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author:("obst, William")
1.  Identifying Entrustable Professional Activities in Internal Medicine Training 
Background
Entrustable professional activities (EPAs) can form the foundation of competency-based assessment in medical training, focused on performance of discipline-specific core clinical activities.
Objective
To identify EPAs for the Internal Medicine (IM) Educational Milestones to operationalize competency-based assessment of residents using EPAs.
Methods
We used a modified Delphi approach to conduct a 2-step cross-sectional survey of IM educators at a 3-hospital IM residency program; residents also completed a survey. Participants rated the importance and appropriate year of training to reach competence for 30 proposed IM EPAs. Content validity indices identified essential EPAs. We conducted independent sample t tests to determine IM educator-resident agreement and calculated effect sizes. Finally, we determined the effect of different physician roles on ratings.
Results
Thirty-six IM educators participated; 22 completed both surveys. Twelve residents participated. Seventeen EPAs had a content validity index of 100%; 10 additional EPAs exceeded 80%. Educators and residents rated the importance of 27 of 30 EPAs similarly. Residents felt that 10 EPAs could be met at least 1 year earlier than educators had specified.
Conclusions
Internal medicine educators had a stable opinion of EPAs developed through this study, and residents generally agreed. Using this approach, programs could identify EPAs for resident evaluation, building on the initial list created via our study.
doi:10.4300/JGME-D-12-00060.1
PMCID: PMC3613318  PMID: 24404227
2.  Optimizing the Implementation of Practice Improvement Modules in Training: Lessons from Educators 
Background
The American Board of Internal Medicine approved the use of Practice Improvement Modules (PIMs) to help training programs teach and assess practice-based learning and improvement (PBLI) and systems-based practice (SBP).
Methods
We surveyed individuals who ordered a PIM in a residency or fellowship training program between June 2006 and August 2009. The 43 programs that volunteered to participate completed a 30-minute anonymous online survey.
Results
Program directors or associate program directors led the PIM process in 30 programs (70%). Trainees' degrees of involvement in PIMs were highly variable between programs, and several respondents felt that trainees were either not sufficiently engaged or not engaged with enough consistency. The most common activity for trainee involvement was data collection through patient surveys or chart review, although only 17 programs (40%) provided protected time for this activity. Few trainees participated in higher level activities such as data analysis or identification for areas of improvement or were given leadership roles; yet most respondents reported that completing the PIM helped trainees learn basic principles of QI and develop competence in PBLI and SBP and that PIM completion improved the program's ability to develop QI initiatives and resulted in program or institutional improvements, including sustainable improvement in patient care. Most respondents reported that the outcome warranted the effort to complete PIMs.
Conclusions
PIMs may be a valuable but underused educational experience for trainees as well as training programs. Focusing on particular themes and facets of PIMs may facilitate implementation.
doi:10.4300/JGME-D-11-00281.1
PMCID: PMC3613323  PMID: 24404231
3.  Educational Milestone Development in the First 7 Specialties to Enter the Next Accreditation System 
Background
The Accreditation Council for Graduate Medical Education (ACGME) Outcome Project introduced 6 general competencies relevant to medical practice but fell short of its goal to create a robust assessment system that would allow program accreditation based on outcomes. In response, the ACGME, the specialty boards, and other stakeholders collaborated to develop educational milestones, observable steps in residents' professional development that describe progress from entry to graduation and beyond.
Objectives
We summarize the development of the milestones, focusing on 7 specialties, moving to the next accreditation system in July 2013, and offer evidence of their validity.
Methods
Specialty workgroups with broad representation used a 5-level developmental framework and incorporated information from literature reviews, specialty curricula, dialogue with constituents, and pilot testing.
Results
The workgroups produced richly diverse sets of milestones that reflect the community's consideration of attributes of competence relevant to practice in the given specialty. Both their development process and the milestones themselves establish a validity argument, when contemporary views of validity for complex performance assessment are used.
Conclusions
Initial evidence for validity emerges from the development processes and the resulting milestones. Further advancing a validity argument will require research on the use of milestone data in resident assessment and program accreditation.
doi:10.4300/JGME-05-01-33
PMCID: PMC3613328  PMID: 24404235
5.  Developing a Cultural Consensus Analysis Based on the Internal Medicine Milestones (M-CCA) 
A national task force identified domains and developmental milestones from the national competencies for resident training. Cultural Consensus Analysis (CCA) is a standard anthropological technique that can identify value conflicts. We created a CCA based on the internal medicine milestones (M-CCA) in 3 steps: converted the 38 domains into active statements; reduced the total number to 12 by summarizing and combining; and simplified the wording. This M-CCA needs further validation, after which it may be useful for assessing the 6-competency model.
doi:10.4300/JGME-D-10-00198.1
PMCID: PMC3184894  PMID: 22655151
6.  Charting the Road to Competence: Developmental Milestones for Internal Medicine Residency Training 
Background
The Accreditation Council for Graduate Medical Education (ACGME) Outcome Project requires that residency program directors objectively document that their residents achieve competence in 6 general dimensions of practice.
Intervention
In November 2007, the American Board of Internal Medicine (ABIM) and the ACGME initiated the development of milestones for internal medicine residency training. ABIM and ACGME convened a 33-member milestones task force made up of program directors, experts in evaluation and quality, and representatives of internal medicine stakeholder organizations. This article reports on the development process and the resulting list of proposed milestones for each ACGME competency.
Outcomes
The task force adopted the Dreyfus model of skill acquisition as a framework the internal medicine milestones, and calibrated the milestones with the expectation that residents achieve, at a minimum, the “competency” level in the 5-step progression by the completion of residency. The task force also developed general recommendations for strategies to evaluate the milestones.
Discussion
The milestones resulting from this effort will promote competency-based resident education in internal medicine, and will allow program directors to track the progress of residents and inform decisions regarding promotion and readiness for independent practice. In addition, the milestones may guide curriculum development, suggest specific assessment strategies, provide benchmarks for resident self-directed assessment-seeking, and assist remediation by facilitating identification of specific deficits. Finally, by making explicit the profession's expectations for graduates and providing a degree of national standardization in evaluation, the milestones may improve public accountability for residency training.
doi:10.4300/01.01.0003
PMCID: PMC2931179  PMID: 21975701

Results 1-6 (6)