Searching for the Patient in Our Assessment Efforts

By: Dan Schumacher (@DrDanSchumacher)

Competency-based medical education (CBME) is a learner-centered, patient-focused approach to developing curricula, training individuals, and assessing those individuals to be sure educational outcomes are met. Some approaches to assessment in CBME, such as the Accreditation Council for Graduate Medical Education milestones, focus on competencies of trainees, such as communication skills, interprofessional teamwork, and professionalism. These approaches are well-built for helping trainees take the next steps in their development for the many competencies deemed important for physicians to possess. However, when we consider the patient, they do not stand alone very well. If a physician possesses excellent skills and abilities in communication, interprofessional teamwork, and professionalism, do we know they can manage a patient presenting with a common, acute problem, such as asthma, to the primary care clinic or emergency department? They may be more likely than someone not possessing excellent skills and abilities in these competency areas, but that is likely the most we can infer. If we want to know if someone can provide care to a patient presenting with a common, acute problem, we likely need to ask this question: Can they provide care to a patient presenting with a common, acute problem?

Managing a patient with a common, acute problem is an example of an entrustable professional activity (EPA). Unlike competencies and milestones, which focus on individuals, EPAs are activities and focus on patients; namely, the care patients need to receive care. Assessment using EPAs, then, focuses on individuals’ abilities to execute the activities detailed in the EPAs. While EPAs are positioned to center the patient in assessment efforts, they can do so in quite different ways. Stephanie Sebok-Syer and colleagues¹ wrote a paper detailing these ways. They posit patients can be characterized 4 ways in EPAs: (1) as a co-producer, (2) as a direct object, (3) as an indirect beneficiary, or (4) as a hidden figure. To the extent possible, I think framing EPAs as being co-produced with patients is the best approach. Using the example above, you can imagine titling the EPA as “manage a patient with a common, acute problem” or “manage a common, acute problem with a patient.” While either EPA could be done in partnership with a patient, the latter option explicitly frames care as co-produced while the former frames the patient as the direct object of the care. Framing an EPA with the patient as an indirect beneficiary arises when an EPA is written as an activity done for the patient, such as “developing a care plan for rehabilitation following trauma.” The final category, framing patients as hidden figures, is seen with EPAs that some would question whether they are truly EPAs, such as “document a history and physical examination,” where the involvement of a patient to any extent is only implied.

Crafting EPAs as activities co-produced with patients underscores the importance of developing them with patient and caregiver input. To date, few published studies have described this^{2, 3}, and I think it is likely that such efforts are uncommon.

EPAs give us the framework to center the patient in our assessment efforts, but work remains to see this come to full fruition. I hope your search for patients in the assessment efforts at your institution is brief and that you find the patient-centered quickly in the work of your training programs. If the patient is only implicit as you examine your local practices, I hope you will undertake efforts to change this. Our patients deserve nothing less.

About the author:
Dan Schumacher, MD, PhD, MEd, DAN SCHUMACHER, MD, PHD, MED, IS A TENURED PROFESSOR OF PEDIATRICS AT CINCINNATI CHILDREN’S HOSPITAL MEDICAL CENTER (CCHMC) AND THE UNIVERSITY OF CINCINNATI COLLEGE OF MEDICINE. DR. SCHUMACHER co-directs the CCHMC EDUCATION RESEARCH UNIT. HE HAS ALSO BEEN INVITED TO PARTICIPATE IN THE KAROLINSKA INSTITUTET PRIZE FOR RESEARCH IN MEDICAL EDUCATION FELLOWS PROGRAM.

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