Milestone Compatible Neurology Faculty of Resident Evaluation Template

Transcription

1 Milestone Compatible Neurology Faculty of Resident Evaluation Template Lyell K. Jones, Jr., MD Mayo Clinic Department of Neurology 200 First Street SW Rochester, MN Overview Traditional Likert style evaluation scales do not translate easily to the milestone based assessments required in the ACGME s Next Accreditation System (NAS). While it may be tempting to use the milestone domains themselves as the faculty of resident evaluation format, the milestones were not intended to serve as direct evaluation tools. The template outlined below represents one strategy to design an evaluation format that 1) is practical, intuitive, reasonably comprehensive, 2) directly informs each of the neurology milestone domains/subcompetencies. The approach uses two question types: 1) questions derived from the milestones, 2) questions based on entrustable professional activities (EPAs). For example, the Neurological Exam/Patient Care domain includes in Levels 3 4 several discrete skills (visualize papilledema, perform a coma exam, perform a brain death exam):

2 This domain highlights the difficulty in using individual subcompetencies as stalone evaluation questions. A trainee may have achieved the overall level of skill required to perform examinations in independent practice (ie, can efficiently perform a relevant al exam accurately incorporating all additional maneuvers as in Level 4), but could be stuck at Level 3 if assessment of ability to visualize papilledema has not been performed. By removing these three items, or roadblocks, an intuitive developmental progression of overall examination skill remains, upon which an evaluation question can be based:

3 To ensure that the ability to visualize papilledema, perform a coma exam, perform a brain death exam are all assessed, an EPA can be developed for each graded on an entrustment scale. Each EPA can then be mapped to the domain level. For example, the papilledema EPA could be mapped to Level 3 of the Neurologic Exam/Patient Care domain: 1. Recognize The trainee cannot The trainee can The trainee can The trainee can perform The trainee has papilledema on ophthalmoscopy perform this task even with direct supervision or perform this task, but requires direct supervision or perform this task with indirect supervision (ie, supervisor not present) this task without supervision (ie, could do this in independent mastered this task (ie, could train others to perform assistance assistance practice) this task)

4 Included below are 29 milestone type questions 33 complementary neurology EPAs derived from the milestones, which collectively can serve as a core set of faculty of resident evaluation questions for neurology residency programs accredited by the ACGME. The table of questions includes the milestone domain informed by the question, room in the right h column to record which rotation or educational activity to which the question can be assigned for any individual program. For example, one might assign the cerebrovascular milestone question to a stroke service rotation, or the headache emergencies EPA to a consult service rotation. Faculty development is required to explain differences inherent in this evaluation approach, for example indicating that even very good junior trainees will often be scored at lower levels, that all lower levels must be achieved to assign a given milestone level. Clinical competency committees can then use results from these evaluation tools to more accurately inform their biannual milestone assessments for each resident. In summary, this list serves as a core set of questions which inform all of the neurology milestone domains. It is not intended to be a comprehensive assessment set for all programs. Individual residency programs would be encouraged to supplement this list based on their individual program needs. Neurology Milestone type Questions For these questions, the evaluator is asked to select the most level based on his/her experience with the trainee: Milestone based Evaluation Questions Evaluator instructions: most level for each of the questions below, based on your experience with this trainee from this rotation. Please note that to select a level, every item in all lower levels must have been achieved. Scale Milestone domain(s) Question Rotations or other education activities to which the question can be assigned:

5 best description of history taking skills Obtains a history Obtains a complete relevant history Obtains a complete, relevant, organized history Efficiently obtains a complete, relevant, organized history Efficiently obtains a complete, relevant, organized history incorporating subtle verbal nonverbal cues History/PC Eg, continuity clinic or general hospital service rotation best description of exam skills Performs complete al exam Performs complete al exam accurately Performs a relevant al exam incorporating some additional maneuvers Efficiently performs a relevant al exam accurately incorporating all additional maneuvers Consistently demonstrates mastery in performing a complete, relevant, organized al exam Neurological Exam/PC ability to manage disease basic knowledge of of patients with disease Discusses general approach to initial treatment of, including risks benefits of treatment Individualizes treatment for specific patients Adapts treatment based on patient response, identifies complications of therapy sophisticated knowledge of treatment subtleties controversies Management/ Treatment/PC patient may have a disorder disorder phenomenolo gy categories (hypokinetic hyperkinetic) Diagnoses, ly refers a disorder patient for a surgical evaluation or other interventional therapies engages in (e.g., teaching, Movement Disorders/PC

6 neuromuscular patient may have a neuromuscula r disorder patterns of neuromuscula r disease (e.g., anterior horn cell disease, nerve root, plexus, peripheral nerve, neuromuscula r junction, muscle) neuromuscula r Diagnoses neuromuscula r neuromuscula r engages in neuromuscula r (e.g., teaching, Neuromuscula r Disorders/PC cerebrovascular patient may have a cerebrovascul ar disorder stroke syndromes etiologic subtypes identifies cerebrovascul ar emergencies specific mechanism of patient s cerebrovascul ar disorder Diagnoses cerebrovascul ar cerebrovascul ar engages in cerebrovascul ar (e.g., teaching, Cerebrovascul ar Disorders/PC cognitive/behavi oral patient may have a cognitive/beh avioral disorder cognitive/beh avioral cognitive/beh avioral, including cognitive effects of traumatic brain injury cognitive/beh avioral cognitive/beh avioral (e.g., teaching, demonstrates sophisticated knowledge of advanced testing controversies Cognitive/Beh avioral Disorders/PC patient may have a disorder acute presentations of Diagnoses engages in (e.g., teaching, Demyelinating Disorders/PC

7 epilepsy patient may have had a seizure epilepsy phenomenolo gy, classification of seizures epilepsies seizure provides antiepileptic drug treatment Diagnoses seizure, ly refers an epilepsy patient for surgical evaluation or other interventional therapies seizure engages in epilepsy (e.g., teaching, Epilepsy/PC headache syndromes headache syndromes headache syndromes headache syndromes headache syndromes headache syndromes (e.g., teaching, Headache Syndromes/PC manifestation of systemic disease patient s symptoms may be due to systemic illness manifestation s of systemic diseases manifestation s of systemic disease manifestation s of systemic disease manifestation s of systemic disease (e.g., teaching, Neurologic Manifestations of Systemic Disease/PC child neurology patients Obtains basic history of infants children Lists the elements of a al examination of infants children, recognizes broad patterns of disease in infants children, lists normal developmenta l milestones Obtains a complete age history of infants children, performs a complete age al examination of infants children, diagnoses child Initiates of childhood, initiates of emergencies in infants children Diagnoses childhood Child Neurology for the Adult Neurologist

8 neuro oncology patients clinical presentations of a brain or spine mass neurooncological emergencies initiates Provides differential diagnosis of brain or spine mass Appropriately refers for advanced testing, including biopsy neurooncology (e.g., teaching, Neuro Oncology/PC patient may have a disorder obtains an history identifies comorbidities in a disease patient s al symptoms are of origin, recognizes patient s symptoms are of origin, identifies major side effects of medications Diagnoses initiates of co morbidities in patients with a disease (e.g., teaching, Psychiatry for the Adult Neurologist/P C ability to interpret neuroimaging studies basic neuroanatomy on brain MR (magnetic resonance ) CT (computerized tomography) basic neuroanatomy on spine MR CT abnormalities of the brain spine on MR CT Interprets MR CT neuroimaging of brain spine Interprets carotid transcranial ultrasound Neuroimaging/ PC understing of electroencephalo graphy (EEG) Explains an EEG procedure in non technical terms Uses terminology related to EEG (e.g., montage, amplitude, frequency) normal EEG features of wake sleep states Interprets EEG abnormalities creates a report Interprets EEG abnormalities, describes normal some abnormal EEG features of wake sleep states in children Electroenceph alogram (EEG)/PC

9 understing of ability to perform electro studies (NCS/EMG) Explains an NCS/EMG procedure in nontechnical terms Uses terminology related to NCS/EMG NCS/EMG data lists NCS/EMG findings in Interprets NCS/EMG data in Performs, interprets, creates a report for NCS/EMG Nerve Conduction Studies (NCS)/Electro myography (EMG)/PC ability to perform lumbar puncture Lists the indications contraindicati ons for lumbar puncture Lists the complications of lumbar puncture their Performs lumbar puncture under direct supervision Performs lumbar puncture without direct supervision Performs lumbar puncture on challenging anatomy Lumbar Puncture/PC ability to localize lesions Attempts to localize lesions within the nervous system, describes basic neuroanatomy Localizes lesions to general regions of the nervous system Accurately localizes lesions to specific regions of the nervous system Efficiently accurately localizes lesions to specific regions of the nervous system, describes advanced neuroanatomy Consistently demonstrates sophisticated detailed knowledge of neuroanatomy in localizing lesions Localization/M K ability to formulate cases Summarizes history exam findings Summarizes key elements of history exam findings identifies relevant pathophysiolo gic categories to generate a broad differential diagnosis Synthesizes information to focus prioritize possibilities Efficiently synthesizes information to focus prioritize possibilities, continuously reconsiders differential in response to changes in clinical circumstances Consistently demonstrates sophisticated detailed knowledge of pathophysiolo gy in diagnosis, effectively educates others about reasoning Formulation/ MK

10 ability to design execute a evaluation general knowledge of tests in neurology Discusses general approach to clinical presentation, lists risks benefits of tests to patient Individualizes approach to the specific patient, accurately interprets results of tests Accurately interprets results of less testing sophisticated knowledge of testing controversies Diagnostic investigation/ MK professionalism compassion, sensitivity, responsivenes s to patients families, demonstrates nondiscriminatory behavior in all interactions, including diverse vulnerable populations, describes effects of sleep deprivation substance abuse on performance steps to address impairment in self, consistently demonstrates professional behavior, including dress timeliness compassionat e practice of medicine, even in context of disagreement with patient beliefs, incorporates patients socio cultural needs beliefs into patient care, demonstrates steps to address impairment in colleagues Mentors others in the compassionat e practice of medicine, even in context of disagreement with patient beliefs, mentors others in sensitivity responsivenes s to diverse vulnerable populations, advocates for quality patient care activity regarding professionalis m Compassion, integrity, accountability, respect for self others Professionalis m adherence to ethical principles basic ethical principles Determines presence of ethical issues in practice Analyzes ethical issues in straightforwar d clinical situations Analyzes ethical issues in complex clinical situations leadership mentorship on applying ethical principles Knowledge about, respect for, adherence to the ethical principles relevant to the practice of medicine /Pr ofessionalism

11 ability to develop relationships, engage in teamwork, managing conflict Develops a positive relationship with patients in uncomplicate d situations, actively participates in team based care simple patient/family related conflicts conflict in complex situations conflict across specialties systems of care activity regarding teamwork conflict Relationship development, teamwork, managing conflict/ics ability to use medical informatics effectively Effectively communicates during patient h overs using a structured communicatio n tool, accurately documents transitions of care Educates patients about their disease, including risks benefits of treatment options, to promote patient safety Effectively communicates the results of a consultation in a timely manner, effectively gathers information from collateral sources when necessary Effectively leads family meetings, effectively ethically uses all forms of communicatio n Develops patient education materials, engages in activity regarding interpersonal communicatio n Information sharing, gathering, technology/ics best reflects the trainee s aptitude for selfdirected learning Acknowledges gaps in knowledge expertise Incorporates feedback Develops an learning plan based upon clinical experience Completes an learning plan based upon clinical experience activity regarding practice based learning improvement Self Directed Learning/PBLI best reflects the trainee s ability to integrate scientific literature into clinical care Uses information technology to search access relevant medical information Uses articles guidelines to answer patient care issues Critically evaluates scientific literature Incorporates evidencebased information into patient care, understs the limits of evidencebased medicine in patient care activity regarding evidencebased medicine Locate, appraise, assimilate evidence from scientific studies related to the patient s health problems/pbli

12 best reflects the trainee s ability to integrate costeffectiveness quality guidelines into clinical practice basic cost risk implications of care cost risk benefit ratios in patient care Makes clinical decisions that balance cost risk benefit ratios Incorporates available quality measures in patient care activity regarding cost riskeffective practice Systems thinking, including cost risk effective practice/sbp best reflects the trainee s ability to work in interprofessional teams to enhance patient safety team members roles in maintaining patient safety reports errors nearmisses potential sources of system failure in clinical care such as minor, major, sentinel events Participates in a team based approach to medical error analysis activity regarding error analysis patient safety Work in interprofessional teams to enhance patient safety/sbp Neurology Entrustable Professional Activities (EPAs) For these questions, the evaluator is asked to select the level of entrustment of ability to perform each task. Again, the papilledema example: 1. Recognize The trainee cannot The trainee can The trainee can The trainee can perform The trainee has papilledema on ophthalmoscopy perform this task even with direct supervision or perform this task, but requires direct supervision or perform this task with indirect supervision (ie, supervisor not present) this task without supervision (ie, could do this in independent mastered this task (ie, could train others to perform assistance assistance practice) this task) Entrustable Professional Activities (EPAs) Evaluator instructions: Based on your experience with this trainee, please choose the level that most ly describes the trainee's ability to perform each task. Milestone/Domain assignment(s) Rotations or other education activities to which the question can be assigned: Recognize papilledema on ophthalmoscopy Neurological Exam/PC Level 3 Eg, OSCE or neuro

13 ophthalmology rotation Accurately perform a al exam on the comatose patient Accurately perform a brain death examination Recognize manage emergencies Appropriately request consultations from non neurology subspecialty care providers for additional evaluation Neurological Exam/PC Level 3 Neurological Exam/PC Level 4 Formulation/MK Level 4 Management/Treatment/PC Level 2/3/4 Neurologic Manifestations of Systemic Disease/PC Level 1/2 Neuroimaging/PC Level 2 Management/Treatment/PC Level 3/4 Movement Disorders/PC Level 4 Cerebrovascular Disorders/PC Level 3 Cognitive/Behavioral Disorders/PC Level 3 Epilepsy/PC Level 4 Neuro Oncology/PC Level 4 Recognize manage disorder emergencies Recognize manage neuromuscular emergencies Appropriately order interpret electro testing Recognize when nerve or muscle biopsy is warranted Underst demonstrate use of systemic thrombolysis for acute ischemic cerebral infarction Appropriately refer for interventional or surgical evaluation of cerebrovascular Manage behavioral complications of cognitive/behavioral Appropriately refer for neuropsychological testing in evaluating cognitive/behavioral Movement Disorders/PC Level 3/4 Neuromuscular Disorders/PC Level 2/3 Neuromuscular Disorders/PC Level 2/3, Diagnostic investigation/mk Neuromuscular Disorders/PC Level 4 Cerebrovascular Disorders/PC Level 2/3 Cerebrovascular Disorders/PC Level 3 Cognitive/Behavioral Disorders/PC Level 3 Cognitive/Behavioral Disorders/PC Level 3 Identify, diagnose, manage emergencies due to systemic disease NeurologicManifestationsof Systemic Disease/PC Levels 1/2 Recognize manage convulsive nonconvulsive status epilepticus Recognize manage headache emergencies Identify manage complications of cancer or the treatment of cancer Epilepsy/PC Level 2/3 Headache Syndromes/PC Level 2/3 Neuro Oncology/PC Level 3/4

14 Recognize emergent imaging findings on brain MR CT Identify anatomy abnormalities on angiographic imaging (CTA, MRA, or conventional angiography) Neuroimaging/PC Level 2 Neuroimaging/PC Level 2/3/5 Recognize EEG patterns of status epilepticus Electroencephalogram (EEG)/PC Level 3 Recognize EEG artifacts Electroencephalogram (EEG)/PC Level 3 Recognize normal EEG variants Electroencephalogram (EEG)/PC Level 4 Describe pitfalls of NCS/EMG Formulate basic NCS/EMG plan for specific, clinical presentations Accurately correlate the patient s clinical presentation with the anatomy of their disorder Nerve Conduction Studies (NCS)/Electromyography (EMG)/PC Level 4 Nerve Conduction Studies (NCS)/Electromyography (EMG)/PC Level 4 Formulation/MK Level 3/4 Explain yield costeffectiveness of testing Recognize indications implications of genetic testing Recognize indications of advanced imaging other studies Diagnostic Investigation/MK Level 4 Diagnostic Investigation/MK Level 4 Diagnostic Investigation/MK Level 4 Use feedback to improve performance Self directed learning/pbli1 Level 2 Participate effectively in daily interdisciplinary team rounds with nursing, social work, pharmacy, other allied health colleagues Employ effective timely clinical documentation (for example, consultation, admission, exam, daily progress, or overnight events) Leads team based patient care activities Communicate use shared decision making with patients/families ly given the patient s level of impairment (for example, cognitive impairment, language dysfunction, alteration of awareness) Information sharing, gathering, technology/ics Level 2 Information sharing, gathering, technology/ics Levels 1 4 Relationship development, teamwork, managing conflict/ics Level 4 Relationship development, teamwork, managing conflict/ics Levels 2 3