Exploring the use of rating scales with entrustment anchors in workplace-based assessment

Development and Pilot Testing of a Programmatic System for Competency Assessment in US Anesthesiology Residency Training

BACKGROUND

In 2018, a set of entrustable professional activities (EPAs) and procedural skills assessments were developed for anesthesiology training, but they did not assess all the Accreditation Council for Graduate Medical Education (ACGME) milestones. The aims of this study were to (1) remap the 2018 EPA and procedural skills assessments to the revised ACGME Anesthesiology Milestones 2.0, (2) develop new assessments that combined with the original assessments to create a system of assessment that addresses all level 1 to 4 milestones, and (3) provide evidence for the validity of the assessments.

METHODS

Using a modified Delphi process, a panel of anesthesiology education experts remapped the original assessments developed in 2018 to the Anesthesiology Milestones 2.0 and developed new assessments to create a system that assessed all level 1 through 4 milestones. Following a 24-month pilot at 7 institutions, the number of EPA and procedural skill assessments and mean scores were computed at the end of the academic year. Milestone achievement and subcompetency data for assessments from a single institution were compared to scores assigned by the institution's clinical competency committee (CCC).

RESULTS

New assessment development, 2 months of testing and feedback, and revisions resulted in 5 new EPAs, 11 nontechnical skills assessments (NTSAs), and 6 objective structured clinical examinations (OSCEs). Combined with the original 20 EPAs and procedural skills assessments, the new system of assessment addresses 99% of level 1 to 4 Anesthesiology Milestones 2.0. During the 24-month pilot, aggregate mean EPA and procedural skill scores significantly increased with year in training. System subcompetency scores correlated significantly with 15 of 23 (65.2%) corresponding CCC scores at a single institution, but 8 correlations (36.4%) were <30.0, illustrating poor correlation.

CONCLUSIONS

A panel of experts developed a set of EPAs, procedural skill assessment, NTSAs, and OSCEs to form a programmatic system of assessment for anesthesiology residency training in the United States. The method used to develop and pilot test the assessments, the progression of assessment scores with time in training, and the correlation of assessment scores with CCC scoring of milestone achievement provide evidence for the validity of the assessments.

The Assessment Burden in Competency-Based Medical Education: How Programs Are Adapting

Residents and faculty have described a burden of assessment related to the implementation of competency-based medical education (CBME), which may undermine its benefits. Although this concerning signal has been identified, little has been done to identify adaptations to address this problem. Grounded in an analysis of an early Canadian pan-institutional CBME adopter's experience, this article describes postgraduate programs' adaptations related to the challenges of assessment in CBME. From June 2019-September 2022, 8 residency programs underwent a standardized Rapid Evaluation guided by the Core Components Framework (CCF). Sixty interviews and 18 focus groups were held with invested partners. Transcripts were analyzed abductively using CCF, and ideal implementation was compared with enacted implementation. These findings were then shared back with program leaders, adaptations were subsequently developed, and technical reports were generated for each program. Researchers reviewed the technical reports to identify themes related to the burden of assessment with a subsequent focus on identifying adaptations across programs. Three themes were identified: (1) disparate mental models of assessment processes in CBME, (2) challenges in workplace-based assessment processes, and (3) challenges in performance review and decision making. Theme 1 included entrustment interpretation and lack of shared mindset for performance standards. Adaptations included revising entrustment scales, faculty development, and formalizing resident membership. Theme 2 involved direct observation, timeliness of assessment completion, and feedback quality. Adaptations included alternative assessment strategies beyond entrustable professional activity forms and proactive assessment planning. Theme 3 related to resident data monitoring and competence committee decision making. Adaptations included adding resident representatives to the competence committee and assessment platform enhancements. These adaptations represent responses to the concerning signal of significant burden of assessment within CBME being experienced broadly. The authors hope other programs may learn from their institution's experience and navigate the CBME-related assessment burden their invested partners may be facing.

Supervising the senior medical resident: Entrusting the role, supporting the tasks

INTRODUCTION

Postgraduate competency-based medical education has been implemented with programmatic assessment that relies on entrustment-based ratings. Yet, in less procedurally oriented specialties such as internal medicine, the relationship between entrustment and supervision remains unclear. We undertook the current study to address how internal medicine supervisors conceptualise entrusting senior medical residents while supervising them on the acute care wards.

METHODS

Guided by constructivist grounded theory, we interviewed 19 physicians who regularly supervised senior internal medicine residents on inpatient wards at three Canadian universities. We developed a theoretical model through iterative cycles of data collection and analysis using a constant comparative process.

RESULTS

On the internal medicine ward, the senior resident role is viewed as a fundamentally managerial and rudimentary version of the supervisor's role. Supervisors come to trust their residents in the senior role through an early 'hands-on' period of assessment followed by a gradual withdrawal of support to promote independence. When considering entrustment, supervisors focused on entrusting a particular scope of the senior resident role as opposed to entrustment of individual tasks. Irrespective of the scope of the role that was entrusted, supervisors at times stepped in and stepped back to support specific tasks.

CONCLUSION

Supervisors' stepping in and stepping back to support individual tasks on the acute care ward has an inconsistent relationship to their entrustment of the resident with a particular scope of the senior resident role. In this context, entrustment-based assessment would need to capture more of the holistic perspective of the supervisor's entrustment of the senior resident role. Understanding the dance of supervision, from relatively static overall support of the resident in their role, to fluidly stepping in and out for specific patient care tasks, allows us insight into the affordances of the supervisory relationship and how it may be leveraged for assessment.

Longitudinal assessment of competency development at The Ohio State University using the competency-based veterinary education (CBVE) model

With the development of the American Association of Veterinary Medical Colleges' Competency-Based Veterinary Education (CBVE) model, veterinary schools are reorganizing curricula and assessment guidelines, especially within the clinical rotation training elements. Specifically, programs are utilizing both competencies and entrustable professional activities (EPAs) as opportunities for gathering information about student development within and across clinical rotations. However, what evidence exists that use of the central tenets of the CBVE model (competency framework, milestones and EPAs) improves our assessment practices and captures reliable and valid data to track competency development of students as they progress through their clinical year? Here, we report on validity evidence to support the use of scores from in-training evaluation report forms (ITERs) and workplace-based assessments of EPAs to evaluate competency progression within and across domains described in the CBVE, during the final year clinical training period of The Ohio State University's College of Veterinary Medicine (OSU-CVM) program. The ITER, used at the conclusion of each rotation, was modified to include the CBVE competencies that were assessed by identifying the stage of student development on a series of descriptive milestones (from pre-novice to competent). Workplace based assessments containing entrustment scales were used to assess EPAs from the CBVE model within each clinical rotation. Competency progression and entrustment scores were evaluated on each of the 31 rotations offered and high-stakes decisions regarding student performance were determined by a collective review of all the ITERs and EPAs recorded for each learner across each semester and the entire year. Results from the class of 2021, collected on approximately 190 students from 31 rotations, are reported with more than 55 299 total competency assessments combined with milestone placement and 2799 complete EPAs. Approximately 10% of the class was identified for remediation and received additional coaching support. Data collected longitudinally through the ITER on milestones provides initial validity evidence to support using the scores in higher stakes contexts such as identifying students for remediation and for determining whether students have met the necessary requirements to successfully complete the program. Data collected on entrustment scores did not, however, support such decision making. Implications are discussed.

Exploring how feedback reflects entrustment decisions using artificial intelligence

CONTEXT

Clinical supervisors make judgements about how much to trust learners with critical activities in patient care. Such decisions mediate trainees' opportunities for learning and competency development and thus are a critical component of education. As educators apply entrustment frameworks to assessment, it is important to determine how narrative feedback reflecting entrustment may also address learners' educational needs.

METHODS

In this study, we used artificial intelligence (AI) and natural language processing (NLP) to identify characteristics of feedback tied to supervisors' entrustment decisions during direct observation encounters of clerkship medical students (3328 unique observations). Supervisors conducted observations of students and collaborated with them to complete an entrustment-based assessment in which they documented narrative feedback and assigned an entrustment rating. We trained a deep neural network (DNN) to predict entrustment levels from the narrative data and developed an explainable AI protocol to uncover the latent thematic features the DNN used to make its prediction.

RESULTS

We found that entrustment levels were associated with level of detail (specific steps for performing clinical tasks), feedback type (constructive versus reinforcing) and task type (procedural versus cognitive). In justifying both high and low levels of entrustment, supervisors detailed concrete steps that trainees performed (or did not yet perform) competently.

CONCLUSIONS

Framing our results in the factors previously identified as influencing entrustment, we find a focus on performance details related to trainees' clinical competency as opposed to nonspecific feedback on trainee qualities. The entrustment framework reflected in feedback appeared to guide specific goal-setting, combined with details necessary to reach those goals. Our NLP methodology can also serve as a starting point for future work on entrustment and feedback as similar assessment datasets accumulate.

An adaptation-focused evaluation of Canada's first competency-based medical education implementation in radiology

OBJECTIVES

Systematic program evaluation of the Queen's University diagnostic radiology residency program following transition to a competency-based medical education (CBME) curriculum.

METHODS

Rapid Evaluation methodology and the Core Components Framework were utilized to measure CBME implementation. A combination of interviews and focus groups were held with program leaders (n = 6), faculty (n = 10), both CBME stream and traditional stream residents (n = 6), and program staff (n = 2). Interviews and focus groups were transcribed and analyzed abductively. Study team met with program leaders to review common themes and plan potential adaptations.

RESULTS

Strengths of CBME implementation included more frequent and timely feedback as well as the role of the Academic Advisor. However, frontline faculty felt insufficiently supported with regards to the theory and practical implementation of the new curriculum and found assessment tools unintuitive. The circumstances surrounding the curricular implementation also resulted in some negative sentiment. Additional faculty and resident education workshops were identified as areas for improvement as well as changes to assessment tools for increased clarity. Residents overall viewed the changes favorably, with traditional stream residents indicating that they also had a desire for increased feedback.

CONCLUSIONS

Rapid Evaluation is an effective method for program assessment following curricular change in diagnostic radiology. A departmental champion driving enthusiasm for change from within may be valuable. Adequate resident and faculty education is key to maximize change and smooth the transition. Advances in knowledge: This study provides insights for other radiology training programs transitioning to a CBME framework and provides a structure for programmatic assessment.