In this post I try to do a couple of things. One is to propose another article as a contribution to the recently inaugurated online journal club. This is a project that Psych Practice introduced and kicked off recently, Psych Practice Free Online Journal Club! – The Practical Psychosomaticist. And the other goal is to highlight our department’s response to the Accreditation Council for Graduate Medical Education (ACGME) Milestone Project for Psychiatry.
We have a regular Clinical Excellence noon meeting (sometimes with food) and I thought I’d share the topic of one recent meeting. It’s about the Psychiatry Milestone Project, about which you’ve heard me rant before, The Milestone Project: Leading The Way Further On in Medical Educaton? – The Practical Psychosomaticist. The group tolerated my rant briefly, then I was bound and gagged so the discussion leader could share her reflections on this new way to evaluate trainees. I really liked her approach because it’s a great example of leading change, not just resisting it, “Lead Change; Don’t Resist It” – The Practical Psychosomaticist.
The discussion leader shared her ideas about how to conceptualize the very complicated Milestone Project and mentioned one idea that involves using the “Entrustable Professional Activities” concept . The link to the article about EPAs for the online journal club by Ten Cate is http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2929.2005.02341.x/pdf.
Addendum: I’ve just been notified that readers can’t access this article and it probably has to do with my choice of using a Wiley Journal link, to which readers and institutions must have a subscription. Thanks to Psych Practice and Dr. George Dawson, I found The Journal of Graduate Medical Education. There are open access articles about Entrustable Projessional Activities at the following link, http://www.jgme.org/toc/jgme/5/1, including the editorial Psych Practice found that is very similar to the Wiley article by Ten Cate, http://www.jgme.org/doi/pdf/10.4300/JGME-D-12-00381.1
Essentially, the author says the core competencies (Medical Knowledge, Patient Care, Professionalism, Interpersonal Skills and Communication, Systems-Based Practice, and Practice-Based Learning and Improvement) can be linked to specific activities that trainees do which operationalize the competencies. If we as teachers are able to entrust these activities to resident physicians, then we can say they’ve achieved a “threshold competence.”
I think it’s also important to point out that several of us in the group could see that EPAs would likely differ depending on the nature of the clinical rotation, e.g., the consultation service compared to outpatient clinic psychotherapy training.
The Entrustable Professional Activities (EPAs) have the following attributes according to Ten Cate:
- are part of essential professional work in a given context;
- must require adequate knowledge, skill, and attitude, generally acquired through training;
- must lead to recognised output of professional labour;
- should usually be confined to qualified personnel;
- should be independently executable;
- should be executable within a time frame;
- should be observable and measurable in their process and their outcome, leading to a conclusion (‘well done’ or ‘not well done’); and
- should reflect one or more of the competencies to be acquired.
So if I can trust a resident to perform the Mini-Cog as part of a delirium assessment, than that could be an EPA that was done well, Lightning Fast Mini-Cog: Video Featuring Drs. Paul Thisayakorn and Alex Gamble – The Practical Psychosomaticist.
Of course, the reason for doing all of this thinking about the Milestone Project is to try to ensure we know when we’ve turned out a professional who is not just a safe and competent “provider”–but an excellent doctor. The discussion leader has a bold idea and she’s not sure if the residency program director will buy it. But I really like the idea of reflecting on what critical activities in my work as a consulting psychiatrist I would “entrust” to a trainee. The element of trust is essential to this enterprise, in my opinion, because the whole Milestone Project and the Maintenance of Certification (MOC) process are predicated in part on what board leaders say the public wants from doctors–to be trustable or trustworthy in providing health care which prioritizes safety.
You know, I’m pretty lucky because, as a consultant, I’m in a position to directly observe my residents conduct critically important EPAs. So I came up with a rough draft of three EPAs anchored to competencies. They are a beginning. I wouldn’t say that the following are in EPA format because they’re not as specific as I’d like them to be, and Ten Cate would probably agree. They need to be more along the lines of conducting the Mini-Cog. But it’s a start:
Assessment and Management of Delirium:
• Patient Care: e.g., H&P; check med list; check problem list; check labs, EKG, radiology, vitals
• Medical Knowledge: e.g., common medical etiologies of delirium
• Professionalism: responding to consult request and reformulating question if necessary (often delirium not recognized, mistaken for something else like anxiety)
• Interpersonal Skills and Communication: convey recommendations about management of agitation, pharmacologic and non-pharmacologic; educate families and consultees about delirium
• Systems-Based Practice: know whether and when to use resources like filing for mental health commitment, transferring to a secure unit or higher level of medical care
• Practice-Based Learning & Improvement: do quick literature searches when questions arise in novel situations
Suicide Risk Assessment:
• Patient Care: collaborate with internal medicine about medical safety of inpatients for transfer to psychiatric units
• Medical Knowledge: know basic things about level of lethality of overdoses (common method of suicide attempts)
• Professionalism: collaborate with internal medicine about triage to psychiatry, emphasizing safety; utilize filing for commitment when necessary
• Interpersonal Skills and Communication: sensitively obtain collateral from outside sources
• Systems-Based Practice: be familiar with hospital resources for managing medical problems related to suicide attempts, know laws in state about commitment
Decisional Capacity Assessment (DCA):
• Patient Care: collaborate with practitioners who are planning med/surg interventions
• Medical Knowledge: emphasize partnership with primary team to assess psychiatric interference with DC and checking patient’s understanding
• Professionalism: inform the patient the reason for the DCA, team up with the primary team to assess
• Interpersonal Skills and Communication: explain why DCA is a team-based, time-sensitive, task specific activity and invite consultee to participate
• Systems-Based Practice: be knowledgeable of local laws about what kind of interventions can be forced
How will the article by Ten Cate about EPAs and the discussion leader’s proposal to link it to the Milestone Project change the way I practice? What I might do is to refine the draft of EPAs above and ask for feedback from the residents who rotate through the service. They could have ideas on how to improve it.
Anyway, that’s my take on the article and this issue of lifelong learning, which I have always taken seriously. Your thoughts?
1. Ten Cate, O. (2005). “Entrustability of professional activities and competency-based training.” Medical Education 39(12): 1176-1177.