Should We Entrust
Learners to Ask
Answerable Questions?
Evidence-Based Clinical Practice
McMaster University June 2014
Cast of Characters
Tom McGinn, MD
Chair of Medicine
Hoffstra Univ, New York
Mark Wilson, MD
Assoc Dean, GME
Univ of Iowa
Scott Richardson, MD
Assoc Dean, UME
GRU/UGA Partnership
Turning Over the Keys
Why???
Gaps Identified between:
•
•
Program Director Expectations and Skills of Entering
Residents
What residents do without supervision and what they
have been documented as competent to do without
supervision
Charge to Drafting Panel
Develop a clear, concise list of what graduating medical
students should be entrusted to do without direct
supervision on DAY ONE of residency
Core Entrustable
Professional Activities
(EPAs) for Entering
Residency (CEPAER):
Report of the Drafting Panel
AAMC Annual Meeting 2013
Entrustable Professional Activity
• Specific units of
professional work
• Tasks that trainees are
entrusted to perform
unsupervised
• After they’ve attained
sufficient competence
Olle ten Cate
Acad Med 2007
Ability to perform a task to a desired
level of performance without direct
supervision
C2
M1
M2
C3
M1
M2
C1
M1
M2
C4
M1
M2
C2
M1
M2
C5
M1
M2
DOC
EPA
EPA: Entrustable
Professional Activity
DOC: Domain of
Competence
C: Competency
M: Milestone
DOC
DOC
Drafting Panel Work
Delineated a set of activities that entering residents should
be expected (entrusted) to perform on day one of residency
without direct supervision.
13 core EPAs for entering residency ranging from:
- give patient handover to transition care
- recognize patient requiring urgent care
- to obtain informed consent
EPA #7: Form clinical questions and retrieve evidence
to advance patient care
http//:mededportal.com/icollaborative/resource/887
Expectations
for the
Medical School
Graduate
Core
EPAs
For Entering
Residency
EPAs
EPAs
For any
Practicing
Physician
For
Specialties
‘Entrustable’ Requires
Direct Observation of:
• Level of K/S/A (Ability)
• Hard work & follow through (Conscientious)
• Absence of deception (Truthfulness)
• Knowing one’s limits (Discernment)
Tara Kennedy
Academic Medicine 2008
Patient
Dilemma
Ask
Acquire
Action
Evidence
Cycle of EBM
Appraise
Apply
Patient
Dilemma
Ask
Action
Acquire
Appraise
Apply
Let’s Listen in on Tom’s
2am New Admission
‘Background’ Questions
• About the disorder, test, treatment, etc.
• 2 components:
a. Root* + Verb: “What causes …”
b. Condition:
“… cystic fibrosis?”
• * Who, What, Where, When, Why, How
• ‘RVC’ = Root, Verb, Condition
‘Foreground’ Questions
• About patient care decisions and actions
• 4 (or 3) components:
a. patient, problem, or population
b. intervention, exposure, or maneuver
c. comparison (if relevant)
d. clinical outcomes (including time horizon)
‘PICO’ = Patient, Intervention, Comparison,
Outcomes
Background & Foreground
How does it feel … ?
To know an answer?
To NOT know an answer?
Emotions in Not Knowing
Ready to …
Feeling
Behaviors
Flee
Fear
Fight
Anger
Cry for help
Distress
Withdraw
Sadness
Leave
Invisible
Disrupt
Undermine
Stop trying
Body stress
Inattention
Detachment
Guiding or Coaching ‘Qs’?
• Try building up from ‘raw’ question to more
complete anatomy (rather than tearing their
efforts down)
• Consider 2 stages:
• “Sounds like you’re asking a question about
… (therapy, prognosis, etc.)”
• “What would be the … (missing anatomy)
you would want to know?”
Now, listen closely for how
this may sound…
‘Hoot Groups’ Task
• Groups of 2 – 3
• What specifically could
you implement back
home to ensure that your
learners can ask
answerable clinical
questions?
• Return in 3 minutes
Entrusting Clinical Questions
Patient
Dilemma
Ask
Action
Acquire
Appraise
Apply