Should We Entrust Learners to Ask Answerable Questions? Evidence-Based Clinical Practice McMaster...

Should We Entrust Learners to Ask

Answerable Questions?

Evidence-Based Clinical PracticeMcMaster University June 2014

Cast of Characters

Tom McGinn, MDChair of MedicineHoffstra Univ, New York

Scott Richardson, MDAssoc Dean, UMEGRU/UGA Partnership

Mark Wilson, MDAssoc Dean, GMEUniv of Iowa

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 PanelDevelop 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

• Specific units of professional work

• Tasks that trainees are entrusted to perform unsupervised

• After they’ve attained sufficient competence

Olle ten CateAcad Med 2007

Entrustable Professional Activity

Ability to perform a task to a desired level of performance without direct supervision

EPA

DOC

DOC

DOC

M1M2

M1M2

M1M2

M1M2

M1M2

M1M2

EPA: Entrustable Professional ActivityDOC: Domain of CompetenceC: CompetencyM: Milestone

C2

C3

C1

C4

C2

C5

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

Drafting Panel Work

http//:mededportal.com/icollaborative/resource/887

CoreEPAs

For Entering Residency

EPAsFor any

Practicing Physician

Expectationsfor the

Medical School Graduate

EPAsFor

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

Ask

Acquire

Appraise Apply

Action

Patient Dilemma

Evidence Cycle of EBM

Ask

Acquire

Appraise Apply

Action

Patient Dilemma

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 populationb. intervention, exposure, or maneuverc. 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 LeaveInvisible

Fight Anger DisruptUndermine

Cry for help Distress Stop tryingBody stress

Withdraw Sadness InattentionDetachment

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

Ask

Acquire

Appraise Apply

Action

Patient Dilemma