Agreement between trainees and supervisors on first-year entrustable professional activities for anaesthesia training

Multi-stakeholder validation of entrustable professional activities for a family medicine care of the elderly residency program: A focus group study

Entrustable Professional Activities (EPAs) have become widely used within Competency-Based Medical Education (CBME) for the training and evaluation of residents. Little is known about the effectiveness of incorporating multiple stakeholder groups in the validation of EPAs. Here, we seek to validate an EPA framework developed for the University of Manitoba Care of the Elderly Enhanced Skills program using online focus groups consisting of five stakeholder groups. Participants were recruited to take part in one of five online focus groups, one for each stakeholder group (physician faculty, residents, non-physician healthcare professionals, administrators/managers, and patients). Each group met one time for 90 minutes over ZOOM®. The themes arising from stakeholder feedback suggest that successful EPAs must neither be too specific nor too expansive in scope, clearly delineate appropriate means of evaluation, and indicate specific clinical settings in which each EPA should be evaluated. Cross-cutting themes included requiring trainees to collaborate with other professionals when it would optimize patient care, and preparing trainees to advocate for their patients' health (Advocacy). The present study demonstrates that multi-stakeholder analysis yields diverse feedback that can help make EPAs more clear, easier to use in evaluation, and more socially accountable.

National consensus on entrustable professional activities for competency-based training in anaesthesiology

Entrustable Professional Activities (EPA) are specialty specific tasks or responsibilities, combining the clinical workplace and the long-demanded competency-based medical education. The first step to transform time-based into EPA-based training is to reach consensus on core EPAs that describe sufficiently the workplace. We aimed to present a nationally validated EPA-based curriculum for postgraduate training in anaesthesiology. Using a predefined and validated list of EPAs, we applied a Delphi consensus approach, involving all German chair directors of anaesthesiology. We then conducted a subsequent qualitative analysis. Thirty-four chair directors participated in the Delphi survey (77% response) and twenty-five completed all the questions (56% overall response). Reflected by the intra-class-correlation, the consensus on the importance (ICC: 0.781, 95% CI [0.671, 0.868]) and the year of entrustment (ICC: 0.973, 95% CI [0.959, 0.984]) of each EPA reached high levels of agreement among the chair directors. The comparison of data assessed in the preceding validation and present study showed excellent and good levels of agreement (ICC entrustment: 0.955, 95% CI [0.902, 0.978]; ICC importance: 0.671, 95% CI [-0.204, 0.888]). The adaptation process, based on the qualitative analysis, resulted in a final set of 34 EPAs. We present an elaborate, fully described and nationally validated EPA-based curriculum, reflecting a broad consensus among different stakeholders of anaesthesiology. We hereby provide a further step towards competency-based postgraduate anaesthesiology training.

Development of a pediatric anesthesia fellowship curriculum in Australasia by the Society for Pediatric Anesthesia of New Zealand and Australia (SPANZA) education sub committee

There has been a recognized need to develop a curriculum for pediatric anesthesia training in Australia and New Zealand. The drivers are safe care for children, clear standards of care for children within and outside of quaternary centres, and clarity of the expertise and skill of the practitioner. Entrustable professional activities (EPAs) made up of multiple competencies and sub-competencies are useful for the description and assessment of contemporary medical education. We have developed an EPA-based curriculum that is not prescriptive in the number or range of EPAs that should be completed. Individuals can shape their learning and training to the EPAs that will support their ability to provide high-quality safe care in the wide variety of institutions that they may be employed in after their pediatric fellowship. Institutions can use the curriculum to describe the skill set required for their institution and location. This paper will explain the process behind the development of the Society for Pediatric Anesthesia in New Zealand and Australia (SPANZA) guidelines of a curriculum for pediatric anesthesia fellowship based on EPAs.

Teaching Practical Skills in Anesthesia, Intensive Care, Emergency and Pain Medicine—What Is Really Relevant for Medical Students? Results of a German National Survey of Nearly 3000 Anesthesiologists

As a part of a major reform of the medical curriculum in Germany, the national catalogue of learning objectives is being revised with the focus shifting from theory-based learning to teaching practical skills. Therefore, we conducted an online survey to answer the question, which practical skills are essential in anesthesia. Participants were asked to rate the relevance of several skills, that medical students should be able to perform at the time of graduation. A total of 2898 questionnaires could be evaluated. The highest ratings were made for “bringing a patient into lateral recumbent position” and “diagnosing a cardiac arrest”. All learning objectives regarding regional anesthesia were rated as irrelevant. Furthermore, learning objectives like “performing a bronchoscopy” or “performing a rapid sequence induction” had low ratings. In the subgroup analysis, physicians with advanced training and those who were working at university hospitals rated most skills with higher relevance compared to others. Our survey provides a good prioritization of practical skills for the development of new curricula and assessment frameworks. The results can also help to establish our discipline as a cross-sectional subject in competency-based medical education, thus further increasing the attractiveness for medical students.

Lebenslanges Lernen in der Notfallmedizin – „Continuous professional development“

Dieser Beitrag stellt drei wesentliche Aspekte zum lebenslangen Lernen in der Medizin vor: (1) die Orientierung der Ausbildungsziele an beruflichen Kompetenzen (Kompetenzbasierung, unterstützt durch „entrustable professional activities“), (2) Befunde zur Entwicklung von beruflicher Expertise (Dreyfus-Modell und „dual process theory“) sowie (3) das CanMEDS(Canadian-Medical-Education-Directives-for-Specialists)-Rollenmodell zur Beschreibung der ärztlichen Handlungsfelder, das auch auf andere medizinische Berufe anwendbar ist. Alle drei Aspekte beeinflussen einander wechselseitig und müssen daher in einem gemeinsamen Kontext gesehen werden.

Airway management procedures in Swedish emergency department patients - a national retrospective study

Background

With the on-going debate about which specialty should be responsible for intubations in the emergency department in mind, the aim of this study was to describe the prevalence of endotracheal intubation and other airway management procedures in emergency department patients in Sweden.

Methods

All patients registered in the Swedish Intensive Care Registry with admission date from January 1 2013 until June 7 2018 and reported admission type “from the emergency department” or “emergency department” reported in the SAPS3 scoring were included. All patients missing codes for procedures were excluded.

Results

A total of 110,072 admissions from an emergency department to an ICU were registered during the study period. Of these, 41,619 admissions (37.8%) were excluded due to lack of codes for medical procedures. The remaining 68,453 admissions (62.2%) were included, and 31,888 emergency airway procedures (within 3 h from admission time to the intensive care unit) were registered. Invasive emergency airway procedures were the most common type of airway procedure (n = 23,446), followed by non-invasive airway procedures (n = 8377) and high-flow nasal cannula (n = 880). In 2017 a total of 4720 invasive emergency airway management procedures were registered.

Conclusions

The frequency of invasive airway management procedures in Swedish EDs is low. With approximately 1.9 million adult ED visits per year, this gives an estimated incidence of 2.4 invasive airway management procedures per thousand ED visits in 2017.

Trial registration

Not applicable.

How to train thoracic anesthesia for residents and consultants?

PURPOSE OF REVIEW

The training of anesthesiologists in thoracic surgery is a significant challenge. International professional societies usually provide only a case number-based or time-based training concept. There are only a few concepts of simulation trainings in thoracic anesthesia and interprofessional debriefings on a daily basis are rarely applied. In this review, we will show how professional curricula should aim for competence rather than number of cases and why simulation-based training and debriefing should be implemented.

RECENT FINDINGS

Recent curricula recommend so-called entrustable professional activities (EPAs)as a way out of the dilemma between the number of cases vs. competence. With these EPAs, competence can be mapped and prerequisites defined.Training concepts from simulation in healthcare have so far not explicitly reached anesthesia for thoracic surgery. In addition to mere technical training, combined technical-behavioral training forms have proven to be an effective training targeting the entire team in the context of the actual working environment in the operating theatre.

SUMMARY

Interdisciplinary and interprofessional learning can take place in simulation trainings and on a daily basis through postevent debriefings. When these debriefings are conducted in a structured way, an improvement in the performance of the entire team can be the result. The basis for these debriefings - as well as for other training approaches - is psychological safety, which should be established and maintained together with all professions involved.

An analysis of core EPAs reveals a gap between curricular expectations and medical school graduates' self-perceived level of competence

BACKGROUND

Entrustable Professional Activities (EPAs) are being implemented worldwide as a means to promote competency-based medical education. In Switzerland, the new EPA-based curriculum for undergraduate medical education will be implemented in 2021. The aim of our study was to analyze the perceived, self-reported competence of graduates in 2019. The data represent a pre-implementation baseline and will provide guidance for curriculum developers.

METHODS

Two hundred eighty-one graduates of the Master of Human Medicine program of the University of Zurich who had passed the Federal Licensing Exam in September 2019 were invited to complete an online survey. They were asked to rate their needed level of supervision ("observe only", "direct, proactive supervision", "indirect, reactive supervision") for 46 selected EPAs. We compared the perceived competence with the expected competence of the new curriculum.

RESULTS

The response rate was 54%. The need for supervision expressed by graduates varied considerably by EPA. The proportion of graduates rating themselves at expected level was high for "history taking", "physical examination" "and documentation"; medium for "prioritizing differential diagnoses", "interpreting results" and "developing and communicating a management plan"; low for "practical skills"; and very low for EPAs related to "urgent and emergency care".

CONCLUSIONS

Currently, there are significant gaps between the expectations of curriculum developers and the perceived competences of students. This is most obvious for practical skills and emergency situations. The new curriculum will either need to fill this gap or expectations might need to be revised.

How novice and expert anaesthetists understand expertise in anaesthesia: a qualitative study

BACKGROUND

The development of expertise in anaesthesia requires personal contact between a mentor and a learner. Because mentors often are experienced clinicians, they may find it difficult to understand the challenges novices face during their first months of clinical practice. As a result, novices' perspectives may be an important source of pedagogical information for the expert. The aim of this study was to explore novice and expert anaesthetists understanding of expertise in anaesthesia using qualitative methods.

METHODS

Semi-structured interviews were conducted with 9 novice and 9 expert anaesthetists from a German University Hospital. Novices were included if they had between 3 and 6 months of clinical experience and experts were determined by peer assessment. Interviews were intended to answer the following research questions: What do novices think expertise entails and what do they think they will need to become an expert? What do experts think made them the expert person and how did that happen? How do both groups value evidence-based standards and how do they negotiate following written guidance with following one's experience?

RESULTS

The clinical experience in both groups differed significantly (novices: 4.3 mean months vs. experts: 26.7 mean years; p < 0.001). Novices struggled with translating theoretical knowledge into action and found it difficult to talk about expertise. Experts no longer seem to remember being challenged as novice by the complexity of routine tasks. Both groups shared the understanding that the development of expertise was a socially embedded process. Novices assumed that written procedures were specific enough to address every clinical contingency whereas experts stated that rules and standards were essentially underspecified. For novices the challenge was less to familiarise oneself with written standards than to learn the unwritten, quasi-normative rules of their supervising consultant(s). Novices conceptualized decision making as a rational, linear process whereas experts added to this understanding of tacit knowledge and intuitive decision making.

CONCLUSIONS

Major qualitative differences between a novice and an expert anaesthetist's understanding of expertise can create challenges during the first months of clinical training. Experts should be aware of the problems novices may have with negotiating evidence-based standards and quasi-normative rules.