Core Competencies in Neurological Surgery: A Matrix Curriculum
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Transcript of Core Competencies in Neurological Surgery: A Matrix Curriculum
Core Competencies in Core Competencies in Neurological Surgery:Neurological Surgery:A Matrix CurriculumA Matrix Curriculum
Society of Neurological SurgeonsSociety of Neurological SurgeonsAmerican Board of Neurological SurgeryAmerican Board of Neurological Surgery
ACGME Residency Review Committee for ACGME Residency Review Committee for Neurological SurgeryNeurological Surgery
The Matrix ProjectThe Matrix Project
Core CompetenciesCore Competencies
• SynthesisSynthesis– SNS SNS
• Committee on Resident Education (CoRE)Committee on Resident Education (CoRE)– Content editorContent editor
– ACGMEACGME• Format Format
– ABNSABNS• Medical KnowledgeMedical Knowledge
– RRCRRC• Technical SkillsTechnical Skills
Both organizations deal with medical knowledge and technical skills
Neurological Surgery CurriculumNeurological Surgery Curriculum
• Consistent with ACGME formatConsistent with ACGME format– Core competenciesCore competencies
• Consistent with ABNSConsistent with ABNS– Primary exam contentPrimary exam content– Oral exam contentOral exam content
• Consistent with RRC goalsConsistent with RRC goals– InstitutionalInstitutional– Chief Resident casesChief Resident cases
CompetenciesCompetencies
• ObjectivesObjectives– ACGME Core CompetenciesACGME Core Competencies– Primary exam categories, key wordsPrimary exam categories, key words– RRC case categoriesRRC case categories
• Teaching methodsTeaching methods– Reading, lecture, modules, Bootcamp, hands on, etcReading, lecture, modules, Bootcamp, hands on, etc
• Assessment toolsAssessment tools– PD, SANS, Primary exam, 360 evals, etcPD, SANS, Primary exam, 360 evals, etc
• Educational goalsEducational goals
Early LearnerEarly Learner
CompetentCompetent
ProficientProficient
ExpertExpert
UnsatisfactoryUnsatisfactory
Progression
Physician Performance Diagnostic Physician Performance Diagnostic InventoryInventory
• Rarely demonstrates competence AND is unexpected to Rarely demonstrates competence AND is unexpected to become competent within the assigned time frame. become competent within the assigned time frame.
• Consistently makes poor decisions or has a consistently Consistently makes poor decisions or has a consistently unsatisfactory approach to solving problems that results in unsatisfactory approach to solving problems that results in poor care delivery or unacceptable behavior. poor care delivery or unacceptable behavior.
• Repeatedly appears incapable of understanding concepts, Repeatedly appears incapable of understanding concepts, performing tasks, exercising judgment or demonstrating performing tasks, exercising judgment or demonstrating behaviors that are important to show ability to learn the behaviors that are important to show ability to learn the element being evaluated.element being evaluated.
UnsatisfactoryUnsatisfactory
• Demonstrates competence occasionally; usually shows ability Demonstrates competence occasionally; usually shows ability to learn in routine, repetitive or non-stressful situations to learn in routine, repetitive or non-stressful situations
• Requires supervisionRequires supervision• Incapable or inconsistent in using experience to address Incapable or inconsistent in using experience to address
circumstances that are unexpected or non-typicalcircumstances that are unexpected or non-typical• The early learner is at a novice level and shows aptitude but The early learner is at a novice level and shows aptitude but
has not yet had sufficient experience, training or skill has not yet had sufficient experience, training or skill acquisition to achieve competenceacquisition to achieve competence
• Unlike the unsatisfactory (who believes they already know it Unlike the unsatisfactory (who believes they already know it all), wants to engage in learningall), wants to engage in learning
Early LearnerEarly Learner
• Demonstrates competence most of the time and under routine Demonstrates competence most of the time and under routine circumstances circumstances
• Can perform without supervision in usual or predictable Can perform without supervision in usual or predictable circumstancescircumstances
• Has developed adequate internal resources, knowledge or skills to Has developed adequate internal resources, knowledge or skills to make good decisions or perform acceptably in routine cases make good decisions or perform acceptably in routine cases
• IMPORTANTLY, the competent physician recognizes limitations and IMPORTANTLY, the competent physician recognizes limitations and accesses support when needed, especially for more challenging accesses support when needed, especially for more challenging situations situations
• This is the level expected from those at the completion of training This is the level expected from those at the completion of training and indicates that they can effectively address the majority of and indicates that they can effectively address the majority of routine situations and will access support when needed in other routine situations and will access support when needed in other cases.cases.
CompetentCompetent
• Demonstrates competence most of the time and under most Demonstrates competence most of the time and under most circumstances through applying intuition to guide an analytical circumstances through applying intuition to guide an analytical thought process in complex and unpredictable situations thought process in complex and unpredictable situations
• Has a good grasp of information, excellent skills and sound Has a good grasp of information, excellent skills and sound principles and applies them to guide actions in unusual or principles and applies them to guide actions in unusual or challenging circumstances challenging circumstances
• Is consistently trusted to deal effectively with complex problems Is consistently trusted to deal effectively with complex problems • Has developed enough internal understanding, ability to flexibly Has developed enough internal understanding, ability to flexibly
apply knowledge and sufficient skills that they can reliably apply knowledge and sufficient skills that they can reliably handle challenging situations without the need for external handle challenging situations without the need for external support.support.
ProficientProficient
• Demonstrates competence almost always through understanding the Demonstrates competence almost always through understanding the conceptual whole with appropriate intuitiveness and adaptability to conceptual whole with appropriate intuitiveness and adaptability to the circumstancethe circumstance
• Can recognize errors or inadequacies in knowledge, judgment, skills or Can recognize errors or inadequacies in knowledge, judgment, skills or behavior in complex situations and is capable of effective remediation behavior in complex situations and is capable of effective remediation
• Is a persuasive lifelong learnerIs a persuasive lifelong learner• Understands the contextual “whole” and is fluid and flexible in Understands the contextual “whole” and is fluid and flexible in
performanceperformance• Has a seeming 6th sense (or a well developed “internal gyroscope”) of Has a seeming 6th sense (or a well developed “internal gyroscope”) of
how to respond to even the most unpredictable and challenging how to respond to even the most unpredictable and challenging situations. Is a resource mentor, teacher, and role model in this area.situations. Is a resource mentor, teacher, and role model in this area.
ExpertExpert
Early LearnerEarly Learner
CompetentCompetent
ProficientProficient
ExpertExpert
UnsatisfactoryUnsatisfactory
Junior Resident (R1-2)*Junior Resident (R1-2)*
Senior Resident (R3-6)*Senior Resident (R3-6)*
Chief Resident/Junior StaffChief Resident/Junior Staff
UsUs
FailFail
Physician Performance Diagnostic Physician Performance Diagnostic InventoryInventory
*RRC definitions
Matrix CurriculumMatrix Curriculum
• Educational goals will varyEducational goals will vary– Training levelTraining level– SubspecialtySubspecialty
• Successful residents will not be EXPERTSuccessful residents will not be EXPERT– Highest level of expectation will be PROFICIENCYHighest level of expectation will be PROFICIENCY
• e.g., Complex spinal surgerye.g., Complex spinal surgery
– Lowest level will be EARLY LEARNERLowest level will be EARLY LEARNER• e.g., Endovascular Surgical Neuroradiologye.g., Endovascular Surgical Neuroradiology
Matrix CurriculumMatrix CurriculumCompetency Objective Teaching
MethodsAssessment
ToolsEducational
Goals
Medical Knowledge and
Skills
Neuroanatomy •Lecture series•Textbooks•AANS/SNS On-line modules•Resident courses•Bootcamps
•Inservice Exams•SANS•ABNS Primary Exam
Proficient(4)
Matrix CurriculumMatrix Curriculum
Competency Objective Teaching Methods
Assessment Tools
Educational Goals
Medical Knowledge(Technical
Skills)
• Lumbar Puncture• Ventriculostomy• CSF Sample• Shunt tap• Traction• Stereotactic frame
placement
•AANS/SNS On-line modules•Conferences•Supervised learning •Bootcamp
•Faculty and Program Director evaluations
Proficient(4)
Training Level : PGY1
Matrix CurriculumMatrix Curriculum
Competency Objective Teaching Methods
Assessment Tools
Educational Goals
Medical Knowledge(Technical
Skills)
• Craniotomy for Aneurysm clipping
• Aneurysm coiling
•AANS/SNS On-line modules•Conferences•Supervised learning
•Faculty/ Program Director evaluations
• Competent(3)
• Early learner
(2)
Training Level : PGY7
Cerebrovascular CompetenciesCerebrovascular Competencies
Milestone Competency ABNSKeyword
Oral ExamTopic
TechnicalSkill
RRC CatCase?
Teaching Method
AssessmentTools
PPDIJ/S/C
Understand AngiographyPARQ
Medical knowledge
Imaging/angiography
Imaging/angiography
N/A No Lecture/reading Primary exam S3C4
Place femoral arterial catheter
Neuroanatomy N/A Imaging/angiography
Endovascular surgical neuroradiology
No Hands-on PD/faculty S3C3
Know anatomy of intracranial vessels
Medical knowledge
Neuroanatomy/vascular
Imaging/angiography
N/A No Lecture/reading Primary exam J2S3 C4
Medical KnowledgeMedical Knowledge
• ABNS Primary Exam CategoriesABNS Primary Exam Categories– A: AnatomyA: Anatomy– B: NeurobiologyB: Neurobiology– C: PathologyC: Pathology– D: ImagingD: Imaging– E: NeurologyE: Neurology– F: NeurosurgeryF: Neurosurgery– G: Critical CareG: Critical Care– H: Core CompetenciesH: Core Competencies
Medical knowledgeMedical knowledge
Medical KnowledgeMedical Knowledge
Medical KnowledgeMedical Knowledge
Technical SkillsTechnical Skills
RRC Case Categories(Proposed)
Matrix CurriculumMatrix Curriculum
• Adheres to ACGME formatAdheres to ACGME format• Uses established goals of ABNS and RRCUses established goals of ABNS and RRC• Acknowledges levels of educational goalsAcknowledges levels of educational goals• Requires more integration of stakeholdersRequires more integration of stakeholders
– SNSSNS– ABNSABNS– RRCRRC
• It can be rapidly implementedIt can be rapidly implemented• It is a dynamic process It is a dynamic process
Process for the Matrix ProjectProcess for the Matrix Project SNS, ABNS and RRC agree to proceed with Matrix SNS, ABNS and RRC agree to proceed with Matrix
ProjectProject Pilot proposals under development in Pilot proposals under development in
Neurointensive CareNeurointensive Care and and Endovascular Surgical Endovascular Surgical NeuroradiologyNeuroradiology
ABNS agrees to appoint SNS representatives to ABNS agrees to appoint SNS representatives to Primary Exam CommitteePrimary Exam Committee
• SNS bylaws change to place ABNS and RRC SNS bylaws change to place ABNS and RRC representatives on SNS Council (ad hoc)representatives on SNS Council (ad hoc)
Process for the Matrix ProjectProcess for the Matrix Project Orientation of Joint Section leadership to the ProjectOrientation of Joint Section leadership to the Project
AANS annual meeting, Denver, CO April 10-14, 2011AANS annual meeting, Denver, CO April 10-14, 2011
• Orientation of SNS members to the Project Orientation of SNS members to the Project – SNS annual meeting, Portland, OR May 21-24, 2011SNS annual meeting, Portland, OR May 21-24, 2011
Joint Sections
SNS Curriculum Sub-Committee
SNS CoRE Committee
SNS Council
SNS Members and PDs
Subspecialty specific curriculum initiation
Development of curriculum proposal
Ensure proposal inMatrix format
Vet curriculum proposal
Final Approval of Matrix curriculum element
Pass proposal toSNS Members and PDs
Comments, suggestions,and revisions
The ACGME Milestones ProjectThe ACGME Milestones Project
ACGME Milestones ProjectACGME Milestones Project
• Translate “general” competencies into specific Translate “general” competencies into specific competencies to be met by all residentscompetencies to be met by all residents
• Create “core” resident outcomes in the Create “core” resident outcomes in the competencies, not “standardization” of all competencies, not “standardization” of all outcomes. outcomes.
Current CurriculaCurrent Curricula
“Educate” residentsCurriculum “time-based”
Choose educational experiences within institution,
faculty
Identify/develop evaluation tools -formative-summative
“Circumstantial Practice”
Future CurriculaFuture Curricula
Produce proficientProduce proficientphysicians physicians
The requiredThe requiredoutcomesoutcomes in each in each domain of Clinical domain of Clinical
Competency (Milestones)Competency (Milestones)
DesignDesign educational educational Experiences,Experiences,
rotations, facultyrotations, faculty
National evaluation tools to measure outcomeNational evaluation tools to measure outcome -formative and summative-formative and summative-clinical outcomes tracking-clinical outcomes tracking
““Intentional Practice”Intentional Practice”
External accountabilityExternal accountabilityfor outcome for outcome
New knowledge or skill set
Entrustable Professional ActivitiesEntrustable Professional Activities
• Equating competency with the point at which Equating competency with the point at which one is ready to practice a a static viewone is ready to practice a a static view
• Competence is content and context specificCompetence is content and context specific• Notion of context fits well with Milestones Notion of context fits well with Milestones
and “entrustable professional activities” and “entrustable professional activities” (EPAs)(EPAs)
Entrustable Professional ActivitiesEntrustable Professional Activities
• Professional life activities that define the specialtyProfessional life activities that define the specialty• Ground the competencies in the everyday work of Ground the competencies in the everyday work of
the physicianthe physician• Activities lead to some output or outcome that can Activities lead to some output or outcome that can
be observedbe observed• Complexity of the activities requires an integration of Complexity of the activities requires an integration of
knowledge, skills, and attitudes across competency knowledge, skills, and attitudes across competency domainsdomains
• 50-100 per specialty50-100 per specialty
Entrustment and CompetenceEntrustment and Competence
• Entrustment occurs when direct supervision is no Entrustment occurs when direct supervision is no longer neededlonger needed
• Faculty understand entrustment more than Faculty understand entrustment more than competencecompetence
• Entrustment infers competenceEntrustment infers competence• Doesn’t suggest that graduating residents reach a Doesn’t suggest that graduating residents reach a
standard of performance to practice every EPA without standard of performance to practice every EPA without direct supervisiondirect supervision
• Opens the door for structured learning after residency Opens the door for structured learning after residency as part of MOC as part of MOC
Back to the Future?Back to the Future?
• Similarities with Apprenticeship modelSimilarities with Apprenticeship model– Relationships are criticalRelationships are critical– Assessment is embedded in a clinical setting taking care of Assessment is embedded in a clinical setting taking care of
real patientsreal patients– Direct observation (not inference) is keyDirect observation (not inference) is key
• Differences from Apprenticeship modelDifferences from Apprenticeship model– Expanded competenciesExpanded competencies– Move from random to deliberate curriculumMove from random to deliberate curriculum– EPAs and competencies require each other for meaningEPAs and competencies require each other for meaning
Milestones Project StatusMilestones Project Status• Draft products createdDraft products created
– Internal MedicineInternal Medicine– PediatricsPediatrics– General SurgeryGeneral Surgery
• Development underwayDevelopment underway– UrologyUrology– Obstetrics-GynecologyObstetrics-Gynecology
• Poised to beginPoised to begin– OpthalmologyOpthalmology– RadiologyRadiology– Transitional yearTransitional year– Neurological SurgeryNeurological Surgery
Where Do We Start?Where Do We Start?
ACGME invitation or specialty expression of ACGME invitation or specialty expression of interestinterest
Certification board and ACGME conversationCertification board and ACGME conversation• Decide on structure, working group chair, and Decide on structure, working group chair, and
membershipmembership• Get started with ACGME staff directionGet started with ACGME staff direction
Group Organization and Group Organization and MembershipMembership
• Working group (n=10-15) MD educational Working group (n=10-15) MD educational experts (Board, RRC, PD organization); 2-3 experts (Board, RRC, PD organization); 2-3 ACGME staffACGME staff
• Advisory group (n=3-13) Organizational Advisory group (n=3-13) Organizational leaders (Board, ACGME, RRC, specialty leaders (Board, ACGME, RRC, specialty organizations)organizations)
Charge to the Milestone GroupCharge to the Milestone Group
• Develop milestonesDevelop milestones– Milestone – behavior, attitude, or outcome Milestone – behavior, attitude, or outcome
related to general competency domains related to general competency domains that that describe a significant accomplishment expected of describe a significant accomplishment expected of a resident a resident by a particular point in timeby a particular point in time
• Identify assessment toolsIdentify assessment tools– Vital, since this is where Outcomes Project failedVital, since this is where Outcomes Project failed
Cerebrovascular MilestonesCerebrovascular Milestones
Milestone Competency ABNSKeyword
Oral ExamTopic
TechnicalSkill
RRC CatCase?
Teaching Method
AssessmentTools
PPDIJ/S/C
Understand AngiographyPARQ
Medical knowledge
Imaging/angiography
Imaging/angiography
N/A No Lecture/reading Primary exam S3C4
Place femoral arterial catheter
Neuroanatomy N/A Imaging/angiography
Endovascular surgical neuroradiology
No Hands-on PD/faculty S3C3
Know anatomy of intracranial vessels
Medical knowledge
Neuroanatomy/vascular
Imaging/angiography
N/A No Lecture/reading Primary exam J2S3 C4
SummarySummary
• Neurological Surgery is a the beginning of a process to Neurological Surgery is a the beginning of a process to redefine residency curriculumredefine residency curriculum– The Matrix ProjectThe Matrix Project
• This project will coordinate the efforts of SNS, ABNS This project will coordinate the efforts of SNS, ABNS and the RRCand the RRC
• The AANS and CNS will participate through their Joint The AANS and CNS will participate through their Joint Sections, and Executive CommitteesSections, and Executive Committees
• This process will converge with an effort by ACGME to This process will converge with an effort by ACGME to redefine how residents are trainedredefine how residents are trained– The Milestones ProjectThe Milestones Project