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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