1. Options for dealing with thresholds

2. Option 1 Build a threshold description into the Performance framework

3. Internal Medicine Component ID: 12345 Competency: Description: http://www.example.org/im_milestones/PC1.xml Type: http://ns.medbiq.org/competencyobject/v1/http://www.example.org/im_milestones/PC1.xmlhttp://ns.medbiq.org/competencyobject/v1 Competency: Description: http://www.example.org/im_framework.xml Type: http://ns.medbiq.org/competencyframework/v1/http://www.example.org/im_framework.xmlhttp://ns.medbiq.org/competencyframework/v1 Title: Gathers and synthesizes essential and accurate information to define each patient’s clinical problem(s).

4. Performance level set Performance Scale Reference: 1 to 5 Position: 1Score: Single Value: 1 Label: Critical Deficiencies Indicator (id = i1_1): Does not collect accurate historical data Indicator (id = i1_2): Does not use physical exam to confirm history Indicator (id = i1_3): Relies exclusively on documentation of others to generate own database or differential diagnosis Indicator (id = i1_4): Fails to recognize patient’s central clinical problems Indicator (id = i1_5): Fails to recognize potentially life threatening problems

5. Position: 2Score: Single Value: 2 Label: Indicator (id = i2_1): Inconsistently able to acquire accurate historical information in an organized fashion Indicator (id = i2_2): Does not perform an appropriately thorough physical exam or misses key physical exam findings Indicator (id = i2_3): Does not seek or is overly reliant on secondary data Indicator (id = i2_4): Inconsistently recognizes patients’ central clinical problem or develops limited differential diagnoses Position: 3Score Single Value: 3 Label: Indicator (id = i3_1): Consistently acquires accurate and relevant histories from patients Indicator (id = i3_2): Seeks and obtains data from secondary sources when needed Indicator (id = i3_3): Consistently performs accurate and appropriately thorough physical exams Indicator (id = i3_4): Uses collected data to define a patient’s central clinical problem(s)

6. Position: 4Score: Single Value: 4 Label: Ready for unsupervised practice Threshold Description: Entrustment Indicator (id = i4_1): Acquires accurate histories from patients in an efficient, prioritized, and hypothesis-driven fashion Indicator (id = i4_2): Performs accurate physical exams that are targeted to the patient’s complaints Indicator (id = i4_3): Synthesizes data to generate a prioritized differential diagnosis and problem list Indicator (id = i4_4): Effectively uses history and physical examination skills to minimize the need for further diagnostic testing

7. Position: 5Score Single Value:5 Label: Aspirational Indicator (id = i5_1): Obtains relevant historical subtleties, including sensitive information that informs the differential diagnosis; Indicator (id = i5_2): Identifies subtle or unusual physical exam findings Indicator (id = i5_3): Efficiently utilizes all sources of secondary data to inform differential diagnosis Indicator (id = i5_4): Role models and teaches the effective use of history and physical examination skills to minimize the need for further diagnostic testing

8. Option 2 Develop a companion specification that describes the thresholds associated with a performance framework.

9. Threshold Performance Framework Component: http://www.acgme- nas.org/assets/InternalMedicineMilestones#12345 Score: 4 Threshold Description: Entrustability

10. Pros and Cons Option 1 Pros – We could address now in the current specification – Simple – Regulatory bodies able to set thresholds more easily Option 1 Cons – Inflexible. Any addition of or change to a threshold would require a change to the identifier of the performance framework.

11. Pros and Cons Option 2 Pros – Flexible. Programs can modify thresholds while using a consistent performance framework. Option 2 Cons – Requires development of a separate specification – More complex. Organizations specifying thresholds for their frameworks would need to distribute two documents and couldn’t “enforce” consistency in thresholds.