Entrustable Professional Activities: Online Journal Club (Updated with Open Access Links)

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 [1]. 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:

  1. are part of essential professional work in a given context;
  2. must require adequate knowledge, skill, and attitude, generally acquired through training;
  3. must lead to recognised output of professional labour;
  4. should usually be confined to qualified personnel;
  5. should be independently executable;
  6. should be executable within a time frame;
  7. should be observable and measurable in their process and their outcome, leading to a conclusion (‘well done’ or ‘not well done’); and
  8. 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?

Reference:

1. Ten Cate, O. (2005). “Entrustability of professional activities and competency-based training.” Medical Education 39(12): 1176-1177.

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Comments

  1. I read the editorial, and these are some of my thoughts:

    1. How do EPA’s differ from the classic “see one do one teach one” we all learned in medical school? I mean, really differ. Not just in substituting in the word “entrustment”.
    2. My residency required us to fill out competency booklets. Each page included something that you were required to know how to do, e.g. an H&P. And there were multiple pages for the most routine things, maybe 5 for H&Ps. On each page, you would write down the date you performed whatever it was, and your supervisor would sign it. And they weren’t just H&Ps. There were concrete things like blood draws, and not so concrete things like developing a treatment plan for a bipolar patient. Again, I don’t see how EPAs differ from this idea.
    3. To my way of thinking, it comes down to a mode of teaching and learning. The traditional approach in residency has been an apprenticeship, starting as a scut-monkey PGY1 who just does what she’s told, and progressing to journeyman on graduation. And the entire arc is supervised, hopefully by supervisors who know when to be heavily involved, and when the resident can solo. This is in contrast to a style that involves rigid quantification. I agree that it’s an excellent idea to have specific expectations, and it’s also a great exercise to sit down and think about what makes a good doctor a good doctor. But it’s similar to using checklists to evaluate patients. Checklists have their role. They can be useful for tracking progress. But appropriate use of checklists, like in the Ham-D article, involves the ability to interview the patient. It’s about people getting to know people.
    So with respect to EPAs, if you get too check-listy, it’s easy to lose sight of how the resident is actually doing. We all know doctors who passed every exam and met every competency standard, and who we wouldn’t allow near anyone we care about.

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    • I’m so glad to hear somebody else point out this obvious feature of psychiatric training–that it’s an apprenticeship. Making the evaluation “check-listy” may help evaluators catch the difficult learner earlier in the apprenticeship. On the other hand, I think check list fatigue can occur, and I think it is similar to the alarm fatigue nurses and doctors are prone to on telemetry units. We get inured to the constant background noise of long, complex rating scales and, amidst all the other tasks we have, we may pick the middle box just to get it done. Paraphrasing Yoda–that is why we fail.

      Jim

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  2. Thanks Jim – feel free to use the poster but I have to admit the original concept is from the TV series Fringe.

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  3. Jim – I can’t access the original article but your post touched on a couple of issues for me. The first is the idea of resistance. Being a former protestor – I can say unequivocally that I have not witnessed a single act of resistance from the medical profession during my career. It seems that physicians of any stripe are quite eager to avoid political battles and as such they are easy marks for any administrator with the “:next big idea.” That includes people who claim that they have only good intentions – like improving the accountability and expertise of the profession. As far as I can tell there are mixed agendas. Professionalism suddenly contains managed care elements. Expertise suddenly involves the use of rating scales. All of this is occurring not only in the absence of evidence (but as you recently pointed out) acknowledgment that this may end up a failed experiment.

    When I see residents, I have a clear idea of what they need to be excellent psychiatrists. I also want to protect them from making mistakes and teach them how to not make the same mistakes I have made. As far as I can tell that is all working and everybody is jumping through whatever hoops the Board is putting in their way.

    Items 3-7 in the EPAs seem to be stretched by an administrator. It seem like their jargon to me. “Observable and measurable in their process and in their outcome…: Does that mean more rating scales? We deal a lot in the unmeasurable and the subjective. To be a good psychiatrist that is where you need to be. I have had goals with patients that took weeks, months or years to attain. In some cases they were never attained. At some point we have to step back and tell ourselves that despite the dial twisters running the assembly line – we are not making Toyotas.

    Oh – and if we ever do form a resistance – I have designed the poster: https://www.dropbox.com/s/v0ncuv60pbgbfc0/GDResistance%20Poster.jpg

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    • George, first let me apologize for not realizing that the link to the article was available through an institutional subscription. Psych Practice pointed out the article was not available open access, but found an editorial by Ten Cate that has a lot of overlap, http://www.jgme.org/doi/pdf/10.4300/JGME-D-12-00381.1. And there are several open access articles about EPAs in the March 2013 issue of the Journal of Graduate Medical Education, http://www.jgme.org/toc/jgme/5/1. I hope I’ve made up for my gaffe.

      I can’t tell you how valuable I think your comments are as clinical pearls for trainees. I’ve asked the chief resident and residents who are rotating through the consultation service to have a peek at this online journal club and pass the word about it on to their peers. I want them to know there is life after residency and they would profit from hearing about psychiatry in the “real” world.

      I want to protect them too. Maybe we can do that by revealing the deeply embedded flaws of the systems which foster our mistakes. They need to see what’s behind the curtain.

      That poster is priceless, George. Can I post it on my site?

      Jim

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  4. I couldn’t access the article. All I could find was this:
    http://www.jgme.org/doi/pdf/10.4300/JGME-D-12-00381.1

    Is there a fair amount of overlap between the two?

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    • Mea culpa! I didn’t notice that my access was through an institutional subscription. I’ve just updated the post with links to the Journal of Graduate Medical Education, in which the editorial you cite is published. In fact, it has a good deal of overlap with the article I read and it’s better because it’s more recent. The link to the March 2013 issue of JGME is http://www.jgme.org/toc/jgme/5/1.

      Sorry about that! On the other hand, you helped uncover what might be a gold mine of open access articles about the Entrustable Professional Activities concept and the Milestone Project.

      Thanks!

      Jim

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