ENDOCRINE ASSESSMENT TOOLS. NAS TASK FORCE June 2014 NAS TASK FORCE

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1 ENDOCRINE ASSESSMENT TOOLS NAS TASK FORCE June 2014 NAS TASK FORCE Ashok Balasubramanyam, MD Ann Danoff, MD Carmel Fratianni, MD Geetha Gopalakrishnan, MD Larry Katznelson, MD Susan Mandal, MD Joshua Safer, MD Dace Trence, MD Pam Taxel, MD Baylor College of Medicine New York University Southern Illinois University Brown University Stanford University University of Pennsylvania Boston University University of Washington University of Connecticut

2 Milestones Reporting Milestones Uniform among all IM fellowships 23 milestones covering the six core competencies Fellows are assessed on a score of 1-9 ACGME Q 6 mo Curricular Milestones Subspecialty Specific Content 68 curricular milestone Endocrine specific content to assess reporting milestones Curricular milestones are not reported to ACGME Template can be modified to meet your specific program Reporting Milestones

3 Reporting Milestone Endocrine Curricular Milestones 4a. Skill in performing and interpreting invasive procedures (PC4a) A. Obtains informed consent (e.g. reviews the procedure, risks, benefits, alternate therapies and any conflict of interest) B. Maintains an accurate and updated procedure log C. Competently performs and/or interprets the following procedure (as per ABIM approved curriculum): 1) Thyroid ultrasound and nodule aspiration

4 Endocrine Curricular Milestone 4b. Skill in performing and interpreting noninvasive testing (PC4b) 12 mo 24 mo A. Obtains informed consent (e.g. reviews the procedure, risks, benefits, alternate therapies and any conflict of interest) B. Appropriately orders and interprets dynamic testing (e.g. suppression and stimulation testing) x x C. Competently coordinates, performs and/or interprets the following noninvasive procedures (as per ABIM approved curriculum): 1) Bone densitometry by DXA x 2) Insulin pump management x 3) Continuous glucose monitoring x Assessment tools to evaluate endocrine curricular milestones and inform clinical competency committee in the completion of reporting milestones Informs Reporting Milestones Faculty Evaluation Rotation assessment (e.g. inpatient, outpatient) Procedural assessment (e.g. Thyroid BX, DXA, CGM, IP) Scholarship assessment (e.g. research, presentations) Multisource Evaluation Allied Health Professionals Peer Patient ESAP Exam Results

5 New Evaluation Tools Goal Automate the evaluation process Simplify assessment of reporting milestones q 6mo Reviewed IM and other subspecialty programs Reviewed evaluation tools currently being used by Endocrine Program Directors Developed new evaluation tools Dreyfus model for skill acquisition Five stages: Novice, Competence, Proficiency, Expertise, Mastery Scale of 1 to 5 Incorporates the idea of entrustments (EPA) Entrustable Professional Activity Clinical competency based on the level of supervision required by trainees Level of Entrustment 1. Fellow cannot perform activity 2. Fellow can perform activity but requires direct supervision 3. Fellow can perform activity but requires occasional direct supervision 4. Fellow can perform activity independently 5. Fellow can act as instructor for activity

6 Five Clinical Entrustments for Endocrine General clinical skills Procedure skills Thyroid US and Biopsy Bone Density Continuous glucose monitor Insulin pump management Other Evaluation Scholarship Research Safety/QI Publication Presentation Multi-source evaluations Allied health professionals Peer Patient

7 Other Evaluation s Scholarship Evaluation 1. Fellow makes no effort to participate in scholarly activity 2. Fellow makes rudimentary effort to participate in scholarly activity 3. Fellow engages scholarly activities with significant guidance 4. Fellow engages scholarly activities with significant independence 5. Fellow is a role model for peers and colleagues Multisource Evaluations 1. Never 2. Rarely 3. Sometimes 4. Often 5. Always Mapping of Evaluation Reporting Milestone Curricular Milestone Clinical Evaluation Procedure Evaluations Multisource Evaluation Scholarship Assessment

8 Mapping of Evaluation CLINICAL EVALUATION 1.Obtains a complete history from review of medical records and clinical encounter 2.Performs a complete physical exam and is able identifies physical findings pertinent to the endocrine system 3. Knows the appropriate use, interpretation and limitations of radiologic, laboratory and dynamic testing. Utilizes testing in a clinically appropriate and cost-effective manner ENTRUSTABILITY SCORE (1-5) COMPETENCY REPORTING CURRICULAR MILESTONES MILESTONE PATIENT CARE PC1 PC1-A, PC1-C PATIENT CARE PC1 PC1-B, PC1-C PATIENT CARE, MEDICAL KNOWLEDGE, SYSTEM BASED PRACTICE, PROFESSIONALISM PC4b, MK2, SBP3,SBP4,P ROF3 PC4b-C, MK2-B, SBP3-A, SBP3-B, SBP4-B, PROF3-A Evaluation to Milestone Evaluation s Reporting Milestone Average score for each reporting milestone can be generated by electronic evaluation programs These can serve a starting point for discussion by the clinical competency committee

9 Entrustment 1. Fellow cannot perform activity 2. Fellow can perform activity but requires direct supervision 3. Fellow can perform activity but requires occasional direct supervision 4. Fellow can perform activity independently 5. Fellow can act as instructor for activity Clinical EPA: General Evaluation 1. Obtains a complete history from review of medical records and clinical encounter 2. Performs a complete physical exam and is able identifies physical findings pertinent to the endocrine system 3. Knows the appropriate use, interpretation and limitations of radiologic, laboratory and dynamic testing. Utilizes testing in a clinically appropriate and cost-effective manner 4. Analyzes clinical data, prioritizes medical problems and delivers cost-effective, quality patient care 5. Monitors clinical course, follow-up on test results and modifies care plan consistent with evidence based guidelines and standard of care 6. Engages and accommodates patients and families. Communicates in a clear, effective, culturally sensitive, ethical and professional manner 7. Collaborates and communicates effectively with other health care providers. Utilizes health information technology effectively. Maintains complete, accurate and timely records 8. Seeks guidance and/or consultation as appropriate. Improves performance based on self-reflection and feedback

10 Clinical EPA: General Evaluation Continued 9. Identifies, reports and develops solutions to problems in knowledge base, clinical care, ethics and/or patient safety 10. Transitions care between the inpatient and outpatient settings effectively. Utilizes outpatient visits and telephone management to minimize readmission where indicated. 11. Reviews and utilizes current literature to guide diagnostic and therapeutic decisions. Participates in professional development and continuing medical education activities. 12. Provides care for patients with a broad spectrum of endocrine disorders Adrenal Disorders Bone, Mineral and Parathyroid Disorders Diabetes and Hypoglycemia Gonadal Disorders Growth and Development Disorders Lipids Nutrition Obesity Pituitary and Neuroendocrine Disorders Reproductive Endocrinology including Pregnancy Thyroid Disorders

11 Procedure EPA: Thyroid Ultrasound and Biopsy 1. Recommends neck ultrasound and nodule aspiration consistent with evidence based guidelines 2. Interprets thyroid imaging (i.e. addresses image quality, parenchymal echotexture, vascularity and size of lobes in addition to size, location and sonographic features of nodule(s)) 3. Performs and documents thyroid ultrasound. Reports the following: Measurement of each thyroid lobe in 3 dimensions with description of thyroid parenchyma echotexture Measurement of isthmus in transverse view Measurement of each nodule of interest in 3 dimensions with description of location and sonographic features (echogenicity, composition, presence of calcifications, margins, vascularity) 4. Obtains informed consent for thyroid aspiration. Effectively reviews risks, benefits, alternatives and any conflict of interest where applicable Performs thyroid nodule aspiration: Accurately places needle in nodules of interest with ultrasound guidance Prepares the specimen for cytologic analysis Obtains samples adequate for diagnosis 5. Interprets thyroid nodule aspiration results Maintains an accurate and updated procedure log Yes No Interprets a minimum 5 Ultrasounds competently Yes No Performs a minimum 5 FNAs procedures competently Yes No Procedure EPA: Bone Densitometry 1. Recommends bone densitometry testing consistent with evidence based guidelines and reviews indications for central vs. peripheral DXA, risks, benefits, costs and any conflict of interest where applicable 2. Interprets Central DXA scan Recognizes proper patient positioning and scan analysis (PA spine, hip, forearm, total body) including common errors Understands skeletal anatomy relevant to DXA Recognizes common artifacts on DXA scan images Compares and contrasts use of different skeletal sites and regions of interest for diagnosis Understands the standardized scores used in bone densitometry (T- and Z-score) Knows the criteria for diagnosis of osteoporosis in postmenopausal women, pre-menopausal women, children and men Understands fracture risk assessment combining BMD with other risk factors (e.g. gender, ethnicity, family history, BMI, medical history, etc.) Understands fracture risk assessment combining BMD with other risk factors. Recognizes the clinical importance of precision error and least significant change Recognizes which skeletal site to measure, and how often to test Understands clinical relevance of changes in BMD 3. Utilizes evidence-based guidelines to generate reports (i.e. applies standard nomenclature, avoids common errors, follows reporting and treatment guidelines) Interprets a minimum 5 studies competently Yes No

12 Procedure EPA: Insulin Pump 1. Reviews insulin pump technology and therapy with the patient including indications, pump features, risks, benefits, alternate therapies and any conflict of interest where applicable 2. Able to guide/initiate insulin pump therapy Determine glucose targets Calculate basal and bolus rates Calculate correction and sensitivity factors 3. Interprets blood glucose logs and modifies care plan/setting(s) as indicated (i.e. adjusts basal/bolus rates, insulin-carbohydrate ratios, or glucose targets) Interprets a minimum 5 logs/downloads competently Yes No Procedure EPA: Continuous Glucose Monitor 1. Recommends Professional and Personal CGM consistent with evidence based guidelines 2. Reviews use of personal and/or professional CGM with patients including CGM technology, risks, benefits, alternatives and any conflict of interest where applicable 3. nterprets Professional (retrospective, masked) CGM Evaluates adequacy of the download data/tracings Integrates logbook with CGM data Interprets and reports CGM data Recommends therapeutic changes based on findings 4. Interprets Personal ( real-time ) CGM Evaluates adequacy of the download data/tracings Integrates logbook with CGM data Interprets CGM data Recommends therapeutic changes based on findings Interprets a minimum 5 studies competently Yes No

13 Scholarship Evaluation Basic, clinical and translational research investigations Safety or QI projects Publications (e.g. abstract, case reports, reviews, book chapters, original research or quality data) Presentation (e.g. local, regional, national) Guide for Scholarship Assessment Fellow makes no effort to participate in scholarly activity 1 Fellow makes rudimentary effort to participate in scholarly activity 2 Fellow engages scholarly activity with significant guidance 3 Fellow engages scholarly activity with significant independence 4 Fellow is a role model for peers and colleagues 5

14 Multisource Evaluation Guide for multisource assessments Never 1 Rarely 2 Sometimes 3 Often 4 Always 5 Patient Evaluation Engages me in a polite and respectful manner Listens to my concerns Encourages me to ask questions Uses words I can understand Explains my medical problem and treatment Shows interest in me as a person Multisource Evaluations Allied Health Professionals Engages and accommodates patients and families Communicates in a clear and professional manner Utilizes health information technology effectively Collaborates within an interdisciplinary team of providers Peer Engages and accommodates patients and families Communicates in a clear and professional manner Utilizes health information technology effectively Collaborates within an interdisciplinary team of providers

15 Evaluation Matrix

16 Pending Action Items APDEM Website Evaluation Template Examples of Evaluation Evaluation Matrix Electronic Evaluation Programs Med Hub (APDEM template almost complete) E-value (Starting to create APDEM templates) New Innovations (Started communications) Other vendors Conclusion Reporting milestones every 6 mo Submit in Dec 2015 Curricular milestones, EPA and other evaluation tools provide frame work Modify as you see fit Next steps Assess the effectiveness of these tools Modify evaluation tools in an evidence based manner