2. Objectives
The apprentice model
– The way we were
Competency based education
– Where we are now
Outcomes based learning
– Procedural focus
– Milestone development
3. Apprenticeship
Successfulfor thousands of years
Key properties:
– Good mentor
– Motivated student
– Adequate exposure AND hands on time
Problems:
– Consistency
– Objective measures of success
– Low ceiling for promotion
The Mystery of Mastery. Psychology Today 1986;20:32
4. Apprenticeship
Works well for very sub-specialized areas
and few centers of excellence
Still model for advanced endoscopy
– AEF match
– Variation in level of exposure and mastery
– Who monitors the mentors?
– How do the graduates do?
Medicine resents outside monitoring
– Better if we did it ourselves
5. Competency based training
ACGME initiative from the 1990s
– Applied to all aspects of training
– Knowledge, professionalism, procedures
Ineffective for procedural training
– GI procedures still in apprentice model
– Little consensus on assessment and outcomes
– Little data to define milestones
How should a 2nd year fellow scope?
Lurie. Med Educ 2012;46:1365
6. Competency based training
Diverse training methods and assessment
techniques
Small programs vs large; research fellows
Silo mentality: no consistent standard
Explains why we have this problem now
7. Outcomes based learning
More process oriented
Focus on the process not the problem
ACGME wants us to move here
Starting point: 1st year fellow
Ending point: Staff GI
Milestone development: easier for
knowledge core vs procedures
N Engl J Med 2012;3686:1051-56
8. Milestone development
Final milestone: Colonoscopy
– >95% cecal intubation rate
– >25% ADR
– Low complication
– Patient satisfaction
Stepwise milestones: None with great data
or evidence
– 1st year vs 2nd vs 3rd
Gastrointest Endosc 2010;71:319-24
9. Procedural Education: initial
focus on process
Intense didactic
– FYF course, DVDs, local resources
Intense hands on training with scope
– ? Simulators
– Training box/tool
– Standardized patient
– Example of pilot training?
10. Procedural Education:
subsequent focus on process
Ongoing, continuous assessment:
– Mentor feedback; patient feedback
– Objective outcomes based assessment tool
– Universal tool ?
Development of outcomes based, data
driven milestones that apply throughout
fellowship
– How???
11. Procedural Education: A
Proposal
Universal
assessment tool agreed upon
Web-based submission of assessments
– Collection and development of milestone
– Feedback to fellow and program
– Fellow compared to peers nationally
Progressionthrough milestones will be
fellow driven, not fixed year driven
13. Procedural Education: A
Proposal
Requirements of system
– Ease of use: minutes, APP for phone, link on
desktop
– Secure
– Can provide data back to program and fellow in
real time
– Dynamic and progressive
14. Procedural Education: A
Proposal
Cost:GI programs, GI societies, ACGME
Web site location and maintenance
– ACGME
– CORI database like initiative
– GIQuik
– Endoscopic report generating systems
Provation initiative with Mayo Clinic
Time frame
16. Integrated Assessment
Are we ready and committed??
Resource Commitment
Staff Commitment
Barriers breaking silos
Only definite: change is here
17. Summary
Prior models and procedural mentoring are
probably inadequate
Classic competency based assessment is
flawed for procedures
Outcomes and milestones are a next step
GI directed development of milestones and
tools is critical