1. Should We Entrust Learners to Ask Answerable Questions? Evidence-Based Clinical Practice McMaster University June 2014

2. Cast of Characters Tom McGinn, MD Chair of Medicine Hoffstra Univ, New York Scott Richardson, MD Assoc Dean, UME GRU/UGA Partnership Mark Wilson, MD Assoc Dean, GME Univ of Iowa

3. Turning Over the Keys

4. Why??? Gaps Identified between: Program Director Expectations and Skills of Entering Residents What residents do without supervision and what they have been documented as competent to do without supervision Charge to Drafting Panel Develop a clear, concise list of what graduating medical students should be entrusted to do without direct supervision on DAY ONE of residency

5. Core Entrustable Professional Activities (EPAs) for Entering Residency (CEPAER): Report of the Drafting Panel AAMC Annual Meeting 2013

6. Specific units of professional work Tasks that trainees are entrusted to perform unsupervised After they’ve attained sufficient competence Olle ten Cate Acad Med 2007 Entrustable Professional Activity Ability to perform a task to a desired level of performance without direct supervision

7. EPA DOC M1M1 M2M2 M1M1 M2M2 M1M1 M2M2 M1M1 M2M2 M1M1 M2M2 M1M1 M2M2 EPA: Entrustable Professional Activity DOC: Domain of Competence C: Competency M: Milestone C2C2 C3C3 C1C1 C4C4 C2C2 C5C5

8. Delineated a set of activities that entering residents should be expected (entrusted) to perform on day one of residency without direct supervision. 13 core EPAs for entering residency ranging from: - give patient handover to transition care - recognize patient requiring urgent care - to obtain informed consent EPA #7: Form clinical questions and retrieve evidence to advance patient care Drafting Panel Work http//:mededportal.com/icollaborative/resource/887

9. Core EPAs For Entering Residency EPAs For any Practicing Physician Expectations for the Medical School Graduate EPAs For Specialties

10. ‘Entrustable’ Requires Direct Observation of: Level of K/S/A (Ability) Hard work & follow through (Conscientious) Absence of deception (Truthfulness) Knowing one’s limits (Discernment) Tara Kennedy Academic Medicine 2008

11. What does this have to do with teaching or EBM???

12. Ask Acquire Appraise Apply Action Patient Dilemma Evidence Cycle of EBM

13. Ask Acquire Appraise Apply Action Patient Dilemma

14. Let’s Listen in on Tom’s 2am New Admission

15. ‘Background’ Questions About the disorder, test, treatment, etc. 2 components: a. Root* + Verb: “What causes …” b. Condition: “… cystic fibrosis?” * Who, What, Where, When, Why, How ‘RVC’ = Root, Verb, Condition

16. ‘Foreground’ Questions About patient care decisions and actions 4 (or 3) components: a. patient, problem, or population b. intervention, exposure, or maneuver c. comparison (if relevant) d. clinical outcomes (including time horizon) ‘PICO’ = Patient, Intervention, Comparison, Outcomes

17. Background & Foreground

18. How does it feel … ? To know an answer? To NOT know an answer?

19. Emotions in Not Knowing Ready to …FeelingBehaviors FleeFearLeave Invisible FightAngerDisrupt Undermine Cry for helpDistressStop trying Body stress WithdrawSadnessInattention Detachment

20. Guiding or Coaching ‘Qs’? Try building up from ‘raw’ question to more complete anatomy (rather than tearing their efforts down) Consider 2 stages: “Sounds like you’re asking a question about … (therapy, prognosis, etc.)” “What would be the … (missing anatomy) you would want to know?”

21. Now, listen closely for how this may sound…

22. ‘Hoot Groups’ Task Groups of 2 – 3 What specifically could you implement back home to ensure that your learners can ask answerable clinical questions? Return in 3 minutes

23. Entrusting Clinical Questions

24. Ask Acquire Appraise Apply Action Patient Dilemma