Building a&amp;nbsp;doctor, one skill at a&amp;nbsp;time: Rethinking clinical training through a&amp;nbsp;new skills-based feedback modality

Kappy, Brandon; Herrmann, Lisa E.; Schumacher, Daniel J.; Statile, Angela

doi:10.1007/s40037-021-00666-9

Cited by 5 publications

(3 citation statements)

References 42 publications

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“…However, using competency and skill for activities has also led some authors to envision EPAs as large, holistic skills or competencies. (Kappy et al, 2021) But if EPAs were just large competencies, how would one envision being entrusted with a competency? 1 3…”

Section: How Competencies and Skills Are Often Used For Activitiesmentioning

confidence: 99%

Entrustable professional activities versus competencies and skills: Exploring why different concepts are often conflated

Cate

Schumacher

2022

Adv in Health Sci Educ

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Despite explanations in the literature, a returning question in the use of entrustable professional activities (EPAs) is how to distinguish them from competencies and skills. In this article, we attempt to analyze the causes of the frequent confusion and conflation of EPAs with competencies and skills, and argue why the distinction is important for education, qualification and patient safety. ‘Tracheotomy’, ‘lumbar puncture’, ‘interprofessional collaboration’ for example are colloquially called ‘skills’, but its is a person’s ability to perform these activities that is the actual skill; the EPA is simply the activity itself. We identify two possible causes for the confusion. One is a tendency to frame all educational objectives as EPAs. Many objectives of medical training can be conceptualized as EPAs, if ‘the ability to do X’ is the corresponding competency; but that does not work for all. We offer ways to deal with objectives of training that are not usefully conceptualized as EPAs. A more fundamental cause relates to entrustment decisions. The permission to contribute to health care reflects entrustment. Entrustment decisions are the links or pivots between a person’s readiness for the task and the actual task execution. However, if entrustment decisions do not lead to increased autonomy in the practice of health care, but only serve to decide upon the advancement to a next stage of training, EPAs can become the tick boxes learners feel they need to collect to ‘pass’. Gradually, then, EPAs can loose their original meaning of units of practice for which one becomes qualified.

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Section: How Competencies and Skills Are Often Used For Activitiesmentioning

confidence: 99%

Entrustable professional activities versus competencies and skills: Exploring why different concepts are often conflated

Cate

Schumacher

2022

Adv in Health Sci Educ

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“…The evidence from implementation of competency-based education is impressive 8 23 34–38. In medicine, the change to competency-based medical education39–43 and entrustable professional activities39 44–48 is progressing rapidly. Ideally, explicit evidence of competence should drive entrustment 39 44.…”

Section: Discussionmentioning

confidence: 99%

Effectiveness of a proficiency-based progression e-learning approach to training in communication in the context of clinically deteriorating patients: a multi-arm randomised controlled trial

McCarthy¹,

Neville²,

Pope³

et al. 2023

BMJ Open

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ObjectiveTo determine the effectiveness of proficiency-based progression (PBP) e-learning in training in communication concerning clinically deteriorating patients.DesignSingle-centre multi-arm randomised double-blind controlled trial with three parallel arms.Randomisation, setting and participantsA computer-generated program randomised and allocated 120 final year medical students in an Irish University into three trial groups.InterventionEach group completed the standard Identification, Situation, Background, Assessment, Recommendation communication e-learning; group 1 Heath Service Executive course group (HSE) performed this alone; group 2 (PBP) performed additional e-learning using PBP scenarios with expert-determined proficiency benchmarks composed of weighted marking schemes of steps, errors and critical errors cut-offs; group 3 (S) (self-directed, no PBP) performed additional e-learning with identical scenarios to (PBP) without PBP.Main outcome measuresPrimary analysis was based on 114 students, comparing ability to reach expert-determined predefined proficiency benchmark in standardised low-fidelity simulation assessment, before and after completion of each group’s e-learning requirements. Performance was recorded and scored by two independent blinded assessors.ResultsPost-intervention, proficiency in each group in the low-fidelity simulation environment improved with statistically significant difference in proficiency between groups (p<0.001). Proficiency was highest in (PBP) (81.1%, 30/37). Post hoc pairwise comparisons revealed statistically significant differences between (PBP) and self-directed (S) (p<0.001) and (HSE) (p<0.001). No statistically significant difference existed between (S) and (HSE) (p=0.479). Changes in proficiency from pre-intervention to post-intervention were significantly different between the three groups (p=0.001). Post-intervention, an extra 67.6% (25/37) in (PBP) achieved proficiency in the low-fidelity simulation. Post hoc pairwise comparisons revealed statistically significant differences between (PBP) and both (S) (p=0.020) and (HSE) (p<0.001). No statistically significant difference was found between (S) and (HSE) (p=0.156).ConclusionsPBP e-learning is a more effective way to train in communication concerning clinically deteriorating patients than standard e-learning or e-learning without PBP.Trial registration numberNCT02937597.

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“…From an ecological perspective, we would interpret the idiosyncratic ways that individuals’ knowledge and skills evolve as a reflection of how they were previously applied to problems in context. Task analysis 45 from the ecological psychology perspective may allow us to expand beyond teaching “micro skills” 75 in a clinical setting to identify effectivities and affordances that together enable summative behaviors as a goal for training. If we extend this to include the role of a coach or teacher, as would be suggested within models of deliberate practice, a learner’s efforts to shape their effectivities to environmental affordances should be supported by supervisors.…”

Section: Discussionmentioning

confidence: 99%

An Ecological Account of Clinical Reasoning

Watsjold¹,

Ilgen²,

Regehr³

2022

Academic Medicine

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Purpose The prevailing paradigms of clinical reasoning conceptualize context either as noise that masks, or as external factors that influence, the internal cognitive processes involved in reasoning. The authors reimagined clinical reasoning through the lens of ecological psychology to enable new ways of understanding context-specific manifestations of clinical performance and expertise, and the bidirectional ways in which individuals and their environments interact. Method The authors performed a critical review of foundational and current literature from the field of ecological psychology to explore the concepts of clinical reasoning and context as presented in the health professions education literature. Results Ecological psychology offers several concepts to explore the relationship between an individual and their context, including affordance, effectivity, environment, and niche. Clinical reasoning may be framed as an emergent phenomenon of the interactions between a clinician’s effectivities and the affordances in the clinical environment. Practice niches are the outcomes of historical efforts to optimize practice and are both specialty-specific and geographically diverse. Conclusions In this framework, context specificity may be understood as fundamental to clinical reasoning. This changes the authors’ understanding of expertise, expert decision making, and definition of clinical error, as they depend on both the expert’s actions and the context in which they acted. Training models incorporating effectivities and affordances might allow for antiableist formulations of competence that apply learners’ abilities to solving problems in context. This could offer both new means of training and improve access to training for learners of varying abilities. Rural training programs and distance education can leverage technology to provide comparable experience to remote audiences but may benefit from additional efforts to integrate learners into local practice niches.

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Building a doctor, one skill at a time: Rethinking clinical training through a new skills-based feedback modality

Cited by 5 publications

References 42 publications

Entrustable professional activities versus competencies and skills: Exploring why different concepts are often conflated

Entrustable professional activities versus competencies and skills: Exploring why different concepts are often conflated

Effectiveness of a proficiency-based progression e-learning approach to training in communication in the context of clinically deteriorating patients: a multi-arm randomised controlled trial

An Ecological Account of Clinical Reasoning

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