About EPAC

Collaborators:

• Accreditation Council for Graduate Medical Education

• Association of American Medical Colleges

• American Board of Pediatrics

Background:

Since the publication of the Flexner report in 1910,[1] and its operationalization in the 1930s, medical schools have been structured in a time-based four year curriculum, with two years devoted primarily to basic sciences and two years to the clinical sciences. Graduate Medical Education has also been structured as time-based programs, with pediatric residency training based on a three year curriculum. The 1990s saw the introduction of the tenets of competency-based medical education at the undergraduate medical education (UME) level through the Medical Student Objectives Project (MSOP)[2] sponsored by the AAMC and at the graduate medical education (GME) level through the Outcome Project[3] sponsored by the Accreditation Council for Graduate Medical Education (ACGME).

These projects sought to redefine the progression along the educational continuum based on the expected outcomes for individuals in the six core competencies of a practicing physician: Patient Care, Medical Knowledge, Professionalism, Interpersonal and Communication Skills (ICS), Systems-Based Practice (SBP) and Practice-Based Learning and Improvement (PBLI). Sub-competencies within these six domains have been defined, and individual specialties have adopted specialty-specific language. Over the course of the past decade, the American Board of Medical Specialties (ABMS) has also focused on the competencies with the adoption of the Maintenance of Certification (MOC) Program, designed to insure that physicians both continue to demonstrate competence and, ultimately, growth within the six domains over the course of their careers. Finally, the Federation of State Medical Boards has also made demonstration of competence the primary tenet of their Maintenance of Licensure program.

While much progress has been made, the prevailing structure of both UME and GME continues to be both time- and tradition-based and thus at odds with a primary tenet of competency-based education, which is the attainment of competence by the individual learner within their own timeframe. The demonstration of competence must serve to both elucidate the transitional milestones (e.g. from undergraduate to graduate medical education or from supervised to supervising resident) and allow advancing responsibility for the learner without direct supervision.

The primary impetus for this project is to test the hypothesis that progression from entrance to medical school to completion of residency can be guided and assessed as a comprehensive medical education program using a competency-based framework. The pediatric community, relatively advanced in its understanding and definition of competence, will serve as the pilot specialty to test this hypothesis. Five medical schools and their associated pediatric residency programs representing a diverse group geographically and structurally, will make up the initial cohort.

Project Goal:

Establish a model for true competency-based medical education through variable-time, meaningfully assessed demonstration of competence across the UME-GME continuum.

Secondary Goals:

• Demonstrate the successful creation of competent physicians with a more focused, learner-centered approach (i.e. pediatric focused UME, and career focused GME) by showing preparedness for practice of graduates (Note: This goal directly addresses a goal of the Carnegie Report of 20104 by allowing individualization of the learning pathway with a focus on pediatrics after the establishment of desired outcomes-EPAs, competencies, and Milestones).
• Improve the meaningfulness of the work at the UME and GME levels for a subset of learners known to desire a career in pediatrics at entrance to medical school.
• Insure that learners meet traditional achievement standards (such as passing the boards) to provide needed flexibility for change in career plans (e.g. no adverse effects to opting out of the program).
• Test the utility of Entrustable Professional Activities and the Pediatric Milestones in establishing performance standards across the UME and GME continuum and determining readiness for transitions from UME to GME and GME to practice.
• Build and sequence a curriculum in pediatrics to address a true continuum of medical education from UME through GME which may serve as a model for other specialties.

• Allow learners to advance beyond competence during the training years in their individual areas of focus.
   

Project Teams:

University of California at San Francisco
Michele Long (Team Leader), Carrie Chen, Dan West, Abhay Dandekar

University of Colorado/Denver Children’s Hospital
Jennifer Soep (Team Leader), Carol Okada, Alexandria Forte, Janice Hanson, Lindsey Lane, Tai Lockspeiser, Adam Rosenberg

University of Minnesota
John Andrews (Team Leader), Emily Borman-Shoap, Katherine Murray, Patricia Hobday, Dani Hans, Kathleen Brooks, Robert Acton

University of Utah
James Bale (Team Leader), Adam Stevenson, Jaime Bruse, Brian Good, Danielle Roussel, Tiffany Glasgow

References:

1. Flexner A. Medical Education in the United States and Canada. New York, NY: Carnegie Foundation for the Advancement of Teaching; 1910.
2. Learning Objectives for Medical Student Education: Guidelines for Medical Schools. Association of American Medical Colleges: Washington, DC: 2010.
3. Outcomes Project. The Accreditation Council for Graduate Medical Education, Chicago, IL, 2001.
4. Cooke M, Irby DM and O’Brien BC. Educating Physicians: A Call for Reform of Medical School and Residency. Carnegie Foundation for the Advancement of Teaching. Jossey-Bass: San Francisco: 2010.
5. Ogur B, Hirsh D, Krupat E, Bor D. The Harvard Medical School-Cambridge integrated clerkship: an innovative model of clinical education. Academic Medicine, 2007: 82 (4); 397-404.
6. Hirsh DA, Ogur B, Thibault GE, Cox M. Continuity as an organizing principle for clinical educational reform. N Engl J Med 2007;356:858–66.
7. Kegan, Robert. The Evolving Self. Harvard University Press, 1982. ISBN 0674272315