이상의 EPA 중 하나 이상에 연결된 각 역량에 대한 이정표를 만들었습니다. 이정표는 발달 연속체를 따라 수행 수준을 향상시키는 학습자의 행동 적 기술자입니다. 우리의 이정표는 시간 내과, 27 건의 외과, 28 건의 소아과, 29 건의 정신과학, 30 건의 응급 의학에서 발표 된 5 세트의 ACGME 전문 이정표에서 주로 얻었습니다 .31 우리는 각 역량에 대해 두 가지 이정표를 개발했습니다. 또는 선임 할 수있는 학습자이고 다른 하나는 직접 감독없이 활동을 수행 할 자격이있는 것으로 정의 된 위임 할 수있는 학습자를 대표한다.

We created milestones for each of the competencies linked to 1 or more of the 13 EPAs through the process described above. Milestones are behavioral descriptors of learners at advancing levels of performance along a developmental continuum. Our milestones were derived predominantly from the five sets of ACGME specialty milestones that were published at the time—internal medicine,27 surgery,28 pediatrics,29 psychiatry,30 and emergency medicine.31 We developed two milestones for each competency—one representing a novice or preentrustable learner and the other representing an entrustable learner, defined as one who is competent to perform the activity without direct supervision.

평가 가이드와 교수 개발

Guiding Assessment and Faculty Development

우리는 선행적이고 신뢰할 수있는 학습자를 위한 이정표를 기반으로 각 EPA에 대한 묘사적인 행동 서사 및 사례 비 네트를 만들었습니다. 그림 1은 EPA, 역량 및 이정표 간의 관계와이 서술 설명을 작성하기위한 이정표의 사용 결과를 보여줍니다.

we created descriptive behavioral narratives and case vignettes for each EPA based on the milestones for preentrustable and entrustable learners. Figure 1 depicts the relationship between EPAs, competencies, and milestones and the resultant use of the milestones to build these narrative descriptions.

최종 버전에는 각 EPA에 대한 설명, 주요 기능 목록, 핵심 역량 및 중요 시점에 대한 링크, 예상 행동 및 임상 적 비 네트에 대한 서술 및 2014 년 6 월에 공유 된 내용이 포함되어 있습니다 .11

The final version includes a description of each EPA, a list of key functions, links to critical competencies and milestones, and narrative descriptions of expected behaviors and clinical vignettes for both preentrustable and entrustable learners, and was shared in June 2014.11

다음 단계

Next Steps: Testing the EPAs in the Field

커리큘럼을 개발할 때 교육자는 구조적 함의에주의를 기울일 필요가 있습니다. 학생들에게 위탁을 가장 효과적으로 전가시키는 교육 구조는 무엇입니까?

In developing curricula, educators will need to pay attention to structural implications. What is the educational structure that best advances students toward entrustment?

핵심 EPA의 최종 목록이 2 년 이내에 발표되었지만이 프레임 워크를 구현하고 테스트하기위한 두 가지 조사 방법이 이미 진행 중입니다. 첫째, AAMC는 각 EPA를 가르치고 의대생을 위탁하기위한 경로를 묘사하는 데 필요한 교과 과정, 평가 및 교수 개발 프로그램을 정의하기 위해 회원 의대 중 10 개국의 다년간 파일럿을 후원합니다.

Although publication of the final list of core EPAs happened less than two years ago, two avenues of inquiry are under way already to implement and test this framework. First, the AAMC is sponsoring a multiyear pilot with 10 of its member medical schools to define the curriculum, assessment, and faculty development program needed to teach each of the EPAs and to delineate pathways to entrustment for medical students.

또한 메릴랜드 주 볼티모어에서 열린 2015 년 AAMC 의학 교육 회의에는 기관이 핵심 EPA를 구현하는 방법에 대한 2 시간짜리 포스터 세션이 포함되었습니다.

In addition, the 2015 AAMC medical education meeting in Baltimore, Maryland included a two-hour poster session devoted to how institutions are implementing the core EPAs.

네덜란드와 독일은 의대 졸업생을위한 핵심 EPA 개발에도 관여하고 있습니다.

The Netherlands and Germany also are engaged in developing core EPAs for their medical school graduates.

핵심 EPA의 구현은 AAMC의 Continuum 프로젝트 (www.aamc.org/initiatives/epac/) 소아과 교육 (Education in Pediatrics) (4 개 기관의 소규모 학습자를 대상으로하는 파일럿 프로그램)을 통해 테스트됩니다.

Implementation of the core EPAs also will be tested through the AAMC’s Education in Pediatrics Across the Continuum project (www.aamc.org/initiatives/epac/), a pilot program involving a small number of learners at four institutions.

핵심 EPA와 전문 분야 및 하위 분야 EPA를 연결하면 전문 개발 궤도에 중요한 영향을 미칠 수있는 연속적인 학습 및 평가가 가능합니다. 

• 첫째, 학습자가 숙련 된 기술로 거주하게되면 프로그램 디렉터와 교수진은 학습자의 능력을 평가할 필요없이 이러한 기본 기술을 즉시 구축 할 수 있습니다. 이것은 거주 기간 동안 발달 연속체를 따라보다 신속한 진전 기회를 제공합니다. 

• 둘째, 수련 교육이 끝날 때 학습자의 수행 수준은 실습으로 전환됨에 따라 인증 유지의 첫 번째 사이클에 대한 학습을 ​​유도 할 수 있습니다.

Linking the core EPAs with specialty and subspecialty EPAs provides a continuum of learning and assessment that could have major implications for professional development trajectories. First, if learners enter residency with a known skill set, program directors and faculty can immediately build on these baseline skills without having to assess the learners’ abilities. This opens an opportunity for more rapid progress along the developmental continuum during residency. Second, learners’ level of performance at the end of residency training could guide their learning for the first cycle of maintenance of certification, as they transition into practice.

Conclusions

시행을 통해서만 우리는 이러한 13 가지 임상 과제에 대한 위탁이 [새로운 의사가 그들의 레지던트 기간이 시작될 때 책임을 맡을 준비가되어지고 첫날부터 환자에게보다 안전한 치료를 제공 할 것]이라는 가설을 시험 할 수 있습니다.

Only through implementation can we test the hypothesis that entrustment on these 13 clinical tasks will result in new physicians being better prepared to assume responsibilities at the outset of their residency years and provide safer care to their patients from day one.

11 Association of American Medical Colleges. Core entrustable professional activities for entering residency. 2013. https://www. mededportal.org/icollaborative/resource/887. Accessed March 1, 2016.

12 Young JQ, Ranji SR, Wachter RM, Lee Toronto, CM, Niehaus B, Auerbach AD. “July effect”: Impact of the academic year- end changeover on patient outcomes: A systematic review. Ann Intern Med. 2011;155:309–315.

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13 Averbukh Y, Southern W. A “reverse July effect”: Association between timing of admission, medical team workload, and 30-day readmission rate. J Grad Med Educ. 2014;6:65–70.

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Acad Med. 2016 Oct;91(10):1352-1358.

Toward Defining the Foundation of the MD Degree: Core Entrustable Professional Activities for Entering Residency.

Englander R1, Flynn T, Call S, Carraccio C, Cleary L, Fulton TB, Garrity MJ, Lieberman SA, Lindeman B, Lypson ML, Minter RM, Rosenfield J, Thomas J, Wilson MC, Aschenbrener CA.

Author information

1

R. Englander was senior director of competency-based learning and assessment, Association of American Medical Colleges, Washington, DC, at the time this work was done. He is now associate dean for undergraduate medical education, University of Minnesota Medical School, Minneapolis, Minnesota.T. Flynn is senior associate dean for clinical affairs, University of Florida College of Medicine, Gainesville, Florida.S. Call is program director for internal medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia.C. Carraccio is vice president for competency-based assessment programs, American Board of Pediatrics, Chapel Hill, North Carolina.L. Cleary is vice president for academic affairs, State University of New York Upstate Medical University, Syracuse, New York.T.B. Fulton is professor of biochemistry and biophysics and competency director for medical knowledge, University of California, San Francisco, School of Medicine, San Francisco, California.M.J. Garrity is associate professor of medicine and physiology and associate dean, University of Colorado Anschutz Medical Campus, Aurora, Colorado.S.A. Lieberman is senior dean for administration, University of Texas Medical Branch School of Medicine, Galveston, Texas.B. Lindeman is chief resident, Department of General Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.M.L. Lypson is professor of internal medicine and learning health sciences, University of Michigan Medical School, and associate chief of staff for education, VA Ann Arbor Healthcare System, Ann Arbor, Michigan.R.M. Minter was associate professor of surgery and learning health sciences, associate chair for education, Department of Surgery, and associate program director in general surgery, University of Michigan Medical School, Ann Arbor, Michigan, at the time this work was done. She is now professor and Alvin Baldwin Jr. Chair, Department of Surgery, UT Southwestern Medical Center, Dallas, Texas.J. Rosenfield is vice dean of the MD program, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.J. Thomas is a resident in emergency medicine, Mayo Clinic, Rochester, Minnesota.M.C. Wilson is clinical professor of internal medicine and associate dean for graduate medical education, University of Iowa Carver College of Medicine, and designated institutional official, University of Iowa Hospitals and Clinics, Iowa City, Iowa.C.A. Aschenbrener was chief medical education officer, Association of American Medical Colleges, Washington, DC, at the time this work was done.

Abstract

Currently, no standard defines the clinical skills that medical students must demonstrate upon graduation. The Liaison Committee on Medical Education bases its standards on required subject matter and student experiences rather than on observable educational outcomes. The absence of such established outcomes for MD graduates contributes to the gap between program directors' expectations and new residents' performance.In response, in 2013, the Association of American Medical Colleges convened a panel of experts from undergraduate and graduate medical education to define the professional activities that every resident should be able to do without direct supervision on day one of residency, regardless of specialty. Using a conceptual framework of entrustable professional activities (EPAs), this Drafting Panel reviewed the literature and sought input from the health professions education community. The result of this process was the publication of 13 coreEPAs for entering residency in 2014. Each EPA includes a description, a list of key functions, links to critical competencies and milestones, and narrative descriptions of expected behaviors and clinical vignettes for both novice learners and learners ready for entrustment.The medical education community has already begun to develop the curricula, assessment tools, faculty development resources, and pathways to entrustment for each of the 13 EPAs. Adoption of these core EPAs could significantly narrow the gap between program directors' expectations and new residents' performance, enhancing patient safety and increasing residents', educators', and patients' confidence in the care these learners provide in the first months of their residency training.

PMID:

 

27097053

 

DOI:

 

10.1097/ACM.0000000000001204