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Domains of Professional Competence APTA Combined Sections Meeting
February 5, 2015
The authors declare no conflict of interest.
Permission of authors required to reproduce these slides. Page 1
Domains of Professional
Competence: Looking Across the
Educational Continuum
Furze J, Jensen GM, Rapport MJ, Christensen N, Briggs M
Paschal K, Hartley G, Nordstrom T
APTA Combined Sections Meeting
February 5, 2015
Indianapolis, IN
Objectives
Upon completion of this session, participants will be able to:
1. Identify the arguments that are part of the public demand for enhanced accountability (including outcome measures and competency-based education) for health professions education.
2. Compare and contrast the evolution of physical therapist education (entry-level through residency and fellowship) with models of competency domains being discussed in medical and pharmacy education.
3. Discuss a working framework of key domains related to patient-centered competencies spanning entry-level through residency/fellowship education.
4. Engage in panel-audience discussion of challenges and opportunities for developing a learning trajectory of professional competencies across levels of education.
2
Outline
• Professional Competency: Exploring What it Means for Physical Therapists
– Learning as a journey and not an ending point in time
– Importance of work-place learning
• Clinical Learning Milestones across a Career – Dreyfus & Dreyfus Model of Skill Acquisition
– Skill development across time
– Assessment of learning – individualized learning
• Lessons from the Health Professions: A Systems Analysis– Comparing and contrasting models of education within doctoring professions
• Laying a Foundation: Considering Common Domains of Competence- Existing silos of specialization
– Trajectory of professional competence
– Proposed core competencies across residency/fellowship education
• Stakeholder Discussant Panel– CAPTE, ABPTRFE, ACOTE
3
Domains of Professional Competence APTA Combined Sections Meeting
February 5, 2015
The authors declare no conflict of interest.
Permission of authors required to reproduce these slides. Page 2
Professional Competency:
What Does it Mean for Physical Therapists
Gail Jensen, PT, PhD, FAPTA
Jennifer Furze, PT, DPT, PCS
What is the Need?
• Entry-level education
– Where are we now?
– Where do we need to be in the future?
– Learning as a journey and trajectory
– Robustness of work-place learning
(clinical experiences and exposure)
5
Professional Competence:
Key Concepts
• Multidimensional concept
• Understanding EXPERTISE and adaptive
(flexible) expertise
• Moving beyond behaviors to DISPOSITIONS
• Elements that are non-negotiable
6
Domains of Professional Competence APTA Combined Sections Meeting
February 5, 2015
The authors declare no conflict of interest.
Permission of authors required to reproduce these slides. Page 3
Flexible Expertise
• What is flexible expertise?
(Do I have it???)
• Flexible or adaptive expertise - Focus on
DEVELOPMENT
• Emphasis on Flexibility and Innovation
• There is more to expertise than
KNOWLEDGE
7
Precursors for Development of
Flexible EXPERTISE(Birney, Beckmann, Wood, 2012)
• Self-reflection (meta-cognitive skills)
• Deliberate practice
– Highly structured
– Requires effort
– Emphasis on improving performance beyond
“sufficient”
8
Virtue
Knowledge
Clinical reasoning
Student Novice
Professional Development
Movement
Clinical reasoningVirtue
Knowledge Movement
Learning Trajectory Across Time
9
Domains of Professional Competence APTA Combined Sections Meeting
February 5, 2015
The authors declare no conflict of interest.
Permission of authors required to reproduce these slides. Page 4
Competent Expert
Professional Development
Clinical reasoning
Virtue
MovementKnowledge
Clinical reasoning
Virtue
MovementKnowledge
Philosophy
of Practice
Learning Trajectory Across Time
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What is the Need?
• Residency/Fellowship Education
– Where are we now? Where do we need to be in the future?
• Current emphasis on technical skills and certifications
• Need to explore the theoretical constructs of education and educational research
• Need to meet the societal need
• Effectiveness of work-place learning
• Need to look at the continuum of learning across time
– Are there common competencies across residency/fellowship programs?
11
Workplace Learning(O’Brien, 2013; Billet, 2014)
• Learning for PRACTICE
• Powerful and ROBUST and Long lasting
• Relationships are critical
• Clinical instructors/mentors facilitate or
inhibit AFFORDANCES for learning
12
Domains of Professional Competence APTA Combined Sections Meeting
February 5, 2015
The authors declare no conflict of interest.
Permission of authors required to reproduce these slides. Page 5
Workplace Learning (WPL)
(adapted from O’Brien, 2011)
Learning throughparticipation
Tasks and activities• Support for development learning
• Student assumes responsibility
Relationships within the practice community• Invitational/welcoming• Personal, engagement• Supported participation
Work practice environment• Workload/ Time pressure
• Organization of work• Multiple roles/demands
Individuals engage in thinking and acting MORE than doing a task
13
Discussion Points
• Importance of both didactic and clinical
education (work-place learning)
• As a profession, are we doing a good job of
building communication and collaboration
between academic and clinical education as
both are VITAL to learning?
– If so, how are we doing this well?
– If not, how can we improve?
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Clinical Learning Milestones
Across A Career
Jennifer Furze, PT, DPT, PCS
Nicole Christensen, PT, PhD, MAppSc
Domains of Professional Competence APTA Combined Sections Meeting
February 5, 2015
The authors declare no conflict of interest.
Permission of authors required to reproduce these slides. Page 6
Dreyfus & Dreyfus Model of Skill
Acquisition
Carraccio et al, 2008
16
Skill Development Across the Continuum
(Teaching & Learning + Assessment)
Knowledge, Skills, & Abilities
Time
Novice Adv Beginner Comp Prof Expert
Entry-levelResident
& Fellow
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Example: Clinical Reasoning Abilities Acquisition Over Time…
Novice
•Following a check-list, rote
•Skills performance-
focused
•Reasoning may not be
connected to actions
•Rarely recognizes
emerging data
•Therapist-centered; not collaborative
Adv Beginner
•Deductive dominates
• Inconsistently prioritizes
•Reflects-on-action
• Inconsistently recognizes
emerging data
• Inconsistently
patient-centered; rarely
collaborative
Competent
•Deductive & Inductive, not
well integrated
•Prioritizes well
simple > complex cases
• Inconsistently Reflects-in-
action
•Recognizes but inconsistently responds to
emerging data
•Patient-centered;
inconsistently
collaborative
Proficient
• Integrates deductive and
inductive well
•Prioritizes well
•Metacognitive; reflects-in-
action
•Responds to emerging data
•Patient-centered;
collaborative
Expert
•Fluid deductive & inductive;
grounded in clinical context
• Prioritizes well
•Highly metacognitive;
reflects-in-action & on
bigger picture
•Responds
quickly to emerging data
•Patient-centered; highly
collaborative
18
Domains of Professional Competence APTA Combined Sections Meeting
February 5, 2015
The authors declare no conflict of interest.
Permission of authors required to reproduce these slides. Page 7
Novice
• Reasoning may not be connected to actions
Adv Beginner
• Reflects-on-action
Competent
• Inconsistently Reflects-in-action
Proficient
• Metacognitive; reflects-in-action
Expert
• Highly metacognitive; reflects-in-action & on bigger picture
Requires Educator to Reflectively Progress
Learning Facilitation Strategies Over Time
• Identify gaps in
skills &
knowledge;
• Link to blind spots
• Questioning,
modeling &
teaching
• Focus on awareness
of depth, breadth, &
accuracy of self-
reflection abilities
• Progressively
challenge reflection
in action
• Progressive
challenge to breadth,
depth & accuracy of
self-reflection
• Challenged to reflect
beyond this one
situation
Progression of the Learner
Progression of Facilitation Strategies
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Assessment of Learning
• Includes - Knowledge, Skills, & Abilities
– Assess learner’s current abilities
• Beginning of curriculum and throughout
• Individualized learning vs one size fits all
• Active learning strategies
– Students perform mental gymnastics when
thinking/performing with cases/patients
– Practice for success
• Repetition with variables
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Assessment of Learning
Entry-Level Education
• Asses student’s knowledge and abilities at beginning
• Work toward meeting “standard bar” that all students need to meet
• Work toward pushing beyond “standard bar” depending on student’s abilities– Even though a student may be
marked as competent on the CPI, the learning doesn’t end there, additional teaching and learning can occur
Residency/Fellowship Education
• Assess resident’s knowledge and abilities at beginning
• Work toward meeting collaborative goals (student & mentor)
• Work toward pushing beyond competent and toward proficient or even farther if possible
– CHALLENGE for both resident & mentor
21
Domains of Professional Competence APTA Combined Sections Meeting
February 5, 2015
The authors declare no conflict of interest.
Permission of authors required to reproduce these slides. Page 8
Competence
Knows
Knows How
Does
Performance or hands on assessment
Written, Oral orComputer based assessment
22
Discussion Points
• How do people perceive competency-based
education?
– Quantitative approach – resident performs a skill 5
times (one right answer)
– Qualitative approach – developmental continuum
over time (grapple with thinking and complexity of
the situation)
– Assessment – Both quantitative and qualitative?
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Lessons from the Health
Professions: A Systems Analysis
Matthew Briggs, PT, DPT, PhD, SCS, AT
Mary Jane Rapport, PT, DPT, PhD, FAPTA
Domains of Professional Competence APTA Combined Sections Meeting
February 5, 2015
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Permission of authors required to reproduce these slides. Page 9
Doctoring Health Care Professions with
Residency/Fellowship Training
Medicine
Dentistry
Pharmacy
Psychology
Optometry25
PharmacyAmerican Society of
Health System
Pharmacists
(ASHP)
DentistryCommission on Dental
Accreditation
(CODA)
PsychologyAmerican
Psychological
Association
Commission on
Accreditation
APA-CoA
OptometryAccreditation Council
on Optometric
Education
(ACOE)
Physical
TherapyAmerican Board of
Physical Therapy
Residency &
Fellowship Education
(ABPTRFE)
1962 1984 1996 1997
MedicineAmerican College of
Graduate Medical
Education
(ACGME)
XXXX
Accreditation Groups for Doctoring
Healthcare Professionals
Is the same group used
for Entry-Level
Accreditation?
NO
NOYES
NO
YES YES
26
PharmacyResidency# 1326
DentistryResidency &
Fellowship# ?
PsychologyResidency# 95
OptometryResidency# 187
Physical
TherapyResidency# XX
Fellowship# XX
1962 1984 1996 1997
MedicineResidency#
Fellowship#
XXXX
Number of Programs
27
Domains of Professional Competence APTA Combined Sections Meeting
February 5, 2015
The authors declare no conflict of interest.
Permission of authors required to reproduce these slides. Page 10
PharmacyAcademic-based
Clinic/Hospital-based
DentistryAcademic Based
PsychologyAcademic-based
Clinic/Hospital-based
Consortiums
OptometryClinic/Hospital Based
but academic
institution must be a
sponsor
Physical
TherapyAcademic-based
Clinic/Hospital-based
Large Collaborative
Consortiums
1962 1984 1996 1997
MedicineXXX
XXX
XXXX
Program Models
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Doctoring Healthcare Professions
without Residency/Fellowship
Training and Accreditation
• Occupational Therapy (MOT/OTD)
• Chiropractic
– The Council on Chiropractic Education (CCE) is
considering this process.
– CCE has established rules stating the residency
program must be affiliated with a sponsoring
institution with an accredited Doctorate of
Chiropractor program
• Audiology
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Training Programs
• Initial focus: Education and skill
• Now more focus on COMPETENCY
– Is the basis for additional training
• Other measures (in MD education)
– Milestones
– Entrustable Professional Activities (EPAs)
30
Domains of Professional Competence APTA Combined Sections Meeting
February 5, 2015
The authors declare no conflict of interest.
Permission of authors required to reproduce these slides. Page 11
Competency-Based
Education Frameworks
• Accreditation Council for Graduate Medical Education. Common program requirements: general competencies. –August 2011
Medicine
“YES”
• ADEA Competencies for the New General Dentist. – 2011
• Badner et al. 2010
Dentistry
“YES”
• Pharmacy Education Taskforce A Global Competency Framework – 2012
• Hill et al. 2006
Pharmacy
“DEVELOPMENT”
31
Competency-Based Outcomes
in Higher Education
• 1990’s competency-based movement in medicine in US
• Developed general competencies – License MD’s based upon outcomes and capabilities versus
length of time in training
– Tension with competency-based education• Specific goals and objectives to meet competencies are reduced to
a checklist
• Don’t take into account the higher-order thinking and contextual factors of practice
– Balanced with Entrustable Professional Activities (EPA) –meaningful acts in practice
(ten Cate, 2014)
32
Physical Therapy Residency and
Fellowships
• Opportunity for professional growth
• Opportunity for clinical specialization
• Opportunity for advanced clinical skills
– General: eg, clinical reasoning
• Opportunity for development of competencies
– through all phases of education and training
33
Domains of Professional Competence APTA Combined Sections Meeting
February 5, 2015
The authors declare no conflict of interest.
Permission of authors required to reproduce these slides. Page 12
Discussion Points
• How has what we learned from the other
health professions about residency and
fellowship guided us?
• Based upon this, are we moving in the right
direction?
34
Laying a Foundation: Considering
Common Domains of Competence
Mary Jane Rapport, PT, DPT, PhD, FAPTA
Nicole Christensen, PT, PhD, MAppSc
Trajectory of Competency
Development:
Entry Level RESIDENCY Fellowship
Learning and Professional
Development
36
Domains of Professional Competence APTA Combined Sections Meeting
February 5, 2015
The authors declare no conflict of interest.
Permission of authors required to reproduce these slides. Page 13
Entry-Level Education
• Competencies: CAPTE
• Established by our profession
• Mirror other professions
37
Residency and Fellowship Education
• Currently competencies seated with each DSP
In the future competencies may be based in a
document specific to residency practice
• Core competencies – cross specialization
• Conclave held in November 2012
• Process of reaching common core competency
domains
38
Existing Common Areas of DSP
Neurologic Competencies
• I. Knowledge Areas of
Neurologic Clinical Specialists
• II. Practice Expectations
– A. Professional Roles,
Responsibilities, and Values
• Leadership
• Education
• Consultation
• EBP
• Virtuous Behavior
– B. Patient/Client Management
Pediatric Competencies
• I. Knowledge Areas of Pediatric Clinical Specialists
• II. Professional Roles, Responsibilities, & Values– A. Professional Behaviors
– B. Leadership
– C. Education
– D. Administration
– E. Consultation
– F. EBP
– G. Research
• III. Practice Expectations
39
Domains of Professional Competence APTA Combined Sections Meeting
February 5, 2015
The authors declare no conflict of interest.
Permission of authors required to reproduce these slides. Page 14
Trajectory of Competency
Development:
Entry Level RESIDENCY Fellowship
Learning and Professional
Development
COMPETENCIES COMPETENCIES
40
Proposed Competency Domains
in Physical Therapy
Professionalism
InterprofessionalSkills &
Communication
Clinical Reasoning
Inquiry Skills
Systems-based Practice
Clinical Skills
Knowledge for
Practice
41
Competencies Across and
Within the ProfessionsProposed Common Core PT
Residency Competencies
Professionalism
Interprofessional
Skills & Communication
Clinical Reasoning
Inquiry Skills
Systems-based practice
Clinical Skills
Knowledge for practice
Medical Core Competencies
Professional-
ism
Practice-
based learning
Systems-
based practice
Interpersonal &
communication skills
Patient care
Medical
knowledge
Interprofessional
Collaborative
Practice
Competency Domains
42
Domains of Professional Competence APTA Combined Sections Meeting
February 5, 2015
The authors declare no conflict of interest.
Permission of authors required to reproduce these slides. Page 15
Examples of
Competency Development
• Knowledge for practice
– EL: general, broad base
– R: deeper, specialized
– F: refined, highly specialized
• Clinical reasoning
– EL: competent; may be proficient in some aspects
– R: highly proficient/some aspects of expertise
– F: expertise in subspecialty practice area
43
Knowledge for
Practice
DPT Education:
The Wading Pool
44
Knowledge for Practice
Residency Education:
The Lap Pool
45
Domains of Professional Competence APTA Combined Sections Meeting
February 5, 2015
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Permission of authors required to reproduce these slides. Page 16
Knowledge for Practice
Fellowship Education: The Dive Pool
46
Interprofessional Collaborative
Practice Competency Domains
Values/Ethics for IP
Practice
Roles & Responsibilities
Teams & Team Work
IP Communication
Patient &
Family
Centered
Community
&
Population
Oriented
Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for
interprofessional collaborative practice: Report of an expert panel. Washington, D.C.:
Interprofessional Education Collaborative. 47
Proposed Competency Domains in
Physical Therapy
• Knowledge for practice
• Clinical reasoning
• Inquiry skills
• Clinical skills
• Systems-based practice
• Interprofessional skills & communication
• Professionalism
48
Domains of Professional Competence APTA Combined Sections Meeting
February 5, 2015
The authors declare no conflict of interest.
Permission of authors required to reproduce these slides. Page 17
Discussion Points
• What feedback do you have on the 7
proposed common competency domains (on
previous slide) we have offered for all PT
residency/fellowship programs?
49
Stakeholder Discussant Panel
Greg Hartley, PT, DPT, GCS,
Karen Paschal, PT, DPT, MS, FAPTA
Terry Nordstrom, PT, EdD
Proposed Competency Domains in
Physical Therapy
Professionalism
InterprofessionalSkills &
Communication
Clinical Reasoning
Inquiry Skills
Systems-based Practice
Clinical Skills
Knowledge for
Practice
51
Domains of Professional Competence APTA Combined Sections Meeting
February 5, 2015
The authors declare no conflict of interest.
Permission of authors required to reproduce these slides. Page 18
Discussion Points
• Final comments & wrap up
52
References
• Birney DP, Beckman JF, Wood RE. Precursors to the development of flexible expertise: Metacognitive self-evaluation as antecedences and consequences in adult learning. Learning and Individual Differences. 2012;22(5):563-574.
• Billet S, ten Cate O. Competency-based medical education: origins, perspectives, and potentialities. Med Educ. 2014;48:325-332.
• O’Brien B. Envisioning the Future. In: Hafler J, ed. Extraordinary Learning in the Workplace. New York: Springer. 2011; 165-194.
• O’Brien BC, Irby D. Enacting the Carnegie Foundation call for reform of medical school and residency. Teach Learn Med. 2013; 25(S1): S1-S8.
• Expert practice in physical therapy. In: Jensen GM, Gwyer J, Hack LM, Shephard KF. Eds. Expertise in Physical Therapy Practice. 2nd ed. St. Louis, MO: Elsevier; 2007: 168.
• Carraccio C, Benson B, Nixon J, Derstine P. From the educational bench to the clinical bedside: translating the Dreyfus developmental model to the learning of clinical skills. Acad Med. 2008; 83:761-767. 53
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• ten Cate O, Billet S. Competency-based medical education: origins, perspectives,
and potentialities. Med Educ. 2014;48:325-332.
• Cooke M. A more ambitious agenda for medical education research. JGME. 2013;
5: 201-202.
• Hayward LM, Black LL, Mostrom E, Jensen GM, Ritzline PD, Perkins J. The first two
years of practice: A longitudinal perspective on learning and professional
development of promising novice physical therapists. Phys Ther. 2013; 93: 369-
383.
• Jones S, Bellah C, Godges J. A comparison of professional development and
leadership activities between graduates and non-graduates of physical therapists
clinical residency programs. JOPTE. 2008;22: 85-88.
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Domains of Professional Competence APTA Combined Sections Meeting
February 5, 2015
The authors declare no conflict of interest.
Permission of authors required to reproduce these slides. Page 19
References
• Kulig K. 18th John H.P. Maley Lecture: Residency education in every town: is it just so simple?
Phys Ther. 2014;94:151–161.
• Smith K, Tichenor CJ, Schroeder M. Orthopedic residency training: A survey of the graduates
perspective. JOSPT. 1999;29:635-655.
• Association of American Medical Colleges. Core Entrustable Professional Activities for
Entering Residency (CEPAER). November 2013.
• Baron R. Can we achieve public accountability for graduate medical education outcomes?.
Acad Med. 2013; 9:1199-201.
• Carraccio C, Englander R. From Flexner to competenices: reflections on a decade and the
journey ahead. Acad Med. 2013;88: 1067-1073.
• Englander R, Cameron T, Ballard A, Dodge J, Bull J, Aschenbrener C. Toward a common
taxonomy of competency domains for the health professions and competencies for
physicians. Acad Med. 2013; 88: 1088-1094. 55
References
• Srinivasan M, Li S, Myers F, Pratt D, Collins J, Braddock C, Skeff K, West D, Henderson M, Hales R, Hilty D. Teaching as a competency: Competencies for medical educators. Acad Med. 2012;86:1212-1220.
• Interprofessional Education Collaborative Expert Panel. Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative, 2011.
• ten Cate O, Snell L, Mann K, Vermunt J. Orienting teaching toward the learning process. Acad Med. 2004; 79:219-228.
• ten Cate O, Scheele F. Viewpoint: Competency-based postgraduate training: can we bridge the gap between theory and clinical practice. Acad Med. 2007;82: 542-547.
• Relationship of GME to Industry and Other Funding Sources ACGME—October 2011—2: http://www.acgme.org/acgmeweb/Portals/0/PFAssets/PublicationsPapers/GME-Funding-Industry-Other-Sources.pdf
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References
• Accreditation Council for Graduate Medical Education. Common program requirements: general competencies. – August 2011: https://www.acgme.org/acgmeweb/tabid/429/ProgramandInstitutionalAccreditation/CommonProgramRequirements.aspx
• Rider E. and Namotniak R, eds. A Practical Guide to Teaching and Assessing the ACGME Core Competencies. hcPro: 2007.
• Iglehart J. The Residency Mismatch. N Engl J Med. 2013, 369;4: 297-299.
• Badner V, Ahluwalia KP, Murrman, MK et al. A competency-based framework for training in advanced dental education. Journal of Dental Education. 2010, 74;2: 130-139.
• Neurologic Physical Therapy Description of Specialty Practice, Specialty Council on Neurologic Physical Therapy, American Board of Physical Therapy Specialties, 2004.
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Domains of Professional Competence APTA Combined Sections Meeting
February 5, 2015
The authors declare no conflict of interest.
Permission of authors required to reproduce these slides. Page 20
References
• Pediatric Physical Therapy Description of Specialty Practice, Specialty Council on Pediatric Physical Therapy, American Board of Physical Therapy Specialties, 2011.
Website References
• www.acgme.org
• www.ashp.org
• www.ada.org
• http://www.adea.org/dental_education_pathways/Pages/AfterDentalSchool.aspx
• http://www.ada.org/en/education-careers/dental-student-resources/career-options-after-dental-school/understanding-advanced-dental-education/program-options-and-descriptions
• www.apa.org/ed/accreditation/about/coa/
• www.aoa.org/optometrists/for-educators/accreditation-council-on-optometric-education?sso=y
• http://www.abptrfe.org
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