Not Just “MK-1”
How learning the skills of EBM
relates to the pediatric
milestones
Martha S Wright, MD, MEd
Rainbow Babies and Children’s Hospital
I have documented no financial
relationships to disclose or Conflicts
of Interest (COIs) to resolve.
I am…
• An EBM Teacher
• Committed to helping
learners develop
these skills both for
• Direct patient care
• Life-long learning
• A Program Director
• Responsible for
adhering to
requirements
• Mindful of
competing demands
and time limitations
3
Objectives
• At the end of this session, you will be able to…
– Describe how and where EBM skill development fits
into the current paradigm of residency training
requirements and performance assessment
– Develop innovative curricula that integrate EBM
training into current and emerging educational models
4
A brief history of “Competency-based Medical
Education (CBME)”
The ACGME
Outcomes Project
Pre-1999
1999
Relatively few
actual
requirements
No duty
hour restrictions
ACGME/ABMS
Adopt 6 Core
Competencies
And Sub-competencies
5
A brief history of “Competency-based Medical
Education (CBME)”
The ACGME
Outcomes Project
Pre-1999
1999
No duty
hour restrictions
Relatively few
actual requirements
2002-2008
Residencies
required to integrate
The Competencies
into their curricula
ACGME/ABMS
Adopt 6 Core
Competencies
And Sub-competencies
6
Core Competencies
•
Attempted to define what
physicians should know
and be able to do
•
Skills and tasks organized
into 6 domains
•
Required us to find ways
to teach, assess AND
DOCUMENT resident
performance in these
domains
7
1999-2008: Job Security for EBM teachers
 EBM Skill development part of the PBLI
competency
 From the ACGME Core Program Requirements:
 “Residents must demonstrate the ability to investigate and evaluate their
care of patients, to appraise and assimilate scientific evidence, and to
continuously improve patient care based on constant self-evaluation and lifelong learning.
 Residents are expected to develop skills and habits to be able to meet the
following goals:
 locate, appraise, and assimilate evidence from scientific studies related
to their patients’ health problems…”
(ACGME 2003, 2007)
8
1999-2008: Job Security for EBM teachers

Sackett, et al. publish Evidence-based
Medicine: How to Practice and Teach EBM

Explosion of GME Curriculum development






Journal Clubs (traditional, guided)
Stand-alone workshops, seminars
On-line educational modules
“On-the-job” training
Morning report sessions
Dedicated rotation blocks
9
Challenges for The Competencies
•
Did not result in assessments that documented resident
ability “to practice independently”
– Context independent
– Assessment tools never fully developed
– Assessments still process-focused
• “Describe (a) how and by whom residents are taught to access,
appraise, and apply knowledge and (b) how and by whom they are
evaluated in so doing.
• Describe (a) the evidence-based medicine exercise that residents
complete during training and attach the tool used for assessment as
Appendix B; and (b) if residents are given the option of choosing from more
that one type of activity to fulfill this requirement, describe each one briefly.
If no options exist, enter “NO” for (b).”
10
A brief history of “Competency-based Medical
Education (CBME)”
The ACGME
Outcomes Project
Pre-1999
1999
No duty
hour restrictions
Relatively few
actual requirements
The ACGME
Milestones Project
2002-2008
2012
Residencies
required to integrate
The Competencies
into their curricula
ACGME/ABMS
Adopt 6 Core
Competencies
And Sub-competencies
2014
Residencies
report data on
21 Milestones
to ACGME
ABP publishes
48 Pediatric
Milestones
11
2012: What the milestones added
•
Descriptions of level-specific learner behaviors along a
developmental continuum
•
Prompted for a longitudinal approach to teaching and assessment
of skill from knowledge to bedside application
•
Required observation-based assessments
12
Pediatricians Understand Milestones
13
MK-1: “The EBM milestone”
14
Teaching and Learning EBM Skills
Acquire knowledge
and skills
Longitudinal
experiences
Use and practice
at the bedside
15
Teaching and Learning EBM Skills
•
Acquire knowledge and skills
– Didactics
– E-learning modules
– Small group activities
– Computer labs
•
Longitudinal experiences
– Journal Clubs
– CATs
– On-going didactics
•
Use and practice at the bedside
– Role modeling
– Educational prescriptions
– Medical librarian on rounds
– Blogs, wikis
– Mobile devices, Apps
16
Pediatric Milestones
PC1: Should I get a CXR on
this asthmatic?
PC4: Which antibiotic should I
choose for this soft
tissue infection?
PBLI 2: What would be the best
source to read about CAP?
Challenges of the Milestones
• Do not assess learners holistically
– Milestones can help us assess where the learner is
along the continuum of individual skill development:
• “gather accurate information about a patient”
• “locate evidence related to their patient’s health problems”
– They don’t tell us whether someone can put it all
together to take care of a patient
18
A brief history of “Competency-based Medical
Education (CBME)”
The ACGME
Outcomes Project
Pre-1999
1999
No duty
hour restrictions
Relatively few
actual requirements
The ACGME
Milestones Project
2002-2008
2012
Residencies
required to integrate
The Competencies
into their curricula
ACGME/ABMS
Adopt 6 Core
Competencies
And Sub-competencies
2015
2014
Residencies
report data on
21 Milestones
to ACGME
48 Pediatric
Milestones
published
by ABP
ABP “finalizes”
Pediatric
EPAs
19
Entrustable Professional Activities (EPAs)
•
Describe routine activities of a pediatrician in specific contexts
•
Require “workplace-based” application and assessment of skills
(e.g. “OPAs” Observed Practice Activities)
20
1. Provide consultation to other health care providers caring for children
2. Provide recommended pediatric health screening
3. Care for the well newborn
4. Manage patients with acute, common diagnoses in an ambulatory,
emergency, or inpatient setting
5. Provide a medical home for well children of all ages.
Pediatric
EPAs
6. Provide a medical home for patients with complex, chronic, or special health
care needs.
7. Recognize, provide initial management and refer patients presenting with
surgical problems
8. Facilitate the transition from pediatric to adult health care
9. Assess and manage patients with common behavior/mental health problems
10. Resuscitate, initiate stabilization of the patient and then triage to align care
with severity of illness
11. Manage information from a variety of sources for both learning and
application to patient care
12. Refer patients who require consultation
13. Contribute to the fiscally sound and ethical management of a practice (e.g.
through billing, scheduling, coding, and record keeping practices)
14. Apply public health principles and quality improvement methods to
improve care and safety for populations, communities, and systems
15. Lead an interprofessional health care team
16. Facilitate handovers to another healthcare provider either within or across
settings
17. Demonstrate competence in performing the common procedures of the
general pediatrician
21
1. Provide consultation to other health care providers caring for children
2. Provide recommended pediatric health screening
3. Care for the well newborn
4. Manage patients with acute, common diagnoses in an ambulatory,
emergency, or inpatient setting
5. Provide a medical home for well children of all ages.
Pediatric
EPAs
6. Provide a medical home for patients with complex, chronic, or special health
care needs.
7. Recognize, provide initial management and refer patients presenting with
surgical problems
8. Facilitate the transition from pediatric to adult health care
9. Assess and manage patients with common behavior/mental health problems
10. Resuscitate, initiate stabilization of the patient and then triage to align care
with severity of illness
11. Manage information from a variety of sources for both learning and
application to patient care
12. Refer patients who require consultation
13. Contribute to the fiscally sound and ethical management of a practice (e.g.
through billing, scheduling, coding, and record keeping practices)
14. Apply public health principles and quality improvement methods to
improve care and safety for populations, communities, and systems
15. Lead an interprofessional health care team
16. Facilitate handovers to another healthcare provider either within or across
settings
17. Demonstrate competence in performing the common procedures of the
general pediatrician
22
EPA Title
Care for the normal well newborn
The functions of this
activity include:
Performing a physical examination to look for congenital anomalies
Identifying and applying key evidence based guidelines for care of the newborn
Caring for common problems that develop primarily in the nursery
Using judgment to know when common problems can be handled at home and
arrange for discharge and follow-up
Assessing maternal/family readiness to care for the infant post discharge
Transitioning care to the community practitioner
Demonstrating confidence that puts new parents at ease
Link with Domains of
Competence
Critical Competencies
_X_ Patient Care
___ Medical Knowledge
_X_ Practice-based Learning and Improvement
_X_ Interpersonal & Communication Skills
___ Professionalism
___ Systems-based Practice
_X_ Personal & Professional Development
PC 3: Transfer of care
PC 5: Physical exam
MK 2/PBLI 6: EBM
ICS 1: Communicate with patients
PPD 7: Self-confidence
23
(updated ABP 3/11/14)
Integration of EBM learning, practice and
assessment into the Clinical Environment
•
Demonstration of skills with direct observation in the “workplace”
1998
2015
24
Opportunities
•
Assessment of EBM skills by direct observation in the clinical
environment
• Observation tool development
• Educator development
•
Use of clinical decision tools in bedside decision making
•
Life-long learning curricula
• The Art of “Keeping Up”
•
High Value, Cost-Conscious Care
• Requires understanding of guidelines, systematic reviews,
diagnostic testing, therapy/harm
• The next EBM frontier
25
Summary
•
In 2015 there is still a place in residency training for teaching and
learning EBM skills
•
EBM curricula should focus on the continuum from knowledge
acquisition to application in the clinical environment
•
Educators will need to:
– integrate educational activities into the existing/evolving clinical
workflow
– create authentic opportunities for learners to demonstrate and
teachers to assess EBM skill application
26
Questions????
27