Longitudinal Assessment of Resident Performance Using Entrustable Professional Activities

Comparison of quantitative internal and external measures of performance for trainees in cytopathology fellowships

INTRODUCTION

Cytopathology fellowships need measures to assess performance of fellows. We sought to compare several internal quantitative assessment metrics in our fellowship with external metrics, such as performance on the American Society of Cytopathology (ASC) Progressive Evaluation of Competency (PEC) examination and United States Medical Licensing Examination (USMLE).

METHODS

Quantitative parameters generated from our laboratory information system (LIS) on cytopathology fellows were evaluated over 6 years, including case volume and diagnostic discrepancies, in addition to ASC PEC and USMLE scores. For discrepancy reports, interpretations made by the fellow were compared with that of the cytopathologist, and classified as none (concordant), minor (<2-levels) or major (≥2-levels).

RESULTS

We evaluated internal and external metrics on 13 fellows over 6 years. The program average diagnostic concordance rate was 89.9%, with an average major discrepancy rate of 1.5%, and an average monthly case volume of 260 cases. More fellows with above-average ASC PEC performance showed above-average concordant diagnoses and lower case volume, while below-average PEC scores were seen more often with higher major discrepancy rates. More fellows with above-average USMLE scores had higher case volumes, while low USMLE scores showed a trend towards higher major discrepancy rates.

CONCLUSION

Our fellowship program has used a variety of internal and external measures of performance for cytopathology fellows. Although the findings show no statistically significant finding correlating performance, these quantitative parameters generated from our LIS were helpful to identify areas of improvement, facilitate comparison to peers, and provide case volume documentation.

Facilitators and Inhibitors to Assessing Entrustable Professional Activities in Pediatric Residency

OBJECTIVE

Research on entrustable professional activities (EPAs) has focused on EPA development with little attention paid to implementation experiences. This constructivist grounded theory study sought to begin filling this gap by exploring the experiences of pediatric residency programs with implementing EPA-based assessment.

METHODS

Interviews with 19 program leader and clinical competency committee participants from 13 sites were held between January and July 2019. Participants were asked about their experiences with implementing EPA-based assessment. Data collection and analysis were iterative.

RESULTS

Participants described a range of facilitators and inhibitors that influenced their efforts to implement EPA-based assessment. These fell into 4 thematic areas: 1) alignment of EPA construct with local views of performance and assessment, 2) assessing EPAs illuminates holes in the residency curriculum, 3) clinical competency committee structure and process impacts EPA-based assessment, and 4) faculty engagement and development drives ability to assess EPAs. Areas described as facilitators by some participants were noted to be inhibitors for others. The sum of a program's facilitators and inhibitors led to more or less ability to assess EPAs on the whole. Finally, the first area functions differently from the others; it can shift the entire balance toward or away from the ability to assess EPAs overall.

CONCLUSION

This study helps fill a void in implementation evidence for EPA-based assessment through better understanding of facilitators and inhibitors to such efforts.

Implementation of a Workplace-Based Assessment System to Measure Performance of the Core Entrustable Professional Activities in the Pediatric Clerkship

OBJECTIVE

The Core Entrustable Professional Activities for Entering Residency (Core EPAs) were developed to address the gap between medical school and residency. There is a lack of instruments to measure performance of the Core EPAs in clerkships. We describe the operationalization and outcomes of a workplace-based assessment (WBA) system to measure performance of the Core EPAs in the pediatrics clerkship.

METHODS

A mobile-friendly WBA was developed at the authors' institution. The WBA incorporated a modified version of the Ottawa Clinic Assessment Tool (OCAT), an instrument that rates performance on a scale of 1 to 4 (1- "I had to do it" to 4- "I had to be there just in case"). During 2018 to 2019, all students were required to request feedback for 6 of the 13 Core EPAs using the WBA in the Pediatrics clerkship. Descriptive and inferential statistics were calculated to assess mean OCAT scores, variance in performance and correlation between scores, clerkship timing, and grades.

RESULTS

Total 1655 WBAs were completed for 218 students. The overall mean OCAT score was 3.47 out of 4. Scores across Core EPAs were greater in later rotations (r = 0.157, P < .001). One-way analysis of variance revealed significant variance on score by student, assessor, and timing of clerkship block. Final grades were correlated with OCAT scores (Spearman's ρ = 0.25, P < .001).

CONCLUSIONS

The results of this study demonstrate initial outcomes for a WBA system to assess performance for the Core EPAs in pediatrics using the OCAT scale. Future studies will assess the system across clerkships.

Launching the Next Steps to Improve Hospice and Palliative Medicine Fellow Performance Assessment: A Look Back to the Initial Toolkit of Assessment Methods

Education leaders in hospice and palliative medicine (HPM) have long acknowledged the challenge of fellow performance assessment and the need for HPM-specific fellow assessment tools. In 2010, and in alignment with the Accreditation Council for Graduate Medical Education's (ACGME's) directive toward competency-based medical education, the national HPM Competencies Workgroup curated a set of assessment tools, the HPM Toolkit of Assessment Methods. The Toolkit has been a resource for HPM fellowship directors in evolving practical, multifaceted fellow assessment strategies. Now, as American Academy of Hospice and Palliative Medicine plans for a national workgroup in 2020 to define current HPM fellow assessment methods and to propose strategies to strengthen and standardize future assessment, the Toolkit provides a strong base from which to launch. However, the field learned important lessons from the 2010 Workgroup about the consensus process, gaps in areas of assessment, opportunities to address gaps with new or adapted tools, and limitations in implementing the Toolkit over time in terms of tracking, accessibility, and dissemination. This article describes the development of the Toolkit, including recommended tools and methods for assessment within each ACGME competency domain, and links the lessons learned to recommendations for the 2020 workgroup to consider in creating the next HPM assessment strategy and toolkit. Effective implementation will be crucial in supporting fellows to reach independent practice, which will further strengthen the field and workforce to provide the highest quality patient and family-centered care in serious illness. This will require an inspired, committed effort from the HPM community, which we enthusiastically anticipate.

Implementing the Behavioral and Mental Health Entrustable Professional Activity: Insights for a Path Forward

OBJECTIVE

Mental health problems in children are growing exponentially. General pediatricians, while in a unique position to address these issues as they arise, report they lack adequate training in assessing and managing behavioral/mental health (B/MH) problems. Underscoring the importance of this area, the American Board of Pediatrics has defined B/MH as one of only 17 foundational entrustable professional activities (EPAs) for general pediatric practice. Our goal was to explore the facilitators and barriers associated with implementing and assessing the B/MH EPA among pediatric residency programs in order to identify best practices and potential solutions to common barriers.

METHODS

In this qualitative study, 18 key faculty members from 4 residency programs with 3 years' experience implementing and assessing their residents on the B/MH EPA were purposively sampled. Semistructured interviews were conducted with each participant, and interviews were analyzed utilizing a thematic analysis.

RESULTS

Five themes were defined in the thematic analysis 1) B/MH training: who's responsible? 2) local context can serve as a barrier or facilitator, 3) B/MH may require longitudinal, integrated, and multidisciplinary training, 4) B/MH specialists: indispensable, yet a hurdle?, and 5) resident and faculty confidence and skill impact B/MH training.

CONCLUSIONS

The need for robust training to prepare pediatric residency graduates to meet the needs of patients with B/MH problems has never been greater. This study provides important insights about gaps in B/MH training. These should inform future directions focused on addressing this need.

Association Between Entrustable Professional Activities and Milestones Evaluations: Real-time Assessments Correlate With Semiannual Reviews

OBJECTIVE

Entrustable professional activities (EPAs) have been developed to refine competency-based education. The American Board of Surgery has initiated a 2-year pilot study to evaluate the impact of EPAs on the evaluation and feedback of surgical residents. The ACGME Milestones in Surgery is a semiannual competency-based evaluation program to measure resident progression through 16 professional attributes across 8 practice domains. The correlation between these 2 evaluation tools remains unclear. The purpose of this study is to evaluate this correlation through comparison of an EPA with the corresponding elements of the ACGME Milestones.

DESIGN

From July, 2018 to October, 2019, all residents submitting EPA evaluations for gall bladder disease were evaluated for preoperative, intraoperative, and/or postoperative entrustability. The ratings were converted to a numerical rank from 0 to 4. Milestones scores from May 2019 and November 2019 were obtained for each resident, with scores ranging from 0 to 4. The gall bladder EPA incorporates the operative PC3 and MK2 and nonoperative PC1, PC2, and ICS3 components. Spearman rank correlation was conducted to evaluate the association between each resident's median EPA ranking and his/her milestones scores.

SETTING

SUNY Upstate Medical University, Syracuse, NY, a university-based hospital.

PARTICIPANTS

General surgery residents.

RESULTS

Among 24 residents, 106 intraoperative EPA evaluations were. For both the May and November milestones, significant positive correlations were noted for PC3 (correlation coefficient ρ = 0.690, p < 0.001; ρ = 0.876, p < 0.001). Similarly, for MK2, a significant positive correlation was noted (ρ = 0.882, p < 0.001; ρ = 0.759, p < 0.001). Interestingly, significant positive correlations were also identified between the 3 nonoperative milestones and the intraoperative entrustability ranking.

CONCLUSIONS

We observed significant correlations between EPAs for cholecystectomy and associated milestones evaluation scores. These findings indicate that EPAs may provide more timely and specific feedback than existing tools and, on aggregate, may improve upon existing formative feedback practices provided through the biannual evaluation of surgical residents.

Shared Mental Models Among Clinical Competency Committees in the Context of Time-Variable, Competency-Based Advancement to Residency

PURPOSE

To evaluate response process validity evidence for clinical competency committee (CCC) assessments of first-year residents on a subset of General Pediatrics Entrustable Professional Activities (EPAs) and milestones in the context of a national pilot of competency-based, time-variable (CBTV) advancement from undergraduate to graduate medical education.

METHOD

Assessments of 2 EPAs and 8 milestones made by the trainees' actual CCCs and 2 different blinded "virtual" CCCs for 48 first-year pediatrics residents at 4 residency programs between 2016 and 2018 were compared. Residents had 3 different training paths from medical school to residency: time-variable graduation at the same institution as their residency, time-fixed graduation at the same institution, or time-fixed graduation from a different institution. Assessments were compared using ordinal mixed-effects models.

RESULTS

Actual CCCs assigned residents higher scores than virtual CCCs on milestones and one EPA's supervision levels. Residents who graduated from a different institution than their residency received lower milestone ratings than either group from the same institution; CBTV residents received higher ratings on one milestone (ICS4) and similar ratings on all others compared with non-CBTV residents who completed medical school at the same institution.

CONCLUSIONS

First-year residents who graduated from CBTV medical school programs were assessed as having the same level of competence as residents who graduated from traditional medical school programs, but response process evidence suggests that members of CCCs may also draw on undocumented personal knowledge of the learner to draw conclusions about resident competence.

Entrustable professional activities for apheresis medicine education

BACKGROUND

Entrustable professional activities (EPAs) are well-defined, executable, observable, and measurable activities that are performed by a trainee and can be performed independently as training progresses. The purpose of this study is to develop EPAs specific for the practice of apheresis medicine (AM).

METHODS

Members of the American Society for Apheresis Graduate Medical Education subcommittee developed a list of 28 apheresis medical activities linked to Accreditation Council for Graduate Medical Education milestones and competencies in five areas: (a) consultation, (b) clinical care for therapeutic apheresis, (c) clinical care for donor collections, (d) test optimization, and (e) vascular access. Ten AM experts using a validated tool to measure the quality of the EPAs (QUEPA) evaluated these activities with use of a Likert scale. Per group consensus, an activity was considered acceptable for each domain if it had received an average score greater than 3.7, and it was rated 4 or 5 (agree or strongly agree) by at least 70% of experts.

RESULTS

Of the 28 activities, 11 did not have acceptable QUEPA scores: 7 activities were rated as unobservable, 4 were rated unfocused, 2 were rated unrealistic and not generalizable, and 2 were rated as not addressing multiple competencies. Four activities had unacceptable scores in more than one domain. Subcommittee members edited these 11 activities over two review cycles to produce a final list of 26 activities.

CONCLUSION

A set of practical, focused, and observable EPAs in AM were systematically developed. These EPAs can be used to assess and support trainee performance in AM.