Transcript Core Competency Curriculum in Neurological Surgery

Core Competencies in
Neurological Surgery:
A Matrix Curriculum
Society of Neurological Surgeons
American Board of Neurological Surgery
ACGME Residency Review Committee for
Neurological Surgery
The Matrix Project
Core Competencies
• Synthesis
– SNS
• Committee on Resident Education (CoRE)
– Content editor
– ACGME
• Format
– ABNS
• Medical Knowledge
– RRC
• Technical Skills
Both organizations
deal with medical
knowledge and
technical skills
Neurological Surgery Curriculum
• Consistent with ACGME format
– Core competencies
• Consistent with ABNS
– Primary exam content
– Oral exam content
• Consistent with RRC goals
– Institutional
– Chief Resident cases
Competencies
• Objectives
– ACGME Core Competencies
– Primary exam categories, key words
– RRC case categories
• Teaching methods
– Reading, lecture, modules, Bootcamp, hands on, etc
• Assessment tools
– PD, SANS, Primary exam, 360 evals, etc
• Educational goals
Physician Performance Diagnostic
Inventory
Unsatisfactory
Early Learner
Competent
Proficient
Expert
Progression
Unsatisfactory
• Rarely demonstrates competence AND is unexpected to
become competent within the assigned time frame.
• Consistently makes poor decisions or has a consistently
unsatisfactory approach to solving problems that results in
poor care delivery or unacceptable behavior.
• Repeatedly appears incapable of understanding concepts,
performing tasks, exercising judgment or demonstrating
behaviors that are important to show ability to learn the
element being evaluated.
Early Learner
• Demonstrates competence occasionally; usually shows ability
to learn in routine, repetitive or non-stressful situations
• Requires supervision
• Incapable or inconsistent in using experience to address
circumstances that are unexpected or non-typical
• The early learner is at a novice level and shows aptitude but
has not yet had sufficient experience, training or skill
acquisition to achieve competence
• Unlike the unsatisfactory (who believes they already know it
all), wants to engage in learning
Competent
• Demonstrates competence most of the time and under routine
circumstances
• Can perform without supervision in usual or predictable
circumstances
• Has developed adequate internal resources, knowledge or skills to
make good decisions or perform acceptably in routine cases
• IMPORTANTLY, the competent physician recognizes limitations and
accesses support when needed, especially for more challenging
situations
• This is the level expected from those at the completion of training
and indicates that they can effectively address the majority of
routine situations and will access support when needed in other
cases.
Proficient
• Demonstrates competence most of the time and under most
circumstances through applying intuition to guide an analytical
thought process in complex and unpredictable situations
• Has a good grasp of information, excellent skills and sound
principles and applies them to guide actions in unusual or
challenging circumstances
• Is consistently trusted to deal effectively with complex problems
• Has developed enough internal understanding, ability to flexibly
apply knowledge and sufficient skills that they can reliably
handle challenging situations without the need for external
support.
Expert
• Demonstrates competence almost always through understanding
the conceptual whole with appropriate intuitiveness and
adaptability to the circumstance
• Can recognize errors or inadequacies in knowledge, judgment, skills
or behavior in complex situations and is capable of effective
remediation
• Is a persuasive lifelong learner
• Understands the contextual “whole” and is fluid and flexible in
performance
• Has a seeming 6th sense (or a well developed “internal gyroscope”)
of how to respond to even the most unpredictable and challenging
situations. Is a resource mentor, teacher, and role model in this area.
Physician Performance Diagnostic
Inventory
Unsatisfactory
Fail
Early Learner
Junior Resident (R1-2)*
Competent
Senior Resident (R3-6)*
Proficient
Chief Resident/Junior Staff
Expert
Us
*RRC definitions
Matrix Curriculum
• Educational goals will vary
– Training level
– Subspecialty
• Successful residents will not be EXPERT
– Highest level of expectation will be PROFICIENCY
• e.g., Complex spinal surgery
– Lowest level will be EARLY LEARNER
• e.g., Endovascular Surgical Neuroradiology
Matrix Curriculum
Competency
Medical
Knowledge and
Skills
Objective
Teaching
Methods
Neuroanatomy •Lecture series
•Textbooks
•AANS/SNS Online modules
•Resident
courses
•Bootcamps
Assessment
Tools
Educational
Goals
•Inservice
Exams
•SANS
•ABNS Primary
Exam
Proficient
(4)
Matrix Curriculum
Training Level : PGY1
Competency
Medical
Knowledge
(Technical
Skills)
Objective
•
•
•
•
•
•
Lumbar Puncture
Ventriculostomy
CSF Sample
Shunt tap
Traction
Stereotactic frame
placement
Teaching
Methods
•AANS/SNS
On-line
modules
•Conferences
•Supervised
learning
•Bootcamp
Assessment
Tools
•Faculty and
Program
Director
evaluations
Educational
Goals
Proficient
(4)
Matrix Curriculum
Training Level : PGY7
Competency
Medical
Knowledge
(Technical
Skills)
Objective
Teaching
Methods
• Craniotomy for
•AANS/SNS
Aneurysm clipping On-line
modules
• Aneurysm coiling •Conferences
•Supervised
learning
Assessment
Tools
Educational
Goals
•Faculty/
Program
Director
evaluations
• Competent
(3)
• Early
learner
(2)
Cerebrovascular Competencies
Milestone
Competency
ABNS
Keyword
Oral Exam
Topic
Technical
Skill
RRC Cat
Case?
Teaching
Method
Assessment
Tools
PPDI
J/S/C
Understand
Angiography
PARQ
Medical
knowledge
Imaging/angiogr
aphy
Imaging/angio
graphy
N/A
No
Lecture/reading
Primary exam
S3
C4
Place femoral
arterial
catheter
Neuroanatomy
N/A
Imaging/angio
graphy
Endovascular
surgical
neuroradiology
No
Hands-on
PD/faculty
S3
C3
Know
anatomy of
intracranial
vessels
Medical
knowledge
Neuroanatomy/
vascular
Imaging/angio
graphy
N/A
No
Lecture/reading
Primary exam
J2
S3
C4
Medical Knowledge
• ABNS Primary Exam Categories
– A:
– B:
– C:
– D:
– E:
– F:
– G:
– H:
Anatomy
Neurobiology
Pathology
Imaging
Neurology
Neurosurgery
Critical Care
Core Competencies
Medical knowledge
Medical Knowledge
Medical Knowledge
Technical Skills
RRC Case Categories
(Proposed)
Matrix Curriculum
•
•
•
•
Adheres to ACGME format
Uses established goals of ABNS and RRC
Acknowledges levels of educational goals
Requires more integration of stakeholders
– SNS
– ABNS
– RRC
• It can be rapidly implemented
• It is a dynamic process
Process for the Matrix Project
 SNS, ABNS and RRC agree to proceed with Matrix
Project
 Pilot proposals under development in Neurointensive
Care and Endovascular Surgical Neuroradiology
 ABNS agrees to appoint SNS representatives to
Primary Exam Committee
• SNS bylaws change to place ABNS and RRC
representatives on SNS Council (ad hoc)
Process for the Matrix Project
 Orientation of Joint Section leadership to the Project
 AANS annual meeting, Denver, CO April 10-14, 2011
• Orientation of SNS members to the Project
– SNS annual meeting, Portland, OR May 21-24, 2011
Joint Sections
SNS Curriculum Sub-Committee
Development of
curriculum proposal
Subspecialty specific
curriculum initiation
Vet curriculum proposal
SNS CoRE Committee
Ensure proposal in
Matrix format
SNS Council
Final Approval of
Matrix curriculum element
Pass proposal to
SNS Members and PDs
SNS Members and PDs
Comments, suggestions,
and revisions
The ACGME Milestones Project
ACGME Milestones Project
• Translate “general” competencies into specific
competencies to be met by all residents
• Create “core” resident outcomes in the
competencies, not “standardization” of all
outcomes.
Current Curricula
Curriculum
“time-based”
Choose educational
experiences within institution,
faculty
“Educate” residents
Identify/develop evaluation tools
-formative
-summative
“Circumstantial Practice”
Future Curricula
The required
outcomes in each
domain of Clinical
Competency (Milestones)
Design educational
Experiences,
rotations, faculty
Produce proficient
physicians
National evaluation tools to measure outcome
-formative and summative
-clinical outcomes tracking
New knowledge
or skill set
External accountability
for outcome
“Intentional Practice”
Entrustable Professional Activities
• Equating competency with the point at which
one is ready to practice a a static view
• Competence is content and context specific
• Notion of context fits well with Milestones
and “entrustable professional activities” (EPAs)
Entrustable Professional Activities
• Professional life activities that define the specialty
• Ground the competencies in the everyday work of
the physician
• Activities lead to some output or outcome that can
be observed
• Complexity of the activities requires an integration of
knowledge, skills, and attitudes across competency
domains
• 50-100 per specialty
Entrustment and Competence
• Entrustment occurs when direct supervision is no
longer needed
• Faculty understand entrustment more than
competence
• Entrustment infers competence
• Doesn’t suggest that graduating residents reach a
standard of performance to practice every EPA
without direct supervision
• Opens the door for structured learning after
residency as part of MOC
Back to the Future?
• Similarities with Apprenticeship model
– Relationships are critical
– Assessment is embedded in a clinical setting taking care of
real patients
– Direct observation (not inference) is key
• Differences from Apprenticeship model
– Expanded competencies
– Move from random to deliberate curriculum
– EPAs and competencies require each other for meaning
Milestones Project Status
• Draft products created
– Internal Medicine
– Pediatrics
– General Surgery
• Development underway
– Urology
– Obstetrics-Gynecology
• Poised to begin
–
–
–
–
Opthalmology
Radiology
Transitional year
Neurological Surgery
Where Do We Start?
ACGME invitation or specialty expression of
interest
Certification board and ACGME conversation
• Decide on structure, working group chair, and
membership
• Get started with ACGME staff direction
Group Organization and
Membership
• Working group (n=10-15) MD educational
experts (Board, RRC, PD organization); 2-3
ACGME staff
• Advisory group (n=3-13) Organizational
leaders (Board, ACGME, RRC, specialty
organizations)
Charge to the Milestone Group
• Develop milestones
– Milestone – behavior, attitude, or outcome related
to general competency domains that describe a
significant accomplishment expected of a resident
by a particular point in time
• Identify assessment tools
– Vital, since this is where Outcomes Project failed
Cerebrovascular Milestones
Milestone
Competency
ABNS
Keyword
Oral Exam
Topic
Technical
Skill
RRC Cat
Case?
Teaching
Method
Assessment
Tools
PPDI
J/S/C
Understand
Angiography
PARQ
Medical
knowledge
Imaging/angiogr
aphy
Imaging/angio
graphy
N/A
No
Lecture/reading
Primary exam
S3
C4
Place femoral
arterial
catheter
Neuroanatomy
N/A
Imaging/angio
graphy
Endovascular
surgical
neuroradiology
No
Hands-on
PD/faculty
S3
C3
Know
anatomy of
intracranial
vessels
Medical
knowledge
Neuroanatomy/
vascular
Imaging/angio
graphy
N/A
No
Lecture/reading
Primary exam
J2
S3
C4
Summary
• Neurological Surgery is a the beginning of a process
to redefine residency curriculum
– The Matrix Project
• This project will coordinate the efforts of SNS, ABNS
and the RRC
• The AANS and CNS will participate through their Joint
Sections, and Executive Committees
• This process will converge with an effort by ACGME
to redefine how residents are trained
– The Milestones Project