Development of Entrustable Professional Activities (EPAs) for Public

Health and Preventive Medicine (PHPM)

PHPM Program Directors April 13, 2015

Brent Moloughney, MD, MSc, FRCPC

Public Health Consultant

Webinar Goal

• Bring PHPM Program Directors up-to-date in preparation for an online survey to seek feedback on a draft, national core set of EPAs

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Overview

• EPAs – what and why

• PD working group and workshop

• Online survey and next steps

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Problem

• Challenges with the PHPM status quo:

– Long list of Objectives of Training:

• Provides detailed expectations

• But potentially overwhelming for residents and faculty

• Competence requires integration of competencies

– Final exam success rates

– All residents prepared for practice?

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Context

Historical • Training defined by specific amount of time in various rotations (‘dwell time’) • Exposure to situations & teaching within rotation (assume) uptake of necessary KSAs to produce professional • End-of-rotation ‘gestalt’ evaluation • Final exam as last hurdle to certification

CBME • Explicit competencies to be acquired • Stages of competence development defined by achievement of competency-based milestones (not time) • More frequent, direct observation to evaluate 5

• Shift in residency education – competence by design not opportunistic learning

Royal College

• Continuing evolution of CBME

• CanMEDS 2015:

– Competence continuum

• Transition to discipline

• Foundations of discipline

• Core of discipline

• Transition to practice

– Milestones

• Observable marker of an individual’s ability along a developmental continuum

– Earlier final examination (out-of-scope for this project)

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Entrustable Professional Activities (EPAs)

• Capture the work that is central/critical to a specialty

• Link competencies/milestones to practice in an integrated/holistic manner

• Be more explicit about assessing and documenting performance of specific activities/tasks

• Support graded supervision – entrust the activity to a trainee to execute once obtained adequate competence

• Being pursued by multiple disciplines around the world 8

Objectives of Training – Analytic Approach

ten Cate. ICRE 2013

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EPAs - Synthetic Approach

ten Cate. ICRE 2013

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EPAs and Milestones

• RC intends to use milestones and EPAs to redesign specialist training and assessment – Milestone is observable marker of an individual's

ability along a developmental continuum

– EPA is the task that must be accomplished - each EPA integrates multiple milestones

• Vision for application: – Use milestones to design educational activities and

teach specific abilities, skills and attitudes

– Assess overall achievement of various milestones using an EPA

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http://www.royalcollege.ca/portal/page/portal/rc/resources/publications/dialogue/vol15_2/epa_milestones

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EPAs are the tasks that must be accomplished, whereas milestones are the abilities of the individual

Example*

• EPA: Manage an infectious disease outbreak

• Milestones (examples) – Transition to discipline (post-MD clinical)

• Elicit relevant information for a suspect reportable disease

– Foundations (coursework) • Describe steps in an outbreak investigation

– Core (early rotations) • Assume under direct supervision a support role (e.g., case

finding plan; generate case definition; etc.)

– Transition to practice (late rotation) • Assume under minimal supervision the lead role (e.g.,

declare outbreak; organize team; plan/implement investigation; etc.)

13 *Calgary EPAs

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RC, PHPM & EPAs

• Number of broader issues that need to be explored with RC (note: opportunity to do so at March meeting): – Looking initially for PHPM EPAs to be a resource to

all programs and be non-prescriptive – issues?

– Looking forward, how might EPAs align with RC activities (e.g., accreditation, final examination)?

– Potential for RC support for future tasks? (e.g., packaging the EPAs, translation, learning & assessment tools, etc.)

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Check-In

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Path to PHPM EPAs

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Queen’s 2-Day Workshop (Mar 2015)

• Attendance: Queen’s, McMaster, Toronto, Ottawa, McGill, Calgary

• Inputs: – Calgary EPAs (with milestones) – 31 – Ontario EPAs (titles) – 27 (in 9 domains) – Experience in EPA development (e.g., Queen’s

pursuing across multiple disciplines)

• EPAs – Literature: 15-30 typically to describe a discipline;

fewer better than many – Focus is on ‘end of training’ EPAs – eventually may

have others for earlier stages of training

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Queen’s 2-Day Workshop (Mar 2015)

• Outputs:

– 20 end-of-training EPAs in 4 groups/domains

– Preliminary milestone work on 6 new EPAs

– Discussed issue of optional ‘clinical’ EPAs

– Discussed need for case-based learning & assessment

– Discussed need to seek feedback from other PDs

• Plan for online survey

• Need to bring other PDs up-to-speed

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End-of-Training EPAs (20) • Core/critical tasks for PHPM graduate – 4 groups:

– Monitor & assess the health of the public – Leadership and management – Protect the public’s health – Promote health and prevent diseases and injuries

• Reflect what was in Calgary and Ontario EPAs – For same concepts wording preference – For differences in scale went macro – Sought better language consistency:

• Verbs: ‘lead and manage’; manage ‘x’ = manage all aspects (reflected in EPA descriptions)

– Addressed balance of content areas: • Identified health promotion/disease prevention items

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Online Survey – Core EPAs

• 20 items are ‘draft’ – need feedback!

• Seek level of agreement and comments on each:

– EPA statement

– EPA brief description

• Plus, when view collectively, whether any suggested deletions or improvements

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Additional ‘Optional’ EPAs

• At the Queen’s workshop, it was noted that some residents pursue work in various clinical settings and in the broader health system; e.g.,:

– Community-oriented primary care practice

– Focussed clinical practice (TB clinic, STI clinic, addictions, travel medicine, etc.)

– Broader health system leadership and stewardship (e.g., RHA).

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Additional ‘Optional’ EPAs (cont’d)

• Challenge: – These career streams mentioned in introduction

of the Objectives of Training,

– But are not explicitly addressed in the competencies (or the draft core EPAs).

• Approach: – Workshop participants requested the survey ask

all PDs whether optional EPAs should be developed for one or more of these career streams.

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Case-Based Learning & Assessment

• EPAs’ focus on observable and measureable learning and assessment

• Considering the expected breadth of PHPM practice, there are intrinsic challenges:

– Training stages do not build seamlessly

– Limited overall field placement time

– Tasks: low volume and high duration

– Some scenarios rare – cannot expect residents to have universal opportunity to address

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Case-Based Learning & Assessment (cont’d)

• Implication is that cannot rely on placements alone for learning and assessment of EPAs

• Need a range of case-based learning and assessment scenarios and simulations

• Ideally, would enable roles for different levels of training

• Online survey will include questions: – To prioritize the EPAs that are most dependent on

scenarios and simulations

– To develop inventory of existing tools • inform future work…

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Survey Logistics

• Planning for distribution week of April 20th

• Provide 2.5-3 weeks to complete

• Have results summarized for end of May meeting with recommendations for next steps.

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Further Information

• PHPM EPA development resources: http://familymedicine.queensu.ca/education/phpm/competency_by_design_initiative/resources

• Brent Moloughney: brent.moloughney@rogers.com

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