Guidelines for resident training in veterinary clinical pathology. IV: Laboratory quality management-Teaching domains, competencies, and suggested learning outcomes

BACKGROUND

The 2019 ASVCP Education Committee Forum for Discussion, presented at the annual ASVCP/ACVP meeting, identified a need to develop recommendations for teaching laboratory quality management principles in veterinary clinical pathology residency training programs.

OBJECTIVES

To present a competency-based framework for teaching laboratory quality management principles in veterinary clinical pathology residency training programs, including entrustable professional activities (EPAs), domains of competence, individual competencies, and learning outcomes.

METHODS

A joint subcommittee of the ASVCP Quality Assurance and Laboratory Standards (QALS) and Education Committees executed this project. A draft guideline version was reviewed by the ASVCP membership and shared with selected ACVP committees in early 2022, and a final version was voted upon by the full QALS and Education Committees in late 2022.

RESULTS

Eleven domains of competence with relevant individual competencies were identified. In addition, suggested learning outcomes and resource lists were developed. Domains and individual competencies were mapped to six EPAs.

CONCLUSIONS

This guideline presents a framework for teaching principles of laboratory quality management in veterinary clinical pathology residency training programs and was designed to be comprehensive yet practical. Guidance on pedagogical terms and possible routes of implementation are included. Recommendations herein aim to improve and support resident training but may require gradual implementation, as programs phase in necessary expertise and resources. Future directions include the development of learning milestones and assessments and consideration of how recommendations intersect with the American College of Veterinary Pathologists training program accreditation and certifying examination.

Demonstrating Digital Health Clinical Competence in Practice: A Method for Developing Entrustable Professional Activities

There is broad agreement regarding fundamental digital health competencies that clinical health professionals should possess. However, there is still no clear way to observe and assess their application, during the actual work practices undertaken in clinical settings. The present paper tackles this competency-practice gap. It describes a novel health workforce research process to evolve competency statements into entrustable professional activities (EPAs) for using digital health and informatics in a clinical profession. It illustrates the use of the EPA-DH-CP framework in the context of physiotherapy. This framework offers a systematic approach for any clinical profession to develop EPAs that set out their expectation of how practitioners will demonstrate relevant digital health competencies. It can inform pre-clinical education and continuing professional development in digital health, and implementation of changes in scopes and standards of digital health clinical practice. It can support interprofessional evaluation of digital health EPAs and other EPAs.

Usability of ENTRUST as an Assessment Tool for Entrustable Professional Activities (EPAs): A Mixed Methods Analysis

OBJECTIVE

As the American Board of Surgery transitions to a competency-based model of surgical education centered upon entrustable professional activities (EPAs), there is a growing need for objective tools to determine readiness for entrustment. This study evaluates the usability of ENTRUST, an innovative virtual patient simulation platform to assess surgical trainees' decision-making skills in preoperative, intra-operative, and post-operative settings.

DESIGN

This is a mixed-methods analysis of the usability of the ENTRUST platform. Quantitative data was collected using the system usability scale (SUS) and Likert responses. Analysis was performed with descriptive statistics, bivariate analysis, and multivariable linear regression. Qualitative analysis of open-ended responses was performed using the Nielsen-Shneiderman Heuristics framework.

SETTING

This study was conducted at an academic institution in a proctored exam setting.

PARTICIPANTS

The analysis includes n = 47 (PGY 1-5) surgical residents who completed an online usability survey following the ENTRUST Inguinal Hernia EPA Assessment.

RESULTS

The ENTRUST platform had a median SUS score of 82.5. On bivariate and multivariate analyses, there were no significant differences between usability based on demographic characteristics (all p > 0.05), and SUS score was independent of ENTRUST performance (r = 0.198, p = 0.18). Most participants agreed that the clinical workup of the patient was engaging (91.5%) and felt realistic (85.1%). The most frequent heuristics represented in the qualitative analysis included feedback, visibility, match, and control. Additional themes of educational value, enjoyment, and ease-of-use highlighted participants' perspectives on the usability of ENTRUST.

CONCLUSIONS

ENTRUST demonstrates high usability in this population. Usability was independent of ENTRUST score performance and there were no differences in usability identified in this analysis based on demographic subgroups. Qualitative analysis highlighted the acceptability of ENTRUST and will inform ongoing development of the platform. The ENTRUST platform holds potential as a tool for the assessment of EPAs in surgical residency programs.

Evaluating the Quality of the Core Entrustable Professional Activities for New Pharmacy Graduates

This study aimed to evaluate the quality of the American Association of Colleges of Pharmacy Core Entrustable Professional Activities (Core EPAs) for New Pharmacy Graduates according to standards outlined in competency-based education literature utilizing the Queen's EPA Quality (EQual) rubric. A cohort of pharmacists with EPA expertise rated Core EPA quality with the EQual rubric and provided recommendations for revisions. A generalizability study determined the reliability of the EQual ratings with pharmacist users. Nine pharmacists responded (4.4%). Most EPAs (9/15) did not reach the overall cut-off score, indicating low quality. EPAs 1 through 5 and EPA 14 (fulfill a medication order) were deemed high quality. EPA 12 (use evidence-based information to advance patient care) scored the lowest at 3.47 (SEM 0.29). EPA 14 scored the highest at 4.60 (SEM 0.14). EPA 15 (create a written plan for continuous professional development) was the only EPA to fail to reach the cut-off across all EQual domains. EPAs in the Patient Care Provider Domain received significantly higher ratings than other EPAs. On average, three respondents recommended revision for each. Most comments aligned with the EPA's EQual rubric performance. The generalizability study analysis revealed excellent reliability (G = 0.80). Determining EPA quality utilizing objective measurement tools should drive EPA development and revisions to more accurately reflect the roles, responsibilities, and expectations of pharmacists on the healthcare team.

Assessment-Seeking Strategies: Navigating the Decision to Initiate Workplace-Based Assessment

Phenomenon: Competency-based medical education (CBME) relies on workplace-based assessment (WBA) to generate formative feedback (assessment for learning-AfL) and make inferences about competence (assessment of learning-AoL). When approaches to CBME rely on residents to initiate WBA, learners experience tension between seeking WBA for learning and for establishing competence. How learners resolve this tension may lead to unintended consequences for both AfL and AoL. We sought to explore the factors that impact both decisions to seek and not to seek WBA and use the findings to build a model of assessment-seeking strategy used by residents. In building this model we consider how the link between WBA and promotion or progression within a program impacts an individual's assessment-seeking strategy. Approach: We conducted 20 semi-structured interviews with internal medicine residents at Queen's University about the factors that influence their decision to seek or avoid WBA. Using grounded theory methodology, we applied a constant comparative analysis to collect data iteratively and identify themes. A conceptual model was developed to describe the interaction of factors impacting the decision to seek and initiate WBA. Findings: Participants identified two main motivations when deciding to seek assessments: the need to fulfill program requirements and the desire to receive feedback for learning. Analysis suggested that these motivations are often at odds with each other. Participants also described several moderating factors that impact the decision to initiate assessments, irrespective of the primary underlying motivation. These included resident performance, assessor factors, training program expectations, and clinical context. A conceptual framework was developed to describe the factors that lead to strategic assessment-seeking behaviors. Insights: Faced with the dual purpose of WBA in CBME, resident behavior in initiating assessment is guided by specific assessment-seeking strategies. Strategies reflect individual underlying motivations, influenced by four moderating factors. These findings have broad implications for programmatic assessment in a CBME context including validity considerations for assessment data used in summative decision-making including readiness for unsupervised practice.

Would I Trust or Will I Trust? The Gap between Entrustment Determinations and Entrustment Decisions for Trainees in Pharmacy and Other Health Professions

Entrustable Professional Activities (EPAs) and entrustment decision making are rapidly becoming mainstream in competency-based education in the health professions. EPAs are the units of professional practice to entrust graduates with once they have developed the required competencies. They were conceived to enable a gradual increase in professional autonomy during training, by allowing trainees to practice activities in which they have demonstrated they have mastered well, with decreasing supervision. However, practicing health care unsupervised generally requires licensure. The question for pharmacy education, as well as for undergraduate medical education, is can students be given any autonomy in practice, even when they have fully mastered an EPA yet remain unlicensed? While entrustment decisions for licensed practitioners have autonomy consequences, some educators in undergraduate programs speak of 'entrustment determinations', to avoid decisions about students that affect patient care, in other words saying, we would trust you, rather than we will trust you. However, graduating learners without the experience of responsibility and reasonable autonomy creates a gap with full practice responsibilities, which may jeopardize patient safety after training. What can programs do to retain the power of using EPAs while at the same time guarding patient safety?

Real-Time Feedback to Enhance the Teaching of Wire Tying

Teaching the art of wire tying is difficult because the instructor is not able to gauge the effectiveness of the final product. The impact of an incorrect technique is usually not evident. Also, the instructor does not have a way to demonstrate the different levels of tension generated by different wire knotting techniques, nor their differing abilities to resist a load that a patient may apply. In this paper, a device is described that can provide real-time feedback on wire tension generated during knot tying, and how particular knots resist an applied distraction. This device has been used to deliver a live demonstration to reinforce lecture material, and in small group teaching exercises, where real-time feedback enhances skills and understanding. A stepwise training schedule for surgery residents structured as an entrustable professional activity is proposed.

Validity Evidence for ENTRUST as an Assessment of Surgical Decision-Making for the Inguinal Hernia Entrustable Professional Activity (EPA)

OBJECTIVE

As the American Board of Surgery (ABS) moves toward implementation of Entrustable Professional Activities (EPAs), there is a growing need for objective evaluation of readiness for entrustment of residents. This requires not only assessment of technical skills and knowledge, but also surgical decision-making in preoperative, intraoperative, and postoperative settings. We developed and piloted an Inguinal Hernia EPA Assessment on ENTRUST, a serious game-based online virtual patient simulation platform to assess trainees' decision-making competence.

DESIGN

This is a prospective analysis of resident performance on the ENTRUST Inguinal Hernia EPA Assessment using bivariate analyses.

SETTING

This study was conducted at an academic institution in a proctored exam setting.

PARTICIPANTS

Forty-three surgical residents completed the ENTRUST Inguinal Hernia EPA Assessment.

RESULTS

Four case scenarios for the Inguinal Hernia EPA and corresponding scoring algorithms were iteratively developed by expert consensus aligned with ABS EPA descriptions and functions. ENTRUST Inguinal Hernia Grand Total Score was positively correlated with PGY-level (p < 0.0001). Preoperative, Intraoperative, and Postoperative Total Scores were also positively correlated with PGY-level (p = 0.001, p = 0.006, and p = 0.038, respectively). Total Case Scores were positively correlated with PGY-level for cases representing elective unilateral inguinal hernia (p = 0.0004), strangulated inguinal hernia (p < 0.0001), and elective bilateral inguinal hernia (p = 0.0003). Preoperative Sub-Scores were positively correlated with PGY-level for all cases (p < 0.01). Intraoperative Sub-Scores were positively correlated with PGY-level for strangulated inguinal hernia and bilateral inguinal hernia (p = 0.0007 and p = 0.0002, respectively). Grand Total Score and Intraoperative Sub-Score were correlated with prior operative experience (p < 0.0001). Prior video game experience did not correlate with performance on ENTRUST (p = 0.56).

CONCLUSIONS

Performance on the ENTRUST Inguinal Hernia EPA Assessment was positively correlated to PGY-level and prior inguinal hernia operative performance, providing initial validity evidence for its use as an objective assessment for surgical decision-making. The ENTRUST platform holds potential as tool for assessment of ABS EPAs in surgical residency programs.

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.

Improving feedback students receive on documentation during the obstetrics and gynecology clerkship

BACKGROUND

Students need feedback on written documentation to optimize their long-term development of this important clinical skill. The culture in surgical specialties does not always prioritize feedback regarding this skill.

OBJECTIVE

This study aimed to examine the effectiveness of 2 specific forms to improve the quantity and quality of feedback to students about their medical documentation.

STUDY DESIGN

In a multiphase quality improvement project, medical students were surveyed after the obstetrics and gynecology clerkship regarding their experience of receiving feedback on written notes. The proportions of students who received feedback on notes and those rating the feedback as meaningful were measured before and after the implementation of a required, formative feedback card. In phase 2, students were randomized to use a simplified feedback card or the original detailed card, and outcomes were compared. This study was conducted at the Medical University of South Carolina, a tertiary care academic medical center. The participants included third-year medical students that completed their 6-week obstetrics and gynecology clerkship.

RESULTS

Before the intervention, of 82 students, 70 (85%) and 55 (67%) received feedback on written notes in the inpatient and outpatient settings, respectively, which increased to 99.6% (254/255) and 98.5% (251/255) (P<.001) after the implementation of any feedback card. Moreover, the proportion of students who felt the feedback helped them improve their clinical documentation skills increased from 72% to 90% (P<.001) with the use of a feedback card. These improvements were noted in all clinical units within the clerkship. There was no difference (P=.3) in outcomes between the simplified and detailed cards.

CONCLUSION

A formative card is a simple, cost-effective, low-resource intervention that can increase both the quantity and quality of written note feedback that students receive during their obstetrics and gynecology clerkship. A less detailed card achieved comparable outcomes and increased faculty satisfaction.

Developing an Entrustable Professional Activity to Improve the Care of LGBTQ+ Youth

Despite the multitude of health inequities often experienced by lesbian, gay, bisexual, transgender, and queer (LGBTQ)+ youth, few training programs consistently and comprehensively address these disparities through education and assessment of learners. Over the past decade, programs have begun to incrementally increase the number of hours dedicated to LGBTQ+ health training; however, the lack of standardization for curricula and assessment remains a significant barrier. As medical education shifts to a competency-based approach, focusing on patient outcomes and the competencies trainees must achieve to meet those outcomes, we must take this opportunity to develop curricula and assessment tools that emphasize inclusive, affirming, equitable, and culturally humble care for LGBTQ+ youth. Entrustable professional activities (EPA) are increasingly used to educate and assess trainees on their progression from full supervision to unsupervised practice. Given their multifaceted use to standardize curricula, assess learners, and highlight programmatic gaps in education, we believe an EPA is the ideal tool to systematically improve LGBTQ+ health training in graduate medical education. Our team of national experts in this field developed an LGBTQ+ health EPA. We describe our methods of development, the functions and curricular components of the EPA, and the many applications for widespread program use.

An Entrustable Professional Activities Model for Assessment of Undergraduate Competence in Anesthesia and Surgery: Performance of the Assessment Scheme and the Impact of Assessment Timing and Variation in Structure of Teaching Activities on Student Outcomes

An entrustable professional activity (EPA) model was used to assess the anesthesia and surgery competence of year 4 students during elective neutering procedures over 3 academic years (cohort A, cohort B, and cohort C). Two competence thresholds were defined by an expert panel, the minimum acceptable standard (MAS) and the standard expected at the start of final-year rotations (SFR). The assessment scheme performed as expected, and the median level of supervision achieved by students either matched or exceeded the SFR for all EPAs except one, which matched the MAS. Semester of assessment was associated with student performance, with more students in semester 2 achieving the SFR. In the EPAs assessing pain management, documentation, and patient discharge, cohort A was associated with reduced student performance; this could be explained by changes in the delivery of teaching that enhanced performance in subsequent cohorts (academic years). For all EPAs combined and for EPAs 3, 5, 6, 8, and 9, student performance at the SFR was associated with academic year. For all EPAs combined and EPAs 3, 8, and 9, there was a reduction in the proportion of students achieving the SFR threshold in each successive year. At the MAS, the only association for all EPAs combined was with cohort C. This progressive reduction in performance may have been related to the negative effect of decreased time spent at the neutering clinic and loss of feedback opportunities outweighing the positive effects of increased staff:student ratio and improvements in the preparative phases.

Student Pharmacists Self-Perceived Confidence in Communication Skills With Healthcare Practitioners Before and After a Seminar Course

INTRODUCTION

Competent pharmacy practice requires the ability to critically evaluate the medical literature and communicate pharmacotherapy information and recommendations to healthcare practitioners. Given the limited research on how these skills are taught, a seminar course in the third year of the pharmacy curriculum was designed to strengthen these skills and abilities.

METHODS

This was a prospective, pre- and post-cohort survey design. Students were informed of the study's intent with participation being voluntary and not affecting their course grade. Students received the same survey at the beginning and end of the semester. The 20-question survey assessed self-perceived confidence in the domains of communication and literature evaluation using a 5-point, Likert-type Strongly Disagree-Strongly Agree Scale. Demographic information and students' previous pharmacy work and internship experience were collected as a part of the survey. Descriptive statistics and Student's t-test were used to assess the research question and comparisons of student demographics.

RESULTS

Sixty-eight of a possible 91 students (75% response rate) completed both the pre- and post-survey. There was no statistically significant differences between any of the measured demographics. Overall, students slightly agreed they were confident in their communication and literature evaluation skills in the pre-course evaluation, with communicating drug interactions as the least confident area. Post-course, students were significantly more confident in all but 5 of 20 measured areas.

CONCLUSION

The Seminar course resulted in a positive change in students' perception of confidence to communicate with healthcare professionals and ability to evaluate drug literature.

Young@Heart clinic: a feasibility study of an undergraduate pharmacy student-led blood pressure and healthy lifestyle clinic

OBJECTIVES

Student-led clinics offer a work-based learning (WBL) opportunity for undergraduate healthcare students to engage with professional activities in a real-life setting. Participation is posited to provide experiential learning and prepare students for clinical practice. This study aims to assess the feasibility of establishing and engaging undergraduate students in one such initiative through the collaboration between one School of Pharmacy and local authority.

METHODS

The clinic was developed using a logic model and delivered in 2019-2020. A service specification and training were developed and provided to volunteering undergraduate pharmacy students. Anonymised service data were collected and process outcomes around student and public engagement were recorded to assess feasibility for longer-term embedding into the undergraduate programme.

KEY FINDINGS

The clinic was operational for 20 days from November 2019 to February 2020. Student volunteers (n = 43, 36.7%) were trained and provided blood pressure screening and healthy living advice to 131 members of the public. Student drop-out occurred due to the voluntary nature of the initiative.

CONCLUSIONS

Collaborative working with the local authority facilitated this WBL experience outside conventional clinical environments. The study demonstrated the potential for students to participate in service provision. This offers value to the local population through a health prevention service when a structured approach to the design and delivery of the educational experience is undertaken. The study provides insight into how the WBL can work, what it requires (e.g. resource, preparation), and learning to inform the wider implementation of this WBL into the undergraduate curriculum.

Bridging the Gap between Undergraduate Veterinary Training and Veterinary Practice with Entrustable Professional Activities

The transition from being a veterinary student to becoming a member of the veterinary profession is known to be challenging. Despite being licensed directly after graduation, many veterinarians do not feel fully equipped to practice unsupervised when they graduate. The increasing rate of attrition from veterinary practice, and a relatively high percentage of burnout during the first years in practice, has been suggested to be related to a lack of early career support. Over the past decade, medical education has adopted the concept of entrustable professional activities (EPAs). Recently, EPAs have been proposed to restructure veterinary education to help support the transition from veterinary student to practicing veterinarian. Implementing an EPA-based approach could help to bridge the gap between school and clinical practice, potentially preventing veterinary graduates from dropping out early on from what could have been a promising and exciting professional career.

Building a Shared Mental Model of Competence Across the Continuum: Trainee Perceptions of Subinternships for Residency Preparation

INTRODUCTION

Toward a vision of competency-based medical education (CBME) spanning the undergraduate to graduate medical education (GME) continuum, University of Minnesota Medical School (UMMS) developed the Subinternship in Critical Care (SICC) offered across specialties and sites. Explicit course objectives and assessments focus on internship preparedness, emphasizing direct observation of handovers (Core Entrustable Professional Activity, "EPA," 8) and cross-cover duties (EPA 10).

METHODS

To evaluate students' perceptions of the SICC's and other clerkships' effectiveness toward internship preparedness, all 2016 and 2017 UMMS graduates in GME training (n = 440) were surveyed regarding skill development and assessment among Core EPAs 1, 4, 6, 8, 9, 10. Analysis included descriptive statistics plus chi-squared and Kappa agreement tests.

RESULTS

Respondents (n = 147, response rate 33%) rated the SICC as a rotation during which they gained most competence among EPAs both more (#4, 57% rated important; #8, 75%; #10, 70%) and less explicit (#6, 53%; #9, 69%) per rotation objectives. Assessments of EPA 8 (80% rated important) and 10 (76%) were frequently perceived as important toward residency preparedness. Agreement between importance of EPA development and assessment was moderate (Kappa = 0.40-0.59, all surveyed EPAs).

CONCLUSIONS

Graduates' perceptions support the SICC's educational utility and assessments. Based on this and other insight from the SICC, the authors propose implications toward collectively envisioning the continuum of physician competency.

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.

Mitigating "Educational Groundhog Day" - The Role of Learner Handoffs Within Clinical Rotations: A Survey of Pediatric Educational Leaders

BACKGROUND

Medical students decry frequent changes in faculty supervision, leading to the experience of "educational groundhog day." The discontinuity in supervision, cursory relationships, and uncoordinated feedback impede students' skill acquisition and delay entrustment decisions. Whereas patient handoff bundles are common, little is known about similarly structured approaches to learner handoffs (LHs).

OBJECTIVE

To describe current LH procedures and practices within pediatric clerkships and subinternships and to gauge interest in a future LH bundle.

METHODS

Nine items included in the 2016 Council on Medical Student Education in Pediatrics annual member survey were analyzed using mixed-methods.

RESULTS

The response rates were 66% (101 of 152) and 40% (165 of 411) for institutions and individuals, respectively. After limiting data to complete responses to programs with traditional block rotations, 54% of individual respondents (76 of 141) identified as inpatient faculty and about a quarter endorsed providing LHs. Inpatient faculty most commonly supervise medical students for 5 to 7 days. Most endorsed needing 1 to 3 days to determine a student's baseline performance and 5 days or more to make entrustment decisions. Three-quarters of inpatient faculty endorsed interest in LHs, while fewer than 16% of course directors currently provide LH expectations. Four themes emerged: instrument features, stakeholder buy-in, impact, and utility.

CONCLUSIONS

Typical inpatient faculty service days approximate the time required for making entrustment decisions about clinical students. While most inpatient faculty desire a LH bundle for use within a clinical rotation, few institutions and faculty currently use LHs. LHs could accelerate entrustment decisions by allowing coordinated feedback that might hasten learner clinical-skill development.

Pharmacy: Addressing substance use in the 21st century

Across all care environments, pharmacists play an essential role in the care of people who use and misuse psychoactive substances, including those diagnosed with substance use disorders. To optimize, sustain, and expand these independent and collaborative roles, the Association for Multidisciplinary Education and Research in Substance Use and Addiction (AMERSA) has developed core competencies for pharmacists to address substance use in the 21st century. Key concepts, skills, and attitudes are outlined, with links to entrustable professional activities to assist with integration into a variety of ideally interdisciplinary curricular activities.

Identifying entrustable professional activities for surgical skills training in companion animal health

BACKGROUND

Veterinary medical education is increasingly moving towards outcome-based training based on competency frameworks. A source of concern is the translation of competencies into the practice of clinical teaching, for example, surgical skills training. It is suggested that the use of entrustable professional activities (EPAs) might bridge this gap. The purpose of this study, therefore, was to identify EPAs related to surgical skills for companion animal health to enhance competency-based education.

METHODS

Draft versions of EPAs related to surgical skills were established by an iterative consensus-based approach through 45-min interview sessions. These draft versions were used to explore the opinion of companion animal veterinarians, both veterinarians (specialists, residents and interns) involved in undergraduate teaching and veterinarians working in private practice involved in extramural clinical teaching, on the relevance and level of entrustment of the EPAs through a modified Delphi procedure. Mean (relevance) and median (level of entrustment) scores were calculated and textual comments were analysed to create a final framework of EPAs related to surgical skills.

RESULTS AND CONCLUSION

The Delphi panel reached consensus in three rounds. Thirty-four per cent of those invited to participate in the study completed the final survey. Finally, a list of 13 EPAs related to companion animal surgical skills a student should be entrusted to perform at time of graduation was established.

To What Degree Are the 13 Entrustable Professional Activities Already Incorporated Into Physicians' Performance Schemas for Medical Students?

Phenomenon: There is an abundance of literature on Entrustable Professional Activities (EPAs) in theory, but there are few studies on the EPAs in practice for undergraduate clinical education. In addition, little is known about the degree to which the EPAs are or are not aligned with physician assessors' performance schemas of the clerkship student. Investigating the degree to which physician assessors' performance schemas are already aligned with the activities described by the EPAs is critical for effective workplace assessment design. Approach: We sampled 1,032 areas of strength (strength) and areas for improvement (improvement) written evaluation comments by 423 physician assessors for clerkship students' performance in academic years 2014-15 and 2015-16 at the University of Utah School of Medicine. Two researchers independently categorized each comment by EPA and/or coded by non-EPA topic. The proportion of comment types was compared between strength comments and improvement comments with the Wilcoxon Signed-Rank Test. Findings: The most frequently mentioned EPAs in comments were about history gathering/physical exam, differential diagnosis, documentation, presentation, and interprofessional collaboration; few mentioned diagnostic tests, patient handovers, recognition of urgent patient care, and patient safety, and none mentioned orders/prescriptions and informed consent. The most frequent non-EPA topics were about medical knowledge, need to read more, learning attitude, work ethic, professionalism/maturity, and receptiveness to feedback. The proportion of comments aligned with an EPA only, a non-EPA topic only, or both an EPA and non-EPA topic was significantly different for clerkship students' strength compared to improvement. Insights: Physician assessors' performance schemas for clerkship students were aligned with EPAs to varying degrees depending on the specific EPA and whether describing strength or improvement. Of interest, the frequently mentioned non-EPA comments represented some of the competencies that contribute to effectively performing particular EPAs and are Accreditation Council for Graduate Medical Education (ACGME) core competencies (e.g., medical knowledge, professionalism), used in residency programs. Because physician assessors for undergraduate medical education often also participate in graduate medical education, the frequency of non-EPA topics aligned to ACGME competencies may suggest influence of graduate medical education evaluative frameworks on performance schemas for clerkship students; this could be important when considering implementation of EPAs in undergraduate medical education.

The Creation of a Competent Global Regulatory Workforce

Regulatory affairs professionals play pivotal roles in ensuring healthcare products adhere to regulations and in gaining regulatory approval for product manufacture and sales. To do this, they must understand the science and technology connected with a product, the company's business goals, and, most importantly, the nuances of national and international regulations and guidances connected to the product. But although they perform complicated work connected to the entire product development lifecycle, surveys have indicated only 14% of regulatory professionals come to the field with a degree related to the work and for more than half, regulatory work is a “second career.” The net result is a heterogeneous professional population that must learn complex, detailed work on the fly in as short a time as possible. Without a structure to guide development, these expectations are a challenge for someone new to the field, that person's supervisor, and for training developers. Various non-profit groups have created competency models to provide this structure, but because competencies only identify traits demonstrated by high-performing professionals, not the specific tasks associated with individual roles, these models have had limited impact on the profession. Identifying and structuring actionable tasks based on a competency model would increase the model's utility, dissemination, and usage. Entrustable professional activities might provide the methodology for doing so.

The Development of Entrustable Professional Activities for Competency-Based Veterinary Education in Farm Animal Health

Entrustable professional activities (EPAs) are professional tasks that can be entrusted to a student under a given level of supervision once he or she has demonstrated competence in these tasks. The EPA construct was conceived to increase transparency in objectives for clinical workplace learning and to help ensure patient safety and the quality of care. A first step in implementing EPAs in a veterinary curriculum is to identify the core EPAs of the profession. The aim of this study was to develop EPAs for farm animal health. An initial set of 36 EPAs for farm animal health was prepared by a team of six veterinarians and curriculum developers and used in a modified Delphi study. In this iterative process, the EPAs were evaluated until higher than 80% agreement was reached. Of 83 veterinarians who participated, 39 (47%) completed the Delphi procedure. After two rounds, the panel reached consensus. A small expert group further refined and reorganized the EPAs for educational purposes into seven core EPAs for farm animal health and 29 sub-EPAs. This study is an important step in optimizing competency-based training in veterinary medicine. Future steps are to implement EPAs in the curriculum and train supervisors to assess students' ability to perform EPAs with increasing levels of independence.

Ward rounds in internal medicine: Validation of an Entrustable Professional Activity (EPA) observation checklist

Objectives: Ward rounds serve a crucial daily activity in hospitals. Building on the Entrustable Professional Activity "Conducting internal medicine ward rounds" consisting of ten competencies and 25 corresponding activities, this study aims at assessing content and external validity of an observation checklist for this EPA. Methods: A focus group aimed at content validation of the checklist. Five participants therefore evaluated it with respect to comprehensiveness and comprehensibility. To investigate external validity, 14 authentic ward rounds were video-taped and rated by two raters with the adapted observation checklist in terms of the appearance of certain activities in the videos. Results: After some adaptions, participants of the focus group agreed on a checklist consisting of nine competencies, 25 activities and 110 examples of observable behaviours supporting content validity. External validity was studied by using the observation checklist for ratings of ward round videos. The checklist was regarded as a valuable tool to structure observation. Along with the high frequencies of observed behaviour and interrater-reliability, external validity can be assumed. Conclusion: The first scientifically developed comprehensive observation checklist for the EPA conducting a ward round in internal medicine is presented. The checklist is a valuable tool for providing elaborated feedback in undergraduate and graduate medical education. Focussing on multi-institutional validation and the cut offs of the checklist to determine the levels of entrustment are recommended for future research.

Tools for Learning About the Referral and Consultation Process for Pediatric Residents

Management of referral and consultation is an entrustable professional activity for pediatric residents; however, few tools exist to teach these skills. We designed and implemented tools to prompt discussion, feedback, and reflection about the process of referral, notably including the family's perspective.

Narrative Derived From Medical Student Reflection in Action: Lessons Learned and Implications for Assessment

A process and tool that prompts learners to think about and reflect on their clinical performance was implemented. Learner narrative reflections about their work and faculty feedback, both captured in the moment, provided data for decisions about level of performance in a competency-based assessment system.

Patient Handoff Education: Are Medical Schools Catching Up?

Communication errors during shift-to-shift handoffs are a leading cause of preventable adverse events. Nevertheless, handoff skills are variably taught at medical schools. The authors administered questionnaires on handoffs to interns during orientation. Questions focused on medical school handoff education, experiences, and perceptions. The majority (546/718) reported having some form of education on handoffs during medical school, with 48% indicating this was 1 hour or less. Most respondents (98%) reported that they believe patients experience adverse events because of inadequate handoffs, and more than one third had witnessed a patient safety issue. Results show that medical school graduates are not receiving adequate handoff training. Yet graduates are expected to conduct safe patient handoffs at the start of residency. Given that ineffective handoffs pose a significant patient safety risk, medical school graduates should have a baseline competency in handoff skills. This will require medical schools to develop, implement, and study handoff education.

Competency-based medical education: An overview and application in pharmacology

Competency-based medical education (CBME) is gaining momentum across the globe. The Medical Council of India has described the basic competencies required of an Indian Medical Graduate and designed a competency-based module on attitudes and communication. Widespread adoption of a competency-based approach would mean a paradigm shift in the current approach to medical education. CBME, hence, needs to be reviewed for its usefulness and limitations in the Indian context. This article describes the rationale of CBME and provides an overview of its components, i.e., competency, entrustable professional activity, and milestones. It elaborates how CBME could be implemented in an institute, in the context of basic sciences in general and pharmacology in particular. The promises and perils of CBME that need to be kept in mind to maximize its gains are described.

Implementation of Competency-Based Pharmacy Education (CBPE)

Implementation of competency-based pharmacy education (CBPE) is a time-consuming, complicated process, which requires agreement on the tasks of a pharmacist, commitment, institutional stability, and a goal-directed developmental perspective of all stakeholders involved. In this article the main steps in the development of a fully-developed competency-based pharmacy curriculum (bachelor, master) are described and tips are given for a successful implementation. After the choice for entering into CBPE is made and a competency framework is adopted (step 1), intended learning outcomes are defined (step 2), followed by analyzing the required developmental trajectory (step 3) and the selection of appropriate assessment methods (step 4). Designing the teaching-learning environment involves the selection of learning activities, student experiences, and instructional methods (step 5). Finally, an iterative process of evaluation and adjustment of individual courses, and the curriculum as a whole, is entered (step 6). Successful implementation of CBPE requires a system of effective quality management and continuous professional development as a teacher. In this article suggestions for the organization of CBPE and references to more detailed literature are given, hoping to facilitate the implementation of CBPE.