Are They Practicing What You are

Preaching?

Entrustable Professional Activities (EPA) for the

Geriatrician

Kelly Caverzagie, MD
Department of Internal Medicine
University of Nebraska Medical Center

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Disclosures
 A portion of my salary at the University
of Nebraska is reimbursed by the ABIM:

◦ Practice Improvement Module (PIM)

Development

◦ Academic Affairs

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Learning Objectives
 Identify the basic principles of Competency-
Based Medical Education (CBME)

 Understand the concept of an Entrustable

Professional Activity (EPA) as it relates to
trainee assessment

 Apply lessons learned to advance work of

community in developing EPA’s

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Outline
 Background review of CBME
◦ Need for meaningful assessment

 Assessment of Competence
◦ Entrustable Professional Activities (EPA)

 Small group activities

◦ Reflect upon draft set of Geriatric EPA’s and
recommend revisions

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Competency-Based Medical Education
CBME is an outcomes-based approach to
the design, implementation, assessment
and evaluation of a medical education
program using an organizing framework of
competencies.

The International CBME Collaborators, 2009

 ACGME – Outcome Project
 Medical Knowledge
 Patient Care and
Procedural Skills
 Introduced 1999
 Implemented 2001  Professionalism
 Interpersonal &
 6 General Communication Skills
Competencies
 Practice-based Learning &
Improvement
 Systems-based Practice
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Struggles Moving Forward
 Programs have had trouble moving from
traditional framework (structure/process) to
CBME framework (competence/outcomes)
◦ Unclear and complex ACGME general
competencies
◦ Difficulty in assessing and evaluating resident
competence
 Old Assessment System
Ambulatory Clinic

Critical Care Medicine

General Medicine Wards

Average 4.32 / 5
for Systems-
Rheumatology Based Practice

Cardiology Consult

Research Elective

Geriatrics
Traditional vs. CBME: Start with System Needs

Frenk
Lancet, 2010
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 ACGME – Outcome Project
 Medical Knowledge
 Patient Care and
Procedural Skills
 Introduced 1999
 Implemented 2001  Professionalism
 Interpersonal &
 6 General Communication Skills
Competencies
 Practice-based Learning &
Improvement
 Systems-based Practice
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IOM High Quality Care
 Timely – reducing waits and harmful delay

 Efficient – avoiding waste

 Equitable – providing care that does not vary in quality

because of personal characteristics

 Safe – avoiding injuries rom care

 Effective – providing services based on scientific knowledge

to all who could benefit

 Patient-centered – providing care that is respectful of and

responsive to patient preferences, needs and values

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 Medicare-Determined Outcomes
 Work effectively in multiple settings
 Coordinate care within and across settings
 Understand cost and value of diagnostic and
treatment options
 Work in inter-professional teams and multi-
disciplinary team-based models
 Identify systematic errors and in implement
systematic solutions in case of errors

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Traditional vs. CBME
Educational Program
Variable Structure/Process Competency-based
Driving force: Curriculum Content Outcome
Goal of educ. encounter Knowledge acquisition Knowledge application
Typical assessment tool Single subjective measure Multiple objective measures
Assessment tool Proxy Authentic
(mimic real tasks of profession)
Setting Removed (gestalt) Direct observation
Focus of Assessment Norm-referenced Criterion-referenced
Timing of assessment Emphasis on summative Emphasis on formative

Adapted from Carracchio, et al. 2002

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 Old Assessment System
Ambulatory Clinic

Critical Care Medicine

General Medicine Wards

Average 4.32 / 5
for Systems-
Rheumatology Based Practice

Cardiology Consult

Research Elective

Geriatrics
 New Assessment
Manage multiple meds
System

Resuscitate critically ill patient

Example
Manage transitions of care activities of
unsupervised
internist
Perform musculoskeletal exam
OR

Inform steps
Consult to non-medicine teams along the way to
becoming an
unsupervised
Critically appraise literature internist

Goals of care discussion

 How does
Brady get to
drive a car?
Competency
An observable ability of a health
professional, integrating multiple
components such as knowledge, skills,
values and attitudes.

The International CBME Collaborators, 2009

Competent
Possessing the required abilities in all
domains in a certain context at a defined
stage of medical education or practice.

The International CBME Collaborators, 2009

Competence
Competence entails more than the
possession of knowledge, skills and
attitudes; it requires you … to apply these
[abilities] in the clinical environment to
achieve optimal results.

ten Cate, Med Teach, 2010

Competenglish
Competency – the thing(s) they need to do

Competent – can do all of the things

Competence – does all of the things

consistently, adapting to contextual and
situational needs
How Does Brady get to Drive a Car?
 Competency
◦ Can accelerate and brake smoothly
◦ Can approach an intersection and can turn left

 Competent
◦ Passes driver’s education classes
◦ Passes driver’s exam to get the license

 Competence
◦ Drives safely on interstate or during bad weather,
avoids accidents, no traffic tickets
◦ Dad gives him the keys and walks away
When do your fellows get the keys to
the car?

 Lots of good evaluations …

 Absence of bad evaluations …
 Survived a year of fellowship…
 Didn’t commit any crimes …

 Your program director followed the

rules…
CBME is a new paradigm
We must know the trainee has
demonstrated competence and is ready
to progress to the next stage of their
career:
◦ Requires clear definition of expected
competencies (i.e. thing they need to do)
◦ Requires assessment to determine whether
these things are done consistently and within
the contextual needs of the clinical
environment
Geriatric Curricular Competencies

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Potential Criticisms
• There are too many!
◦ Programs cannot assess all of them

 Reductionistic?
◦ Potential to deconstruct the learners’
performance into discreet tasks or checklists
◦ Checking off competencies does not equate
to competence
CBME Challenge
 Ensure that the outcomes of the
assessment actually demonstrate
competence in the activities that define
the profession

 Do they equate to the things that the

public trusts that geriatricians are doing?

 Entrustable Professional Activities (EPA’s)

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Entrustable Professional Activities
“… identify the critical activities that
constitute a specialty … the activities of
which we would all agree should be only
carried out by a trained specialist.”

ten Cate et al.

Acad Med 2007; 82: 542-47
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An Entrustable Professional Activity
 Part of essential work for a qualified professional
 Requires specific knowledge, skill, attitude
 Acquired through training
 Leads to recognized output
 Observable and measureable, leading to a
conclusion
 Reflects the competencies expected

 EPA’s together constitute the core of the

profession
ten Cate et al.
Acad Med 2007; 82: 542-47
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Entrustable Professional Activities
“Patients’ and instructors’ … entrustment of
responsibility to a trainee is an essential
concept in this approach…”

ten Cate et al.

Acad Med 2007; 82: 542-47
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Entrustment in Residency Training
 Attending physicians assess a multi-
dimensional construct of
“trustworthiness” when deciding a level
of supervision

 Entrustment implies a level of

competence

Kennedy, et. al.

Acad Med 2008; 83(10 Suppl): S89-92
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COMPETENCE

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“Windows to Competence”
Caverzagie and Iobst
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EPA - Lead and work within
interprofessional teams

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 EPA - Lead and work within
Accept feedback interprofessional teams

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EPA - Lead and work within
interprofessional teams

Manage diverse
opinions with
goal optimizing
patient care

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 EPA - Lead and work within
interprofessional teams

Maintain
climate of
mutual respect
and shared
values

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EPA - Lead and work within
interprofessional teams

Engage in
collaborative
communication

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 EPA - Lead and work within
interprofessional teams

Identify and
understand
roles of team
members 38
 EPA - Lead and work within
Accept feedback interprofessional teams

Maintain Manage diverse

climate of opinions with
mutual respect goal optimizing
patient care Engage in
and shared
Identify and collaborative
values
understand communication
roles of team
members 39
 DRAFT Geriatricians EPA’s (v13)
1. Prevent, diagnose and treat conditions in older adults with attention to
multimorbidity, age-related changes in physiology, function, treatment efficacy
and response, medication management and psychosocial issues.
2. Prevent, diagnose and treat geriatric syndromes.
3. Provide and coordinate health care for older adults in all settings, during
transitions of care, and at end of life.
4. Provide geriatric consultation.
5. Conduct meetings with patients, families and caregivers to clarify goals of
care and make complex decisions in the context of prognosis, net benefit
and burden, preferences and values.
6. Collaborate effectively as a member or leader of a health care team.
7. Teach the principles of geriatric care and aging-related health care issues to
professionals and nonprofessionals.
8. Participate in quality improvement and other systems-based initiatives to
assure patient safety and improve outcomes for older adults.
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Group Activity #1 - Task
 Using your assigned Geriatric EPA …
◦ Describe the activity
◦ Identify the tasks required for you to entrust the
fellow to do this activity at the end of training

 Goals
◦ Develop ‘shared mental model’ of the EPA in
order to inform meaningful assessment
◦ Write down recommendations and provide to
________________.

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Considerations
 Compare / contrast to Internal Medicine EPA’s

 Use Geriatric Curricular Competencies as a guide

 Balance between specific vs. vague / standardized vs.

flexible

 Ideally, the description and tasks will be evidence-based

and informed by the knowledge, skills and attitudes
required of physicians to meet the outcomes expected
of the future health care system

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Group Activity #2 - Task
 Consider the entire list of Geriatric EPAs
◦ Is anything missing? Is anything redundant?
◦ Do they reflect the expected outcomes?
 Profession
 Patient / Public
 Policy makers

 Goals
◦ Hand in recommend revisions
◦ Use your expertise to guide community
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Building Assessments for an EPA
Step 1 – Describe the activity. What tasks are
required for you to entrust the fellow to do this
activity at the end of training?

Step 2 – Identify the Curricular Competencies

that will help you assess a fellow performing this
activity

Step 3 – Identify specific assessment methods /

tools

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 Clinical
Educational Milestones
Competency
Committee

Assessment
System

ADS Update Self Study

Resident Survey Faculty Survey

Board Pass Rate CLER Visit

Clinical Experience Core Faculty

Log Scholarly Activity

Next Accreditation
System
Learning Objectives
 Identify the basic principles of Competency-
Based Medical Education (CBME)

 Understand the concept of an Entrustable

Professional Activity (EPA) as it relates to
trainee assessment

 Apply lessons learned to advance work of

community in developing EPA’s

46
Thank You!

kelly.caverzagie@unmc.edu

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