以能力為本的临床评估
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Competency-based medical education focuses on assessing competencies through milestones and entrustable professional activities (EPAs) rather than time-based assessments. The document discusses competency-based assessment in the workplace and outlines milestones and EPAs. It provides examples of milestones for the domain of clinical care, assessing abilities from the beginning of training through to independent practice. EPAs for family medicine are also presented, describing essential units of professional practice that can be entrusted to competent learners.
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以能力為本的临床评估
- 1. Competency-based Assessment in Workplace Milestones & EPAs 2016.07.09 台灣家庭醫學教育學會 Yaw-Wen Chang, MD Tri-Service General Hospital, National Defense Medical Center
- 2. 2
- 3. Educating physicians: a call for reform 3
- 4. Carnegie Report 2010 4 Challenges Recommendations Not outcome based Standardize learning outcome through assessment of competencies Inflexible & overly too long Individualize learning process, allow opportunity to progress within and across levels when competencies are achieved Not learner-centered Offer elective programs to support the development skills for inquiry and improvement Irby DM, Cooke M, O’Brien BC. Calls for Reform of Medical Education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Academic Medicine 2010;85:220. doi:10.1097/ACM.0b013e3181c88449
- 7. Professional Competence (勝任) Competence ?is the array of abilities across multiple domains or aspects of physician performance in a certain context ?is multi-dimensional and dynamic ? changes over time, experience, and setting Frank JR, Snell L, ten Cate O, Holmboe ES, Carraccio C, Swing SR, et al. Competency-based medical education: theory to practice. Med Teacher. 2010;32:638-45. 7
- 8. Competence Doing the right thing at the right time in the right way in complex situations 8 !!
- 9. Competency (勝任能力) ? “An observable ability of a health professional, integrating multiple components such as knowledge, skills, values and attitudes. ? Since competencies are observable, they can be measured and assessed to ensure their acquisition.” 9Frank JR, Snell L, ten Cate O, Holmboe ES, Carraccio C, Swing SR, et al. Competency-based medical education: theory to practice. Med Teacher. 2010;32:638-45.
- 10. 職業汽車駕駛員應具備的能力 ? 應有職業道德 ? 應熟稔交通法律、具備安全意識 ? 應有良好駕駛技術 ? 駕駛姿勢 ? 後照鏡的使用 ? 方向盤操作 ? 油門、離合器操作 ? 煞車運用 ? 應了解汽車的構造原理 ? 可以進行汽車的正常保養與維護 ? 可判斷一般故障原因並自行排除 10 http://baike./subview/301566/15004725.htm
- 12. Competency-based medical education ?Time-based vs. outcome-based ? Accountability ? Flexibility ? Learner-centeredness 12
- 13. 醫師的核心能力 13
- 14. 14 ACGME Outcome Project 1999 CanMEDS 2005 What you do What you know How you get betterHow you interact with others How you act How you work within the system Who you are
- 15. Knows Shows how Knows how DoesProfessionalauthenticity Standardised Assessment (mostly established) Non- standardised assessment (emerging) Miller GE. The assessment of clinical skills/competence/performance. Academic Medicine (Supplement) 1990; 65: S63-S7. Miller’s pyramid
- 16. Workplace-based assessment ? Mini-Clinical Evaluation Exercise (mini-CEX) ? Direct Observation of Procedural Skills (DOPS) ? Case-based Discussion (CBD) ? Multi-Source Feedback 16
- 18. Milestones 18
- 19. 19 Dreyfus & Dreyfus, 1986; ten Cate 2010
- 20. Milestones ? competency-based developmental outcomes ? demonstrated progressively by residents ? from the beginning of their education through graduation to the unsupervised practice of their specialties 20 http://www.acgme.org/What-We-Do/Accreditation/Milestones/Overview
- 21. Why milestones For program ? Provide a rich descriptive, developmental framework for clinical competency committees ? Guide curriculum development of the residency or fellowship ? Support better assessment practices ? Enhance opportunities for early identification of struggling residents and fellows For residents ? Provide more explicit and transparent expectations of performance ? Support better self-directed assessment and learning ? Facilitate better feedback for professional development 21 http://www.acgme.org/What-We-Do/Accreditation/Milestones/Overview
- 22. 22
- 23. Medical competence Patient care Medical knowledge Practice-based learning & improvement Interpersonal & communication skills Professionalism System-based practice 23 PC 1 MK 1 PBLI 1 C 1 PRO 1 SBP 1 PC 2 PC 3 PC 4 PC 5 MK 2 PBLI 2 PBLI 3 C 2 C 3 C 4 PRO 2 PRO 3 PRO 4 SBP 4SBP 3SBP 2
- 24. 病人照護 ? PC1 能夠在各種醫療場域中，照顧緊急和危急的病人或傷患 ? PC2 能夠照護慢性病況的病人 ? PC3 能夠與病人、家庭、社區成為夥伴關係，透過疾病預防及健康促進以改 善健康 ? PC4 透過以病人為中心、符合成本效益的方法，與病人成為夥伴關係，持續 關注經過評估與治療，卻無法掌握明確診斷的病人，所呈現持續的症狀、徵 候、或健康狀態 ? PC5 展現符合以個人、家庭及社區為對象的健康照護所需之專科技術，而且 對於其他專科的照護知識也有所了解並應用於照護當中 24
- 25. PC-1 能夠在各種醫療場域中，照顧緊急和危急的病人或傷患 未達Lv.1 Level 1 Level 2 Level 3 Level 4 Level 5 能夠蒐集與病人 相關的必要資訊 (包含病史、檢查、 診斷性檢驗、心 理社會背景) 能夠產生鑑別診 斷 能夠認識臨床標 準處置和指引在 急性情況中的角 色 具有一致的能力 可辨別需要緊急 或危急的醫療照 顧的常見情況 能夠使用適當的 臨床標準處置和 指引來穩定急性 病人 能夠對於病人所 有的症狀描述產 生適當的鑑別診 斷 能夠對於急性病 況擬定適當的診 斷性及治療性計 畫 具有一致的能力 可辨別需要緊急 或危急的醫療照 顧的複雜情況 能夠對於急性病 人適當地調整處 置的優先順序 能夠對於較少見 的急性病況擬定 適當的診斷性及 治療性計畫， 能夠思索急性病 對病人及家屬在 心理社會層面的 影響 能夠在後續的照 護轉移過程中給 予適當的安排 能夠與轉診醫師 (顧問)及社區服務 單位協調急性病 人的照顧 能夠了解自身在 照顧急性病人上 能力的限制(關於 技術、知識、及 經驗) 能夠運用地區及 區域照護系統的 資源，提供及協 調急性病人的照 顧 □ □ □ □ □ □ □ □ □ □ 評語： 25
- 26. 32Johna S. Perm J 2015;19(4):61-63 Nasca TJ. N Engl J Med 2012;366(11):1051-6.
- 30. Entrustable Professional Activity A unit of professional practice that can be entrusted to a sufficiently competent learner ? Entrustable: 可以獨立執行的，不需要監督 ? Professional activity:可以單獨執行的臨床工作 Ten Cate 2005 36
- 31. Competencies versus EPAs Competencies EPAs Person-descriptors Work-descriptors Knowledge, skills, attitudes, values Essential parts of professional practice ? Content expertise ? Collaboration ability ? Communication ability ? Management ability ? Professional attitude ? Scholarly habits ? Discharge patients ? Counsel patients ? Design treatment plans ? Lead family meetings ? Perform paracenteses ? Resuscitate if needed 37
- 32. The EPAs-competencies matrix 38 Acad Med 2007;82:542
- 33. 39 EPAs in Family Medicine Shaughnessy, A. J Graduate Med Educ 2013
- 34. EPAs for Fam Med End of Residency Training 1 1. Provide a usual source of comprehensive, longitudinal medical care for people of all ages. 持續提供所有年齡的民眾周全性、連續性的醫療照護。 2. Care for patients and families in multiple settings. 在多種場域中照顧病患及家屬。 3. Provide first-contact access to care for health issues and medical problems. 提供民眾關於健康議題及醫療問題的初步照護。 4. Provide preventive care that improves wellness, modifies risk factors for illness and injury, and detects illness in early, treatable stages. 提供預防性照護以改善健康、減少疾病及傷害的風險、早期發現疾病。 5. Provide care that speeds recovery from illness and improves function. 提供照護以加速疾病恢復與改善功能。 40 http://www.stfm.org/NewsJournals/STFMNews/NewsSep302015
- 35. EPAs for Fam Med End of Residency Training 2 6. Evaluate and manage undifferentiated symptoms and complex conditions. 評估並處置未分化的症狀及複雜狀況。 7. Diagnose and manage chronic medical conditions and multiple co-morbidities. 診斷並處置慢性病況及多重共病。 8. Diagnose and manage mental health conditions. 診斷並處置心理健康狀況。 9. Diagnose and manage acute illness and injury. 診斷並處置急性病及傷害。 10. Perform common procedures in the outpatient or inpatient setting. 在門診或住院場域中施行一般性的手術。 41 http://www.stfm.org/NewsJournals/STFMNews/NewsSep302015
- 36. EPAs for Fam Med End of Residency Training 3 11. Manage prenatal, labor, delivery and post-partum care. 提供懷孕、生產及產後的照護。 12. Manage end-of-life and palliative care. 提供生命末期及緩和照護。 13. Manage inpatient care, discharge planning, transitions of care. 提供住院照護、出院準備、過渡照護。 14. Manage care for patients with medical emergencies. 提供緊急醫療照護。 15. Develop trusting relationships and sustained partnerships with patients, families and communities. 與病人、家屬及社區發展互信關係與持續性夥伴關係。 42 http://www.stfm.org/NewsJournals/STFMNews/NewsSep302015
- 37. EPAs for Fam Med End of Residency Training 4 16. Use data to optimize the care of individuals, families and populations. 使用數據來優化個人、家庭及大眾的照護。 17. In the context of culture and health beliefs of patients and families, use the best science to set mutual health goals and provide services most likely to benefit health. 在符合病人及家庭的文化與健康信念下，使用最佳的科學證據來設定健康目標並提供最 有益健康的服務。 18. Advocate for patients, families and communities to optimize health care equity and minimize health outcome disparities. 維護病人、家庭及社區的健康照護平等並減少健康的差距。 19. Provide leadership within interprofessional health care teams. 領導跨領域的健康照護團隊。 20. Coordinate care and evaluate specialty consultation as the condition of the patient requires. 依照病人的需要來協調照護並評估專科會診意見。 43 http://www.stfm.org/NewsJournals/STFMNews/NewsSep302015
- 38. 45 Domain of Clinical Care Entrustable Professional Activities Maternity and Newborn Care Care of the Prenatal Patient Care of the Intrapartum Patient Care of the Postpartum Patient Care of the Newborn Care of Children and Adolescents Care of the Well Baby and Child Care of a Child or Adolescent with a Minor Episodic Problem Care of a Child or Adolescent with Acute Serious Presentation Care of the Adolescent Patient Care of a Child or Adolescent with a Chronic Condition Care of Adults Performing a Periodic Health Review of an Adult Patient Care of the Adult with a Minor Episodic Problem Care of the Adult with a Chronic Condition Care of the Adult with Multiple Medical Problems Care of the Adult with an Acute Serious Presentation Care of the Elderly Patient Performing a Periodic Health Review of an Elderly Patient Care of an Elderly Patient with a Minor Episodic Problem Care of an Elderly Patient with a Chronic Condition Care of an Elderly Patient with Multiple Medical Problems Care of an Elderly Patient with an Acute Serious Presentation End of Life Care Symptom Control Care for a Palliative Patient Determining Goals of Care / Facilitating a Family Meeting Caring for the Complex or Palliative Patient at Home Behavioural Medicine Breaking Bad News Providing Lifestyle or Behaviour Modification Counselling Care of a Patient with a Mental Health Issue Global Health and Care of the Vulnerable and Underserved Care of a Patient from another Culture Care of a Patient Living in Poverty Care of a Patient with an Intellectual/ Developmental Disability Surgical and Procedural Skills Care of the Perioperative Patient Performing an Acute Care Procedure Performing a Minor Office Procedure Physicianship Being a Professional Managing a Practice Being a Leader Being a Teacher Being Self-Reflective and a Self-Directed Learner https://www.mededportal.org/icollaborative/resource/3993 36 EPAs for a postgraduate Canadian family medicine training program
- 39. 47 ten Cate 2010
- 40. Entrustment decisions as assessment ? Discard artificial grades and scales (1-9; A-F) ? Focus on required supervision (linked to patient safety) ? Ask yourself: ? Can I leave the room? ? Do I need to return to check? ? Can the trainee finish without me? ? Can the trainee manage the admission of a patient without proactive assistance? ? Look into the future and take a calculated risk 49 ten Cate 2015
- 44. 61
- 45. How is this Different from Traditional Model? Traditional time-based Competency-based Focus, structure and content Content: knowledge, skills, attitudes Rotations Outcomes demonstration of competence Relevant, paced learning opportunities Goal Knowledge acquisition Knowledge application Actors Teacher to Learner Teacher and Learner Relevant role models Assessment Evaluation form Norm-referenced Summative Evaluation portfolio Criterion referenced Formative Program completion Fixed time Variable time Tannenbaum D, Kerr J, Konkin J, Organek A, Parsons E, Saucier D, Shaw L, Walsh A. Triple C competency-based curriculum. Report of the Working Group on Postgraduate Curriculum Review-Part 1. Mississauga ON: College of Family Physicians of Canada; 2011 63
- 47. Becoming a Family Physician A Lifelong Journey UNDERGRADUATE MEDICAL EDUCATION 65
- 48. Becoming a Family Physician A Lifelong Journey UNDERGRADUATE MEDICAL EDUCATION FAMILY MEDICINE RESIDENCY TRAINING BOARDEXAM Beginning Specialist in Family Medicine 66
- 49. Becoming a Family Physician A Lifelong Journey UNDERGRADUATE MEDICAL EDUCATION FAMILY MEDICINE RESIDENCY TRAINING BOARDEXAM Beginning Specialist in Family Medicine CONTINUING PROFESSIONAL DEVELOPMENT IncludesFormalEnhancedSkillsTraining CONTINUING PROFESSIONAL DEVELOPMENT IncludesFormalEnhancedSkillsTraining 67
- 51. AAMC Core Entrustable Professional Activities for Entering Residency – Curriculum Developers’ Guide 2014 69
- 53. Thank you 71