Competencies in practice A curriculum for internal medicine

Drivers for Change Shape of Training

• Increased generalism

• Changing demography etc

• Published 2013 Generic Professional Capabilities (GMC)

• To be embedded in all curricula from 2017

• 9 domains Enhancing (General) Internal Medicine Burden of assessment

Internal Medicine Curriculum

The ultimate goal

The aim of medical training is to prepare learners for

unsupervised practice As level of performance increases, level of

supervision decreases

Swinging pendulum

Between

• Old view … “we just know that this a good trainee and are happy that they are fully competent…”

• Atomised, individual tick-box competencies

» “this trainee can look after a patient with fever and a rash”

» “this trainee can look after a patient with fever and diarrhoea”

Some domains are difficult to assess

Assessment – the challenges

Not integrated into routine practice

Ticks in all the boxes but everyone knows they are weak

Too many assessments

We have to assess everything

No feedback given

Priority

Assessment strategy needs to drive learning and provide reassurance BUT needs to be practical and feasible for:

• Trainers

• Trainees

• Patients

• Service delivery

Competencies in Practice (CiPs)

“a unit of professional practice identified as a task or

responsibility to be entrusted to a learner to execute unsupervised once sufficient competence has been demonstrated”

AKA “Entrustable Professional Activities” (EPAs)

Levels of trust Presumptive trust

• based entirely on qualifications/state of training Initial trust

• “Swift/thin” trust. Based on first impressions. Obvious limitations

Grounded trust

• Based on prolonged experience with trainee and specific assessment data (exams, WBAs etc)

CiPs

• Focus on what happens in clinical practice

• Translate competencies into clinical practice

• Requires demonstration of multiple competencies simultaneously

and specific knowledge, skills, attitudes and behaviours

• Acquired through training

• Observable and measurable

• Are being developed in The Netherlands, Canada, US, Australia, New

Zealand, UK

Competencies or CiPs – what’s the difference? Competencies CiPs

Descriptors of physicians Descriptors of tasks

Knowledge, skills, attitudes, values

Essential parts of professional practice

• Content expertise • Communication ability • Management ability

• Discharge patients • Design treatment plans • Manage patients in an outpatient

clinic

Role of the supervisor

Clinical supervisor

• Familiar with day to day practice of the trainee. Observing them and interacting with them on a regular basis. Providing feedback and making informal entrustment decisions within context on a regular basis. Will make advisory/formative CiP recommendations.

Role of the supervisor

Educational supervisor

• May have personal clinical experience of trainee but has overall supervision of programme and will receive feedback from clinical supervisors and others that are integrated into a summative CiP recommendation

Trainee attributes that support entrustment

• Competence

• Integrity/honesty

• Conscientiousness/reliability

• Insight (aware of limitations)

Information/evidence to inform and support an entrustment decision • Personal knowledge of/experience with trainee

• Informal “intelligence” from medical and non-medical colleagues

• Workplace based assessments

• ACAT, DOPS, mini-CEX, CbD, MSF, TO, QIPAT, Patient survey etc.

• Specific courses/qualifications

• MRCP, SCE, ALS, etc

• Specific feedback/reports

• CS Report

CiP example

CiPs

There are 14 CiPs split into two

categories:

• Clinical • Non-clinical

CiPs - Clinical 1. Managing an acute unselected take 2. Managing an acute specialty-related take 3. Providing continuity of care to medical in-patients, including management of

comorbidities and cognitive impairment 4. Managing patients in an outpatient clinic, ambulatory or community setting,

including management of long term conditions 5. Managing medical problems in patients in other specialties and special cases 6. Managing a multi-disciplinary team including effective discharge planning 7. Delivering effective resuscitation and managing the acutely deteriorating

patient 8. Managing end of life and palliative care skills 9. Achieving procedural skills

Entrustment level descriptors, Clinical

Level 1: Observations of the activity – no execution

Level 2: Trusted to act with close supervision

Level 3: Trusted to act with supervision available quickly

Level 4: Trusted to act unsupervised (with clinical oversight within training)

CiPs – Non-Clinical

10. Is focused on patient safety and delivers effective quality

improvement in patient care 11. Carrying out research and managing data appropriately 12. Acting as a clinical teacher and clinical supervisor 13. Dealing with ethical and legal issues related to specialty clinical

practice 14. The ability to successfully function within NHS organisational and

management systems

Entrustment level descriptors, non-clinical

Level 1: No or limited knowledge or experience

Level 2: Knowledge but limited experience, trusted to act with close supervision

Level 3: Knowledge and experience, trusted to act with guidance available

Level 4: Experienced and trusted to level of independent practice

What is expected of you in the CiP study?

• Trainee

• Clinical Supervisor

• Educational Supervisor

Trainee • Ensure your clinical supervisor has completed an

assessment of your performance using the CiP Study Clinical Supervisor Report by Friday 15 July

• Consider what evidence you need to provide to inform the decisions made about your performance at each CiP

• You will need to complete a self-assessment of all 14 CiPs on the e-portfolio before the meeting with your educational supervisor

• Complete an evaluation questionnaire

Clinical Supervisor

• Review the trainee’s e-portfolio and consider your personal experience of the trainee

• Complete a CiP Study Clinical Supervisor Report to indicate what level the trainee is performing for each CiP by Friday 15 July

• Complete an evaluation questionnaire

Educational Supervisor

• Review your trainee’s e-portfolio and consider the Clinical Supervisor Report(s) and trainee self assessment report

• Meet with your trainee to discuss progress and performance and agree and document a level of performance for each CiP on the CiP Study Educational Supervisor Report by Friday 29 July

• Complete an evaluation questionnaire

Accessing the documentation through the ePortfolio • Trainees have been assigned new programme and

post location: CiP Study Programme/Hospital – CiP • Ensure you are logged on in correct role (CS, ES) • Supervisor reports for the study can be accessed

via the Progression tab • Trainee self-assessment form accessed via

Assessment - Generic

Guidance and support

• Webpage • Participant guide • ePortfolio user guides • Webinar • curriculum@jrcptb.org.uk

Summary, evaluation and close