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Clinical competency committees (CCCs) and residency program leaders may find it difficult to interpret workplace-based assessment (WBA) ratings knowing that contextual factors and bias play a large role.We describe the development of an expected entrustment score for resident performance within the context of our well-developed Observable Practice Activity (OPA) WBA system.Observational study PARTICIPANTS: Internal medicine residents MAIN MEASURE: Entrustment KEY RESULTS: Each individual resident had observed entrustment scores with a unique relationship to the expected entrustment scores. Many residents' observed scores oscillated closely around the expected scores. However, distinct performance patterns did emerge.We used regression modeling and leveraged large numbers of historical WBA data points to produce an expected entrustment score that served as a guidepost for performance interpretation.

Introduction Narrative assessment data are valuable in understanding struggles in resident performance. However, it remains unknown which themes in narrative data that occur early in training may indicate a higher likelihood of struggles later in training, allowing programs to intervene sooner. Methods Using learning analytics, we identified 26 internal medicine residents in three cohorts that were below expected entrustment during training. We compiled all narrative data in the first 6 months of training for these residents as well as 13 typically performing residents for comparison. Narrative data were blinded for all 39 residents during initial phases of an inductive thematic analysis for initial coding. Results Many similarities were identified between the two cohorts. Codes that differed between typical and lower entrusted residents were grouped into two types of themes: three explicit/manifest and three implicit/latent with six total themes. The explicit/manifest themes focused on specific aspects of resident performance with assessors describing 1) Gaps in attention to detail, 2) Communication deficits with patients, and 3) Difficulty recognizing the “big picture” in patient care. Three implicit/latent themes, focused on how narrative data were written, were also identified: 1) Feedback described as a deficiency rather than an opportunity to improve, 2) Normative comparisons to identify a resident as being behind their peers, and 3) Warning of possible risk to patient care. Discussion Clinical competency committees (CCCs) usually rely on accumulated data and trends. Using the themes in this paper while reviewing narrative comments may help CCCs with earlier recognition and better allocation of resources to support residents’ development.

Educators use entrustment, a common framework in competency-based medical education, in multiple ways, including frontline assessment instruments, learner feedback tools, and group decision making within promotions or competence committees. Within these multiple contexts, entrustment decisions can vary in purpose (i.e., intended use), stakes (i.e., perceived risk or consequences), and process (i.e., how entrustment is rendered). Each of these characteristics can be conceptualized as having 2 distinct poles: (1) purpose has formative and summative, (2) stakes has low and high, and (3) process has ad hoc and structured. For each characteristic, entrustment decisions often do not fall squarely at one pole or the other, but rather lie somewhere along a spectrum. While distinct, these continua can, and sometimes should, influence one another, and can be manipulated to optimally integrate entrustment within a program of assessment. In this article, the authors describe each of these continua and depict how key alignments between them can help optimize value when using entrustment in programmatic assessment within competency-based medical education. As they think through these continua, the authors will begin and end with a case study to demonstrate the practical application as it might occur in the clinical learning environment.

Medical education is situated within health care and educational organizations that frequently lag in their use of data to learn, develop, and improve performance. How might we leverage competency-based medical education (CBME) assessment data at the individual, program, and system levels, with the goal of redefining CBME from an initiative that supports the development of physicians to one that also fosters the development of the faculty, administrators, and programs within our organizations? In this paper we review the Deliberately Developmental Organization (DDO) framework proposed by Robert Kegan and Lisa Lahey, a theoretical framework that explains how organizations can foster the development of their people. We then describe the DDO's conceptual alignment with CBME and outline how CBME assessment data could be used to spur the transformation of health care and educational organizations into digitally integrated DDOs. A DDO-oriented use of CBME assessment data will require intentional investment into both the digitalization of assessment data and the development of the people within our organizations. By reframing CBME in this light, we hope that educational and health care leaders will see their investments in CBME as an opportunity to spur the evolution of a developmental culture.

INTRODUCTION: Internal medicine residents perform paracentesis, but programs lack standard methods for assessing competence or maintenance of competence and instead rely on number of procedures completed. This study describes differences in resident competence in paracentesis over time. METHODS: From 2016 to 2017, internal medicine residents (n = 118) underwent paracentesis simulation training. Competence was assessed using the Paracentesis Competency Assessment Tool (PCAT), which combines a checklist, global scale, and entrustment score. The PCAT also delineates two categorical cut-point scores: the Minimum Passing Standard (MPS) and the Unsupervised Practice Standard (UPS). Residents were randomized to return to the simulation lab at 3 and 6 months (group A, n = 60) or only 6 months (group B, n = 58). At each session, faculty raters assessed resident performance. Data were analyzed to compare resident performance at each session compared with initial training scores, and performance between groups at 6 months. RESULTS: After initial training, all residents met the MPS. The number achieving UPS did not differ between groups: group A = 24 (40%), group B = 20 (34.5%), p = 0.67. When group A was retested at 3 months, performance on each PCAT component significantly declined, as did the proportion of residents meeting the MPS and UPS. At the 6-month test, residents in group A performed significantly better than residents in group B, with 52 (89.7%) and 20 (34.5%) achieving the MPS and UPS, respectively, in group A compared with 25 (46.3%) and 2 (3.70%) in group B (p

Background and Objectives: Much can be gained by the three primary care disciplines collaborating on efforts to transform residency training toward interprofessional collaborative practice. We describe findings from a study designed to align primary care disciplines toward implementing interprofessional education. Methods: In this mixed methods study, we included faculty, residents and other interprofessional learners in family medicine, internal medicine, and pediatrics from nine institutions across the United States. We administered a web-based survey in April/May of 2018 and used qualitative analyses of field notes to study resident exposure to team-based care during training, estimates of career choice in programs that are innovating, and supportive and challenging conditions that influence collaboration among the three disciplines. Complete data capture was attained for 96.3% of participants. Results: Among family medicine resident graduates, an estimated 87.1% chose to go into primary care compared to 12.4% of internal medicine, and 36.5% of pediatric resident graduates. Qualitative themes found to positively influence cross-disciplinary collaboration included relationship development, communication of shared goals, alignment with health system/other institutional initiatives, and professional identity as primary care physicians. Challenges included expressed concerns by participants that by working together, the disciplines would experience a loss of identity and would be indistinguishable from one another. Another qualitative finding was that overwhelming stressors plague primary care training programs in the current health care climate—a great concern. These include competing demands, disruptive transitions, and lack of resources. Conclusions: Uniting the primary care disciplines toward educational and clinical transformation toward interprofessional collaborative practice is challenging to accomplish.

Background With the implementation of competency-based assessment systems, education programs are collecting increasing amounts of data about medical learners. However, learning analytics are rarely employed to use this data to improve medical education. Objective We identified outstanding issues that are limiting the effective adoption of learning analytics in medical education. Methods Participants at an international summit on learning analytics in medical education generated key questions that need to be addressed to move the field forward. Small groups formulated questions related to data stewardship, learner perspectives, and program perspectives. Three investigators conducted an inductive qualitative content analysis on the participant questions, coding the data by consensus and organizing it into themes. One investigator used the themes to formulate representative questions that were refined by the other investigators. Results Sixty-seven participants from 6 countries submitted 195 questions. From them, we identified 3 major themes: implementation challenges (related to changing current practices to collect data and utilize learning analytics); data (related to data collection, security, governance, access, and analysis); and outcomes (related to the use of learning analytics for assessing learners and faculty as well as evaluating programs and systems). We present the representative questions and their implications. Conclusions Our analysis highlights themes regarding implementation, data management, and outcomes related to the use of learning analytics in medical education. These results can be used as a framework to guide stakeholder education, research, and policy development that delineates the benefits and challenges of using learning analytics in medical education.

Purpose To examine the reliability and attributable facets of variance within an entrustment-derived workplace-based assessment system. Method Faculty at the University of Cincinnati Medical Center internal medicine residency program (a 3-year program) assessed residents using discrete workplace-based skills called observable practice activities (OPAs) rated on an entrustment scale. Ratings from July 2012 to December 2016 were analyzed using applications of generalizability theory (G-theory) and decision study framework. Given the limitations of G-theory applications with entrustment ratings (the assumption that mean ratings are stable over time), a series of time-specific G-theory analyses and an overall longitudinal G-theory analysis were conducted to detail the reliability of ratings and sources of variance. Results During the study period, 166,686 OPA entrustment ratings were given by 395 faculty members to 253 different residents. Raters were the largest identified source of variance in both the time-specific and overall longitudinal G-theory analyses (37% and 23%, respectively). Residents were the second largest identified source of variation in the time-specific G-theory analyses (19%). Reliability was approximately 0.40 for a typical month of assessment (27 different OPAs, 2 raters, and 1-2 rotations) and 0.63 for the full sequence of ratings over 36 months. A decision study showed doubling the number of raters and assessments each month could improve the reliability over 36 months to 0.76. Conclusions Ratings from the full 36 months of the examined program of assessment showed fair reliability. Increasing the number of raters and assessments per month could improve reliability, highlighting the need for multiple observations by multiple faculty raters.

Current models of quality improvement and patient safety (QIPS) education are not fully integrated with clinical care delivery, representing a major impediment toward achieving widespread QIPS competency among health professions learners and practitioners. The Royal College of Physicians and Surgeons of Canada organized a 2-day consensus conference in Niagara Falls, Ontario, Canada, called Building the Bridge to Quality, in September 2016. Its goal was to convene an international group of educational and health system leaders, educators, frontline clinicians, learners, and patients to engage in a consensus-building process and generate a list of actionable strategies that individuals and organizations can use to better integrate QIPS education with clinical care.Four strategic directions emerged: prioritize the integration of QIPS education and clinical care, build structures and implement processes to integrate QIPS education and clinical care, build capacity for QIPS education at multiple levels, and align educational and patient outcomes to improve quality and patient safety. Individuals and organizations can refer to the specific tactics associated with the 4 strategic directions to create a road map of targeted actions most relevant to their organizational starting point.To achieve widespread change, collaborative efforts and alignment of intrinsic and extrinsic motivators are needed on an international scale to shift the culture of educational and clinical environments and build bridges that connect training programs and clinical environments, align educational and health system priorities, and improve both learning and care, with the ultimate goal of achieving improved outcomes and experiences for patients, their families, and communities.

Recent discussions have brought attention to the utility of contribution analysis for evaluating the effectiveness and outcomes of medical education programs, especially for complex initiatives such as competency-based medical education. Contribution analysis focuses on the extent to which different entities contribute to an outcome. Given that health care is provided by teams, contribution analysis is well suited to evaluating the outcomes of care delivery. Furthermore, contribution analysis plays an important role in analyzing program-and system-level outcomes that inform program evaluation and program-level improvements for the future. Equally important in health care, however, is the role of the individual. In the overall contribution of a team to an outcome, some aspects of this outcome can be attributed to individual team members. For example, a recently discharged patient with an unplanned return to the emergency department to seek care may not have understood the discharge instructions given by the nurse or may not have received any discharge guidance from the resident physician. In this example, if it is the nurse's responsibility to provide discharge instructions, that activity is attributed to him or her. This and other activities attributed to different individuals (e.g., nurse, resident) combine to contribute to the outcome for the patient. Determining how to tease out such attributions is important for several reasons. First, it is physicians, not teams, that graduate and are granted certification and credentials for medical practice. Second, incentive-based payment models focus on the quality of care provided by an individual. Third, an individual can use data about his or her performance on the team to help drive personal improvement. In this article, the authors explored how attribution and contribution analyses can be used in a complimentary fashion to discern which outcomes can and should be attributed to individuals, which to teams, and which to programs.

Construct: The construct that is assessed is competency in Pediatrics and Internal Medicine residency training. Background: The Accreditation Council for Graduate Medical Education (ACGME) created milestones to measure learner progression toward competence over time but not as direct assessment tools. Ideal measurement of resident performance includes direct observation and assessment of patient care skills in the workplace. Residency programs have linked these concepts by mapping workplace-based assessments to the milestones of ACGME subcompetencies. Mapping is a subjective process, and little is known about specific techniques or the resulting consequences of mapping program-specific assessment data to larger frameworks of competency. Approach: In this article, the authors compare and contrast the techniques used to link workplace-based assessments called Observable Practice Activities (OPAs) to ACGME subcompetencies in two large academic residency programs from different specialties (Internal Medicine and Pediatrics). Descriptive analysis explored the similarities and differences in the assessment data generated by mapping assessment items to larger frameworks of competency. Results: Each program assessed the core competencies with similar frequencies. The largest discrepancy between the two subspecialties was the assessment of Medical Knowledge, which Internal Medicine assessed twice as often. Pediatrics also assessed the core competency Systems-based Practice almost twice as often as Internal Medicine. Both programs had several subcompetencies that were assessed more or less often than what appeared to be emphasized by the blueprint of mapping. Despite using independent mapping processes, both programs mapped each OPA to approximately three subcompetencies. Conclusions: Mapping workplace-based assessments to the ACGME subcompetencies allowed each program to see the whole of their curricula in ways that were not possible before and to identify existing curricular and assessment gaps. Although each program used similar assessment tools, the assessment data generated were different. The lessons learned in this work could inform other programs attempting to link their own workplace-based assessment elements to ACGME subcompetencies.

Purpose To inform graduate medical education (GME) outcomes at the individual resident level, this study sought a method for attributing care for individual patients to individual interns based on "footprints" in the electronic health record (EHR). Method Primary interns caring for patients on an internal medicine inpatient service were recorded daily by five attending physicians of record at University of Cincinnati Medical Center in August 2017 and January 2018. These records were considered gold standard identification of primary interns. The following EHR variables were explored to determine representation of primary intern involvement in care: postgraduate year, progress note author, discharge summary author, physician order placement, and logging clicks in the patient record. These variables were turned into quantitative attributes (e.g., progress note author: yes/no), and informative attributes were selected and modeled using a decision tree algorithm. Results A total of 1,511 access records were generated; 116 were marked as having a primary intern assigned. All variables except discharge summary author displayed at least some level of importance in the models. The best model achieved 78.95% sensitivity, 97.61% specificity, and an area under the receiver-operator curve of approximately 91%. Conclusions This study successfully predicted primary interns caring for patients on inpatient teams using EHR data with excellent model performance. This provides a foundation for attributing patients to primary interns for the purposes of determining patient diagnoses and complexity the interns see as well as supporting continuous quality improvement efforts in GME.

Background Internal medicine (IM) residency programs receive information about applicants via academic transcripts, but studies demonstrate wide variability in satisfaction with and usefulness of this information. In addition, many studies compare application materials to only 1 or 2 assessment metrics, usually standardized test scores and work-based observational faculty assessments. Objective We sought to determine which application materials best predict performance across a broad array of residency assessment outcomes generated by standardized testing and a yearlong IM residency ambulatory long block. Methods In 2019, we analyzed available Electronic Residency Application Service data for 167 categorical IM residents, including advanced degree status, research experience, failures during medical school, undergraduate medical education award status, and United States Medical Licensing Examination (USMLE) scores. We compared these with post-match residency multimodal performance, including standardized test scores and faculty member, peer, allied health professional, and patient-level assessment measures. Results In multivariate analyses, USMLE Step 2 Clinical Knowledge (CK) scores were most predictive of performance across all residency performance domains measured. Having an advanced degree was associated with higher patient-level assessments (eg, physician listens, physician explains, etc). USMLE Step 1 scores were associated with in-training examination scores only. None of the other measured application materials predicted performance. Conclusions USMLE Step 2 CK scores were the highest predictors of residency performance across a broad array of performance measurements generated by standardized testing and an IM residency ambulatory long block.

The ongoing adoption of competency-based medical education (CBME) across health professions training draws focus to learner-centred educational design and the importance of fostering a growth mindset in learners, teachers, and educational programs. An emerging body of literature addresses the instructional practices and features of learning environments that foster the skills and strategies necessary for trainees to be partners in their own learning and progression to competence and to develop skills for lifelong learning. Aligned with this emerging area is an interest in Dweck's self theory and the concept of the growth mindset. The growth mindset is an implicit belief held by an individual that intelligence and abilities are changeable, rather than fixed and immutable. In this paper, we present an overview of the growth mindset and how it aligns with the goals of CBME. We describe the challenges associated with shifting away from the fixed mindset of most traditional medical education assumptions and practices and discuss potential solutions and strategies at the individual, relational, and systems levels. Finally, we present future directions for research to better understand the growth mindset in the context of CBME.

Problem Health professions education has shifted to a competency-based paradigm in which many programs rely heavily on workplace-based assessment (WBA) to produce data for summative decisions about learners. However, WBAs are complex and require validity evidence beyond psychometric analysis. Here, the authors describe their use of a rhetorical argumentation process to develop a map of validity evidence for summative decisions in an entrustment-based WBA system. Approach To organize evidence, the authors cross-walked 2 contemporary validity frameworks, one that emphasizes sources of evidence (Messick) and another that stresses inferences in an argument (Kane). They constructed a validity map using 4 steps: (1) Asking critical questions about the stated interpretation and use, (2) Seeking validity evidence as a response, (3) Categorizing evidence using both Messick's and Kane's frameworks, and (4) Building a visual representation of the collected and organized evidence. The authors used an iterative approach, adding new critical questions and evidence over time. Outcomes The first map draft produced 25 boxes of evidence that included all 5 sources of evidence detailed by Messick and spread across all 4 inferences described by Kane. The rhetorical question-response process allowed for structured critical appraisal of the WBA system, leading to the identification of evidentiary gaps. Next steps Future map iterations will integrate evidence quality indicators and allow for deeper dives into the evidence. The authors intend to share their map with graduate medical education stakeholders (e.g., accreditors, institutional leaders, learners, patients) to understand if it adds value for evaluating their WBA programs' validity arguments.

Educators use entrustment, a common framework in competency-based medical education, in multiple ways, including frontline assessment instruments, learner feedback tools, and group decision making within promotions or competence committees. Within these multiple contexts, entrustment decisions can vary in purpose (i.e., intended use), stakes (i.e., perceived risk or consequences), and process (i.e., how entrustment is rendered). Each of these characteristics can be conceptualized as having 2 distinct poles: (1) purpose has formative and summative, (2) stakes has low and high, and (3) process has ad hoc and structured. For each characteristic, entrustment decisions often do not fall squarely at one pole or the other, but rather lie somewhere along a spectrum. While distinct, these continua can, and sometimes should, influence one another, and can be manipulated to optimally integrate entrustment within a program of assessment. In this article, the authors describe each of these continua and depict how key alignments between them can help optimize value when using entrustment in programmatic assessment within competency-based medical education. As they think through these continua, the authors will begin and end with a case study to demonstrate the practical application as it might occur in the clinical learning environment.

Once medical students attain a certain level of medical knowledge, success in residency often depends on noncognitive attributes, such as conscientiousness, empathy, and grit. These traits are significantly more difficult to assess than cognitive performance, creating a potential gap in measurement. Despite its promise, competency-based medical education (CBME) has yet to bridge this gap, partly due to a lack of well-defined noncognitive observable behaviors that assessors and educators can use in formative and summative assessment. As a result, typical undergraduate to graduate medical education handovers stress standardized test scores, and program directors trust little of the remaining information they receive, sometimes turning to third-party companies to better describe potential residency candidates. The authors have created a list of noncognitive attributes, with associated definitions and noncognitive skills-called observable practice activities (OPAs)-written for learners across the continuum to help educators collect assessment data that can be turned into valuable information. OPAs are discrete work-based assessment elements collected over time and mapped to larger structures, such as milestones, entrustable professional activities, or competencies, to create learning trajectories for formative and summative decisions. Medical schools and graduate medical education programs could adapt these OPAs or determine ways to create new ones specific to their own contexts. Once OPAs are created, programs will have to find effective ways to assess them, interpret the data, determine consequence validity, and communicate information to learners and institutions. The authors discuss the need for culture change surrounding assessment-even for the adoption of behavior-based tools such as OPAs-including grounding the work in a growth mindset and the broad underpinnings of CBME. Ultimately, improving assessment of noncognitive capacity should benefit learners, schools, programs, and most importantly, patients.

Introduction/Objectives: Coaching is emerging as a form of facilitation in health professions education. Most studies focus on one-on-one coaching rather than team coaching. We assessed the experiences of interprofessional teams coached to simultaneously improve primary care residency training and interprofessional practice. Methods: This three-year exploratory mixed methods study included transformational assistance from 9 interprofessional coaches, one assigned to each of 9 interprofessional primary care teams that included family medicine, internal medicine, pediatrics, nursing, pharmacy and behavioral health. Coaches interacted with teams during 2 in-person training sessions, an in-person site visit, and then as requested by their teams. Surveys administered at 1 year and end study assessed the coaching relationship and process. Results: The majority of participants (82% at end of Year 1 and 76.6% at end study) agreed or strongly agreed that their coach developed a positive working relationship with their team. Participants indicated coaches helped them: (1) develop as teams, (2) stay on task, and (3) respond to local context issues, with between 54.3% and 69.2% agreeing or strongly agreeing that their coaches were helpful in these areas. Cronbach’s alpha for the 15 coaching survey items was 0.965. Challenges included aligning the coach’s expertise with the team’s needs. Conclusions: While team coaching was well received by interprofessional teams of primary care professionals undertaking educational and clinical redesign, the 3 primary care disciplines have much to learn from each other regarding how to improve inter- and intra-professional collaborative practice among clinicians and staff as well as with interprofessional learners rotating through their outpatient clinics.

Competency-based medical education has been advocated as the future of medical education for nearly a half-century. Inherent to this is the promise that advancement and transitions in training would be defined by readiness to practice rather than by time. Of the logistical problems facing competency-based, time-variable (CBTV) training, enacting time variability may be the largest hurdle to clear. Although it is true that an 'all or nothing' approach to CBTV training would require massive overhauls of both medical education and health care systems, the authors propose that training institutions should gradually evolve within their current environments to incrementally move toward the best version of CBTV training for learners, supervisors, and patients. In support of this evolution, the authors seek to demonstrate the feasibility of advancing toward the goal of realistic CBTV training by detailing examples of successful CBTV training and describing key features of initial steps toward CBTV training implementation.

Health care revolves around trust. Patients are often in a position that gives them no other choice than to trust the people taking care of them. Educational programs thus have the responsibility to develop physicians who can be trusted to deliver safe and effective care, ultimately making a final decision to entrust trainees to graduate to unsupervised practice. Such entrustment decisions deserve to be scrutinized for their validity. This end-of-training entrustment decision is arguably the most important one, although earlier entrustment decisions, for smaller units of professional practice, should also be scrutinized for their validity. Validity of entrustment decisions implies a defensible argument that can be analyzed in components that together support the decision. According to Kane, building a validity argument is a process designed to support inferences of scoring, generalization across observations, extrapolation to new instances, and implications of the decision. A lack of validity can be caused by inadequate evidence in terms of, according to Messick, content, response process, internal structure (coherence) and relationship to other variables, and in misinterpreted consequences. These two leading frameworks (Kane and Messick) in educational and psychological testing can be well applied to summative entrustment decision-making. The authors elaborate the types of questions that need to be answered to arrive at defensible, well-argued summative decisions regarding performance to provide a grounding for high-quality safe patient care.

Internal medicine (IM) residents frequently perform invasive bedside procedures during residency training. Bedside procedure training in IM programs may compromise patient safety. Current evidence suggests that IM training programs rely heavily on the number of procedures completed during training as a proxy for resident competence instead of using objective postprocedure patient outcomes. The authors posit that the results of procedural training effectiveness should be reframed with outcome metrics rather than process measures alone. This article introduces the as low as reasonably achievable (ALARA) approach, which originated in the nuclear industry to increase safety margins, to help assess and reduce bedside procedural risks. Training program directors are encouraged to use ALARA calculations to define the risk trade-offs inherent in current procedural training and assess how best to reliably improve patient outcomes. The authors describe 5 options to consider: training all residents in bedside procedures, training only select residents in bedside procedures, training no residents in bedside procedures, deploying 24-hour procedure teams supervised by IM faculty, and deploying 24-hour procedure teams supervised by non-IM faculty. The authors explore how quality improvement approaches using process maps, fishbone diagrams, failure mode effects and analyses, and risk matrices can be effectively implemented to assess training resources, choices, and aims. Future research should address the drivers behind developing optimal training programs that support independent practice, correlations with patient outcomes, and methods that enable faculty to justify their supervisory decisions while adhering to ALARA risk management standards.

The iconic Miller's pyramid, proposed in 1989, characterizes 4 levels of assessment in medical education ("knows," "knows how," "shows how," "does"). The frame work has created a worldwide awareness of the need to have different assessment approaches for different expected outcomes of education and training. At the time, Miller stressed the innovative use of simulation techniques, geared at the third level ("shows how"); however, the "does" level, assessment in the workplace, remained a largely uncharted area. In the 30 years since Miller's conference address and seminal paper, much attention has been devoted to procedures and instrument development for workplace-based assessment. With the rise of competency-based medical education (CBME), the need for approaches to determine the competence of learners in the clinical workplace has intensified. The proposal to use entrustable professional activities as a framework of assessment and the related entrustment decision making for clinical responsibilities at designated levels of supervision of learners (e.g., direct, indirect, and no supervision) has become a recent critical innovation of CBME at the "does" level. Analysis of the entrustment concept reveals that trust in a learner to work without assistance or supervision encompasses more than the observation of "doing" in practice (the "does" level). It implies the readiness of educators to accept the inherent risks involved in health care tasks and the judgment that the learner has enough experience to act appropriately when facing unexpected challenges. Earning this qualification requires qualities beyond observed proficiency, which led the authors to propose adding the level "trusted" to the apex of Miller's pyramid.

BACKGROUND: Graduate medical education (GME) training has long-lasting effects on patient care quality. Despite this, few GME programs use clinical care measures as part of resident assessment. Furthermore, there is no gold standard to identify clinical care measures that are reflective of resident care. Resident-sensitive quality measures (RSQMs), defined as “measures that are meaningful in patient care and are most likely attributable to resident care,” have been developed using consensus methodology and piloted in pediatric emergency medicine. However, this approach has not been tested in internal medicine (IM). OBJECTIVE: To develop RSQMs for a general internal medicine (GIM) inpatient residency rotation using previously described consensus methods. DESIGN: The authors used two consensus methods, nominal group technique (NGT) and a subsequent Delphi method, to generate RSQMs for a GIM inpatient rotation. RSQMs were generated for specific clinical conditions found on a GIM inpatient rotation, as well as for general care on a GIM ward. PARTICIPANTS: NGT participants included nine IM and medicine-pediatrics (MP) residents and six IM and MP faculty members. The Delphi group included seven IM and MP residents and seven IM and MP faculty members. MAIN MEASURES: The number and description of RSQMs generated during this process. KEY RESULTS: Consensus methods resulted in 89 RSQMs with the following breakdown by condition: GIM general care—21, diabetes mellitus—16, hyperkalemia—14, COPD—13, hypertension—11, pneumonia—10, and hypokalemia—4. All RSQMs were process measures, with 48% relating to documentation and 51% relating to orders. Fifty-eight percent of RSQMs were related to the primary admitting diagnosis, while 42% could also be related to chronic comorbidities that require management during an admission. CONCLUSIONS: Consensus methods resulted in 89 RSQMs for a GIM inpatient service. While all RSQMs were process measures, they may still hold value in learner assessment, formative feedback, and program evaluation.

Medical education has shifted to a competency-based paradigm, leading to calls for improved learner assessment methods and validity evidence for how assessment data are interpreted. Clinical competency committees (CCCs) use the collective input of multiple people to improve the validity and reliability of decisions made and actions taken based on assessment data. Significant heterogeneity in CCC structure and function exists across postgraduate medical education programs and specialties, and while there is no "one-size-fits-all" approach, there are ways to maximize value for learners and programs. This paper collates available evidence and the authors' experiences to provide practical tips on CCC purpose, membership, processes, and outputs. These tips can benefit programs looking to start a CCC and those that are improving their current CCC processes.

In this issue of Academic Medicine, Dewan and Norcini examine the significant variability of time-in-training between patient care "giants"-the physicians, nurse practitioners, and physician assistants who practice primary care-and they call for further studies to determine optimal training duration and eventual scope of practice. They ask, what is the minimum education and training required to practice primary care, or "how tall is the shortest giant?" In this Invited Commentary, the authors reframe the question from identifying the minimum length of training required, to identifying desired patient care outcomes. Primary care is not a uniform entity. It ranges from complex elderly chronically ill patients, to twentysomething millennials with acute problems, to pregnant women, to families, and everything in between. The authors argue that training should be fit for purpose and produce high-quality outcomes for patients. Competence should be defined by these outcomes. Drawing parallels with Major League Baseball, the authors note that time to competence development will be variable for different training programs depending on purpose, and also variable for people within those programs, even with shared purpose. While time is a tool for competence attainment, it should not be the metric by which readiness for practice is measured.

Background: Implicit gender bias leads to differences in assessment. Studies examining gender differences in resident milestone assessment data demonstrate variable results. The purpose of this study was to determine if observational entrustment scores differ by resident and assessor gender in a program of assessment based on discrete, observable skills. Methods: We analyzed overall entrustment scores and entrustment scores by Accreditation Council for Graduate Medical Education (ACGME) core competency for 238 residents (49% female) from 396 assessors (38% female) in one internal medicine residency program from July 2012 to June 2019. We conducted analyses at 1-12 months, 1-36 months, 1-6 months, 7-12 months, and 31-36 months. We used linear mixed-effect models to assess the role of resident and assessor gender, with resident-specific and assessor-specific random effect to account for repeated measures. Results: Statistically significant interactions existed between resident and assessor gender for overall entrustment at 1-12 months (p < 0.001), 1-36 months (p< 0.001), 1-6 months (p Conclusions: No significant differences in entrustment scores were found based on resident or assessor gender in our large, robust entrustment-based program of assessment. Determining the reasons for our findings may help identify ways to mitigate gender bias in assessment.

Multiple studies have demonstrated that the information included in the Medical Student Performance Evaluation fails to reliably predict medical students’ future performance. This faulty transfer of information can lead to harm when poorly prepared students fail out of residency or, worse, are shuttled through the medical education system without an honest accounting of their performance. Such poor learner handovers likely arise from two root causes: (1) the absence of agreed-on outcomes of training and/or accepted assessments of those outcomes, and (2) the lack of standardized ways to communicate the results of those assessments. To improve the current learner handover situation, an authentic, shared mental model of competency is needed; high-quality tools to assess that competency must be developed and tested; and transparent, reliable, and safe ways to communicate this information must be created. To achieve these goals, the authors propose using a learner handover process modeled after a patient handover process. The CLASS model includes a description of the learner’s Competency attainment, a summary of the Learner’s performance, an Action list and statement of Situational awareness, and Synthesis by the receiving program. This model also includes coaching oriented towards improvement along the continuum of education and care. Just as studies have evaluated patient handover models using metrics that matter most to patients, studies must evaluate this learner handover model using metrics that matter most to providers, patients, and learners.

PURPOSE The Accreditation Council for Graduate Medical Education (ACGME) requires programs to report learner progress using specialty-specific milestones. It is unclear how milestones can best identify critical deficiencies (CDs) in trainee performance. Specialties developed milestones independently of one another; not every specialty included CDs within milestones ratings. This study examined the proportion of ACGME milestone sets that include CD ratings, and describes one residency program's experiences using CD ratings in assessment. METHOD The authors reviewed ACGME milestones for all 99 specialties in November 2015, determining which rating scales contained CDs. The authors also reviewed three years of data (July 2012-June 2015) from the University of Cincinnati Medical Center (UCMC) internal medicine residency assessment system based on observable practice activities mapped to ACGME milestones. Data were analyzed by postgraduate year, assessor type, rotation, academic year, and core competency. The Mantel-Haenszel chi-square test was used to test for changes over time. RESULTS Specialties demonstrated heterogeneity in accounting for CDs in ACGME milestones, with 22% (22/99) of specialties having no language describing CDs in milestones assessment. Thirty-three percent (63/189) of UCMC internal medicine residents received at least one CD rating, with CDs accounting for 0.18% (668/364,728) of all assessment ratings. The authors identified CDs across multiple core competencies and rotations. CONCLUSIONS Despite some specialties not accounting for CDs in milestone assessment, UCMC's experience demonstrates that a significant proportion of residents may be rated as having a CD during training. Identification of CDs may allow programs to develop remediation and improvement plans.

PURPOSE Given resource constraints, many residency programs would consider adopting an entrustment-based assessment system from another program if given the opportunity. However, it is unclear if a system developed in one context would have similar or different results in another. This study sought to determine if entrustment varied between programs (community based and university based) when a single assessment system was deployed in different contexts. METHOD The Good Samaritan Hospital (GSH) internal medicine residency program adopted the observable practice activity (OPA) workplace-based assessment system from the University of Cincinnati (UC). Comparisons for OPA-mapped subcompetency entrustment progression for programs and residents were made at specific timepoints over the course of 36 months of residency. Data collection occurred from August 2012 to June 2017 for UC and from September 2013 to June 2017 for GSH. RESULTS GSH entrustment ratings were higher than UC for all but the 11th, 15th, and 36th months of residency (P < .0001) and were also higher for the majority of subcompetencies and competencies (P < .0001). The rate of change for average monthly entrustment was similar, with GSH having an increase of 0.041 each month versus 0.042 for UC (P = .73). Most residents progressed from lower to higher entrustment, but there was significant variation between residents in each program. CONCLUSIONS Despite the deployment of a single entrustment-based assessment system, important outcomes may vary by context. Further research is needed to understand the contributions of tool, context, and other factors on the data these systems produce.

Ambulatory training in internal medicine residency programs has historically been considered less robust than inpatient-focused training, which prompted a 2009 revision of the Accreditation Council for Graduate Medical Education (ACGME) Program Requirements in Internal Medicine. This revision was intended to create a balance between inpatient and outpatient training standards and to spur innovation in the ambulatory setting.We explored innovations in ambulatory education in internal medicine residency programs since the 2009 revision of the ACGME Program Requirements in Internal Medicine.The authors conducted a scoping review of the literature from 2008 to 2017, searching PubMed, ERIC, and Scopus databases. Articles related to improving educational quality of ambulatory components of US-based internal medicine residency programs were eligible for inclusion. Articles were screened for relevance and theme categorization and then divided into 6 themes: clinic redesign, curriculum development, evaluating resident practice/performance, teaching methods, program evaluation, and faculty development. Once a theme was assigned, data extraction and quality assessment using the Medical Education Research Study Quality Instrument (MERSQI) score were completed.A total of 967 potentially relevant articles were discovered; of those, 182 were deemed relevant and underwent full review. Most articles fell into curriculum development and clinic redesign themes. The majority of included studies were from a single institution, used nonstandardized tools, and assessed outcomes at the satisfaction or knowledge/attitude/skills levels. Few studies showed behavioral changes or patient-level outcomes.While a rich diversity of educational innovations have occurred since the 2009 revision of the ACGME Program Requirements in Internal Medicine, there is a significant need for multi-institution studies and higher-level assessment.

W. Edwards Deming, in his System of Profound Knowledge, asserts that leaders who wish to transform a system should understand four essential elements: appreciation for a system, theory of knowledge, knowledge about variation, and psychology. The Accreditation Council for Graduate Medical Education (ACGME) introduced the milestones program as a part of the Next Accreditation System to create developmental language for the six core competencies and facilitate programmatic assessment within graduate medical education systems. Viewed through Deming's lens, the ACGME can be seen as the steward of a large system, with everyone who provides assessment data as workers in that system. The authors use Deming's framework to illustrate the working components of the assessment system of the University of Cincinnati College of Medicine's internal medicine residency program and draw parallels to the macrocosm of graduate medical education. Successes and failures in transforming resident assessment can be understood and predicted by identifying the system and its aims, turning information into knowledge, developing an understanding of variation, and appreciating the psychology of motivation of participants. The authors offer insights from their experience for educational leaders who wish to apply Deming's elements to their own assessment systems, with questions to explore, pitfalls to avoid, and practical approaches in doing this type of work.

Introduction Structured procedural education and assessment of competency are growing needs for residency and fellowship programs. Simulation is a useful way to learn, experience, and practice procedural skills with competence. Paracentesis is a common procedure encountered in internal medicine. This educational resource for paracentesis education includes didactics, cases, and assessments to address cognitive skills, a simulation experience to address psychomotor procedural skills, and an entrustment-based assessment tool. Methods Prior to the simulation, learners completed preprocedural didactics and self-assessments. Utilizing a paracentesis trainer, ultrasound, and paracentesis kit, the case of a 46-year-old male with ascites in need of a paracentesis was presented. During the simulation, learners initially performed a paracentesis step by step, with assistance and feedback from the case instructor. This was immediately followed by paracentesis without assistance, where the instructor evaluated the learners with an assessment tool encompassing a procedural checklist, global skill assessment scale, and entrustment scale. Afterwards, learners completed case-based reviews and returned to the simulation lab several months later to repeat an unassisted paracentesis. Results The curriculum was used with internal medicine and medicine-pediatric residents of all training levels. To date, over 120 residents have completed the curriculum. Residents reported an increase in self-confidence and competence using ultrasound to identify ascites and performing a paracentesis. Learners provided positive feedback. Discussion This curriculum offers the opportunity for both cognitive and psychomotor paracentesis education in a low-risk simulation environment. The comprehensive strategy with didactics, cases, and multiple simulations is designed to promote knowledge and skill retention.

Theory: Networking has positive effects on career development; however, personal characteristics of group members such as gender or diversity may foster or hinder member connectedness. Social network analysis explores interrelationships between people in groups by measuring the strength of connection between all possible pairs in a given network. Social network analysis has rarely been used to examine network connections among members in an academic medical society. This study seeks to ascertain the strength of connection between program directors in the Association of Program Directors in Internal Medicine (APDIM) and its Education Innovations Project subgroup and to examine possible associations between connectedness and characteristics of program directors and programs. Hypotheses: We hypothesize that connectedness will be measurable within a large academic medical society and will vary significantly for program directors with certain measurable characteristics (e.g., age, gender, rank, location, burnout levels, desire to resign). Method: APDIM program directors described levels of connectedness to one another on the 2012 APDIM survey. Using social network analysis, we ascertained program director connectedness by measuring out-degree centrality, in-degree centrality, and eigenvector centrality, all common measures of connectedness. Results: Higher centrality was associated with completion of the APDIM survey, being in a university-based program, Educational Innovations Project participation, and higher academic rank. Centrality did not vary by gender; international medical graduate status; previous chief resident status; program region; or levels of reported program director burnout, callousness, or desire to resign. Conclusions: In this social network analysis of program directors within a large academic medical society, we found that connectedness was related to higher academic rank and certain program characteristics but not to other program director characteristics like gender or international medical graduate status. Further research is needed to optimize our understanding of connection in organizations such as these and to determine which strategies promote valuable connections.

Background Burnout is typically viewed as an individual condition, and no link has been identified between burnout and loneliness. Objective To investigate the association of burnout with loneliness and social network degree and centrality. Methods A survey containing the Maslach Burnout Inventory (MBI), a 3-question loneliness scale, and a social connectivity component was sent to residents in a large urban academic medical center internal medicine residency program. Results The response rate was 77% (95 of 124 residents). We defined significant burnout as MBI subscores of ≥ 27 for emotional exhaustion (EE), ≥ 10 for depersonalization (DP), or both. This was met by 43 (45%), 47 (49%), and 31 (33%) out of 95 respondents, respectively. Those with significant burnout had higher loneliness scores: 5.6 versus 4.5 for EE (P = .002; OR = 1.50; 95% CI 1.15–1.95); 5.4 versus 4.6 for DP (P = .024; OR = 1.33; 95% CI 1.03–1.71); and 5.8 versus 4.6 for both EE and DP (P = .001; OR = 1.54; 95% CI 1.17–2.02). Rating a larger number of coresidents as closer connections on a 5-point Likert scale was not associated with lower burnout scores. No measures of centrality were associated with burnout scores for EE and/or DP. High personal accomplishment subscores on the MBI did correlate significantly with several measures of centrality. Conclusions Burnout was associated with loneliness in a dose-dependent fashion. Greater sense of personal accomplishment was associated with greater network centrality.