1. 2/25/13
Internal
Medicine
Subspecialty
Milestones
Summit:
February
11-­‐12,
2013,
Alexandria,
VA
Milestone
Suzanne
Rose,
MD,
MSEd
Senior
Associate
Dean
for
Educa2on
Professor
of
Medicine
University
of
Connec2cut
School
of
Medicine
Background
• New
ERA
for
GME
• Next
AccreditaMon
System:
NAS
New
Nomenclature,
Processes,
and
Compliance
• Competencies
and
Milestones
• EPA’s:
Entrustable
Professional
AcMviMes
• CLER
Visits
A
Key
element
of
the
NAS
is
the
measurement
and
reporMng
of
outcomes
through
the
educaMonal
milestones….
Programs
in
the
NAS
will
submit
composite
milestone
data
on
their
residents
every
6
months,
synchronized
with
residents’
semiannual
evaluaMons.
1

2. 2/25/13
Components
of
NAS
• Program
aXriMon
• Program
changes
• Resident
survey
• Board
pass
rate
• Clinical
experience
log
• Core
faculty
scholarly
acMviMe
• Faculty
survey
• CLER
visit
• Repor&ng
of
milestones
Where
are
we
now?
• Six
specialMes
ready
for
the
ACGME
Milestones
2013
– DiagnosMc
radiology
– EM
– IM
– Neuro
Surg
– Orthopedics
– Pediatrics
– Urology
• IM
has
established
22
sub-­‐competencies
• Now
it
is
Mme
for
the
IM
subspecialMes
to
create
their
competencies/milestones
• Summit
organized
to
bring
together
the
Chairs
of
the
EducaMon
and
Training
CommiXees
in
the
Sub-­‐specialty
socieMes
• Develop
subspecialty
milestones
now
• ImplementaMon
in
2014
Before
the
MeeMng
2

3. 2/25/13
MeeMng
Agenda
• Key
Stakeholder
PerspecMves
–
AAIM,
ABIM,
and
ACGME
• Basics
of
Competency-­‐based
Medical
EducaMon:
Concepts
of
Curricular
Milestones,
EPAs,
and
NAS
ReporMng
Milestones
• Review
of
some
of
the
subspecialty
work:
– Geriatrics
– Cardiology
– GI-­‐Transplant
Hepatology
(wonderful
work
of
Oren
Fix,
MD
and
colleagues!)
• Small
group
work
• Large
group
review
of
small
group
work
RepresentaMon
from
GI
at
the
meeMng:
AASLD,
ACG,
AGA,
ASGE
ACGME
Competencies
Introduced
1999
Implemented
2001
• PaMent
Care
• Medical
Knowledge
• Systems-­‐Based
PracMce
• PracMce-­‐Based
Learning
&
Improvement
• Professionalism
• Interpersonal
&
CommunicaMon
Skills
CBME,
NAS,
EPA
• CBME:
assessing
meaningful
outcomes
– Work-­‐based
– AuthenMc
• NAS:
reporMng
meaningful
outcomes
– Developmental
progression
over
Mme
(MILESTONES)
• EPA:
strategy
to
create
meaningful,
work-­‐
based
assessments
of
residents/fellows
– can
generate
data
for
reporMng
milestones
in
NAS
3

4. 2/25/13
Entrustable
Professional
AcMviMes
“…
idenMfy
the
criMcal
ac2vi2es
that
consMtute
a
specialty
…
the
ac2vi2es
of
which
we
would
all
agree
should
be
only
carried
out
by
a
trained
specialist.”
• Observed
and
measurable
to
an
conclusion
• Reflects
expected
competencies
• EPA’s
=
Core
of
the
profession
• EPA’s
are
not
mandatory
and
not
reportable
to
ACGME
• EPA’s
=
strategy
for
meaningful,
work-­‐based
assessment
of
a
resident/fellow
• EPA’s
provide
assessment
data
for
reporMng
of
milestones
to
the
ACGME
via
NAS
ten
Cate
et
al.
Acad
Med
2007;
82:
542-­‐47
How
will
we
use
milestones?
• Clinical
Competency
CommiXee
(CCC)
will
review
all
assessment
data
(end-­‐of-­‐rotaMon
faculty
evaluaMons,
peer
evals,
case
logs,
simulaMon,
self-­‐assessments)
• CCC
will
review
and
assess
data
from
these
mulMple
evaluaMons
and
apply
them
to
the
milestones
to
note
the
progress
of
a
resident/
fellow
IM
Milestones
and
Sub-­‐competencies
• PC:
PaMent
Care
-­‐
5
• MK:
Medical
Knowledge
-­‐
2
• SBP:
Systems-­‐Based
PracMce
-­‐
4
• PBLI:
PracMce-­‐Based
Learning
and
Improvement
-­‐
4
• PROF:
Professionalism
-­‐
4
• ICS:
Interpersonal
and
CommunicaMon
Skills
–
3
Total
of
22
Subcompetencies
4

5. 2/25/13
Summit
Small
Group
AcMvity
• IM
reporMng
milestones
for
the
6
ACGME
General
Competencies
are
composed
of
22
sub-­‐
competency
streams
– Do
these
22
streams
make
sense
for
sub-­‐specialMes?
• Each
sub-­‐competency
stream
is
composed
of
a
series
of
milestones
that
describe
developmental
competence
of
learner
in
behavioral
terms
– Can
these
be
applied
to
a
fellow?
IM
Sub-­‐Competencies
PaMent
Care
1. Gathers
and
synthesizes
essenMal
and
accurate
informaMon
to
define
each
paMent’s
clinical
problem(s).
(PC1)
2. Develops
and
achieves
comprehensive
management
plan
for
each
paMent.
(PC2)
3. Manages
paMents
with
progressive
responsibility
and
independence.
(PC3)
4. Skill
in
performing
procedures.
(PC4)
5. Requests
and
provides
consultaMve
care.
(PC5)
Sub-­‐Competency
Milestone
5

6. 2/25/13
IM
Sub-­‐Competencies
Medical
Knowledge
6. Clinical
knowledge.
(MK1)
7. Knowledge
of
diagnosMc
tesMng
and
procedures.
(MK2)
IM
Sub-­‐Competencies
Systems-­‐Based
PracMce
8. Works
effecMvely
within
an
interprofessional
team
(e.g.
peers,
consultants,
nursing,
ancillary
professionals
and
other
support
personnel.
(SBP1)
9. Recognizes
system
error
and
advocates
for
system
improvement.
(SBP2)
10. IdenMfies
forces
that
impact
the
cost
of
health
care,
and
advocates
for,
and
pracMces
cost-­‐effecMve
care.
(SBP3)
11. TransiMons
paMents
effecMvely
within
and
across
health
delivery
systems.
(SBP4)
IM
Sub-­‐Competencies
PracMce-­‐Based
Learning
and
Improvement
12. Monitors
pracMce
with
a
goal
for
improvement.
(PBLI1)
13. Learns
and
improves
via
performance
audit.
(PBLI2)
14. Learns
and
improves
via
feedback.
(PBLI3)
15. Learns
and
improves
at
the
point
of
care.
(PBLI4)
6

7. 2/25/13
IM
Sub-­‐Competencies
Professionalism
16. Has
professional
and
respecpul
interacMons
with
paMents,
caregivers
and
members
of
the
interprofessional
team
(e.g.
peers,
consultants,
nursing,
ancillary
professionals
and
support
personnel.
(PROF1)
17. Accepts
responsibility
and
follows
through
on
tasks.
(PROF2)
18. Responds
to
each
paMent’s
unique
characterisMcs
and
needs.
(PROF3)
19. Exhibits
integrity
and
ethical
behavior
in
professional
conduct.
(PROF4)
IM
Sub-­‐Competencies
Interpersonal
and
CommunicaMon
Skills
20. Communicates
effecMvely
with
paMents
and
caregivers.
(ICS1)
21. Communicates
effecMvely
in
interprofessional
teams
(e.g.
peers,
consultants,
nursing,
ancillary
professionals
and
other
support
personnel).
(ICS2)
22. Appropriate
uMlizaMon
and
compleMon
of
health
records.
(ICS3)
Summit
Process
• Small
group
work
by
subspecialty
• Our
small
group
had
representaMon
from
– AASLD
– ACG
– AGA
– ASGE
• The
group
concluded:
– Sub-­‐competencies
from
medicine
could
apply
to
GI/
Hepatology
with
different
behavioral
milestones
– May
require
a
shiq
to
the
leq
in
terms
of
our
fellows
starMng
out
at
a
higher
level
than
a
resident
in
IM
7

8. 2/25/13
Summit
Discussions
The
large
group
reconvened:
• Consensus:
The
IM
reporMng
subcompetencies
seem
like
a
good
foundaMon
and
can
apply
to
the
subspecialMes
– Systems-­‐Based
PracMce
– PracMce-­‐Based
Learning
and
Improvement
– Professionalism
– Interpersonal
and
CommunicaMon
Skills
Should
be
applicable
even
with
the
same
EPA’s
but
the
levels
of
competency
may
shiq
if
we
assume
the
fellow
comes
in
at
the
milestone
level
of
a
resident
• Concerns:
Not
clear
if
PaMent
Care
and
Medical
Knowledge
can
be
the
same
Next
Steps
• OWN
(Oversight
Working
Network)
will
meet
at
DDW
• The
GI
SocieMes
have
made
a
commitment
to
work
jointly
on
this
endeavor
• Summit
organizers
will
convene
a
smaller
group
of
subspecialty
educators
– To
create
a
template
– To
make
a
proposal
regarding
what
the
subspecialMes
can
keep
from
the
IM
effort
– To
determine
what
new
informaMon
needs
to
be
created
• OWN
will
need
to
work
on
the
PC
and
MK
areas
in
parMcular
How
can
you
help?
• Program
Directors
for
all
GI/Hepatology
programs
are
key
stakeholders
in
this
process
• Through
OWN
and
this
group
convening
at
this
Summit,
we
must
work
together
to:
– Create
what
makes
sense
– Develop
what
is
pracMcal
– Achieve
the
goals
of
the
ACGME,
ABIM,
AAIM
– Generate
what
speaks
to
the
needs
of
our
PD’s
and
our
fellows
• Must
consider
a
uniform
tracking
system
across
all
programs
to
make
this
pracMcal,
transferable,
and
helpful…
8

9. 2/25/13
Final
Thoughts
• We
are
at
a
crossroads,
advancing
towards
a
new
paradigm
for
GME
• It
will
be
a
lot
of
work
• But
there
are
opportuniMes:
– Career
paths
for
many
of
you
– RecogniMon
of
the
great
work
you
do
– Dedicated
Mme
to
do
what
you
do
in
Graduate
Medical
EducaMon
– Improved
educaMon
for
our
trainees
– CollaboraMve
work
that
will
role
model
the
team
spirit
we
are
trying
to
inculcate
in
our
trainees
Time
to:
Contact
Info
for
Suzi
Rose:
srose@uchc.edu
9