Developing Entrustable Professional Activities for the ambulatory internist

Transcription

1 Developing Entrustable Professional Activities for the ambulatory internist Author: Rupal Shah, Lindsay Melvin and Rodrigo B. Cavalcanti Date: October 1, 2016

2 Disclosures I do not have an affiliation (financial or otherwise) with a pharmaceutical, medical device or communications organization. Je n ai aucune affiliation (financière ou autre) avec une entreprise pharmaceutique, un fabricant d appareils médicaux ou un cabinet de communication.

3 Introduction Current trends Ambulatory care Competency based education EPAs Gaps Standardized expectations reflecting real life practice Core versus subspecialty GIM Aim Let s talk about it

4 Entrustable Professional Activities

5 Methods Review of Literature and RCPSC Objectives Initial draft of EPAs for the ambulatory internist Expert Consultation Iterative process to finalize EPAs Multi-Centre Survey Goal identify and understand disagreements

6 Proposed EPAs: PGY 1-3 EPA 1 Triage, diagnose and manage patients referred with common general medical conditions including urgent referrals from the emergency department. EPA 2 Manage the longitudinal care of patients with chronic multisystem disease. EPA 3 EPA 4 EPA 5 EPA 6 Minimize risk factors for disease progression and complications utilizing pharmacologic and non-pharmacologic preventative measures. Assess, counsel and mange patients with medically unexplained symptoms or asymptomatic patients with incidental laboratory and radiological findings. Co-manage patients with multiple internal medicine co-morbidities in the perioperative period including risk stratification and management. Diagnose, investigate and manage internal medicine conditions before, during and after pregnancy.

7 Proposed EPAs: PGY4-5 EPA 7 Manage a typical ambulatory GIM practice including patient referrals, flow and follow-up. EPA 8 Coordinate the longitudinal care of medically complex patients with multiple co-morbidities over the evolution of their disease alongside family practitioners and other subspecialists.

8 Results 253 invited, 63 participated 25%

9 Results EPA 6 Diagnose, investigate and manage internal medicine conditions before, during and after pregnancy % disagreed Across sites Both inpatient and outpatient Agreement (%) EPA 1 EPA 2 EPA 3 EPA 4 EPA 5 EPA 6 EPA 7 EPA 8

10 Results EPAs well understood More training required beyond PGY3 Should not be under GIM Perceived barriers to implementation

11 More training I don't think the pregnancy EPA belongs in core PGY- 1-3, but More should training be required the PGY-4/5 beyond category. PGY3 Should not be under GIM EPAs well understood Some Perceived internists have barriers a specialization to implementation in this area and would be best suited to care of the pregnant patient

12 Non GIM (EPA 2) Many chronic multisystem diseases are more easily followed by More training family required physicians beyond or specialists PGY3 with expertise in the area (i.e. Diabetes) and the resources (to) provide Should the patient not be with under the best GIM care Perceived barriers to implementation EPAs well understood A fine balance needs to be taken to ensure that internists remain specialists and not primary care providers.

13 Perceived Benefits it is a worthy aim but unless a large number of longitudinal More clinics training are required provided beyond (residents)will PGY3 not be able to do this Should satisfactorily. not be under A 4 GIM or 8 week block is not sufficient. Perceived barriers to implementation EPAs well understood

14 EPAs misunderstood Knowledge of community health services and process for referral Missing and EPAs proper individual use competencies EPAs misunderstood Communication appropriate communication with referring doctor Office management Transitional care something about time management and many more depending etc on how granular these are defined Palliative care

15 These EPAs are overly general. It's hard to see what they add over current goals and objectives of training. Also, given how vague they are it is hard to appreciate how they'd be accurately measured and evaluated.

16 Conclusions Content related Obstetrical medicine implications for PGY3 RCE Concept related How to define and translate EPAs?

17 Food for thought EPA#1 - Triage, diagnose and manage patients referred with common general medical conditions including urgent referrals from the emergency department. This EPA includes the management of high and low acuity patients in the outpatient setting. It includes: Taking of a full history and performing a physical examination of an ambulatory patient referred to general internal medicine Evaluation of the patient referred to ambulatory general internal medicine for rapid assessment and diagnosis of a medical condition from the emergency department Identification and prioritization of the internal medicine problem(s) that must be managed, based on acuity Communication of all actions to the patient Collaboration with allied health including physical therapy, occupational therapy, social worker, pharmacist, and community resources as required Determining appropriate investigations and expediting any urgent tests required Arranging appropriate follow up in the ambulatory setting and/or with other consulting and/or primary care physicians Transferring the patient to another level of care (i.e. emergency department, internal medicine ward) where necessary Producing clear, concise and timely written and verbal communication to consulting physicians and other health care providers involved in the patient s care

18 Thank-you! Laura Marcotte Debra Pugh Irene Ma Andrew Smaggus Serena Gundy Lacey Pitre Participants!

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21 Extra Slides

22 Results

23 Results

24 Results Rate expertise in ambulatory care and medical education

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