Competency by Design

[hero147]

Anybody have any opinions about the Competency by design and EPA roll out in residency programs? Is it as hated at your institutions as it is in mine? 

[rmorelan]

Ha, we are starting that up right now. Why is does it happen to be despised so much where you are at?

[1D7]

It is just being introduced for the fresh residents in my specialty. The off-service residents that come through tell me it is disliked, as it adds a lot of administrative work/documentation without much benefit.

The benefit is not clear, at least not right now. 

[blob]

My program has been in the process of rolling it out over the past few years. A few of the issues my cohort has been having include: 

1) The required frequency of our weekly EPA attempts appears to be higher than a lot of other programs in the country. There are certain rotations where it is very difficult keep up with the required frequency as the opportunities to achieve EPAs are far and few between. Despite this, we are still held accountable by our program if we do not achieve the required frequency (even if we're on track to complete the national CBD requirements). This adds additional stress to what is already a very stressful training process. 

2) The criteria to "pass" an EPA doesn't make a lot of sense for off-service rotations. You only achieve these EPAs if your preceptor feels comfortable with you managing the cases as if you were practicing independently - doesn't really compute when you're in a given specialty for a month and it is not your field of interest. Additionally some preceptors are not trained on CBD and they will not pass you on an EPA regardless of your performance ("you're still in training, why would I trust or expect you to practice independently?"). As well, the level of observation required to pass an EPA is quite strict (eg. working a busy overnight call shift where you don't have time to see a patient with your evaluator, you do a good job on the case but you can't use it for an EPA because your evaluator was not in the room with you at the time). 

3) The quality of the feedback is often quite generic because people don't have the time/energy to fill out the forms properly. It's seen as just another layer of administrative burden added on by academic physicians.

4) The feedback is ultimately going to be cherry-picked. You choose the EPAs you want done. If you feel like you did poorly on a case or were given critical verbal feedback, you'll be hesitant to put that  in writing for your program to see. Also, if you don't pass an EPA once, even if you achieved the required amount of passes for that particular skill overall, your program can still make you do more to convince themselves of your competency. The actual opportunities for important feedback are therefore limited to an extent based on how the system is designed. 

[attempt2]

I (an incoming resident) was told that the EPAs were very specific and if missed, there is (for our program) limited time to find future opportunities to meet the same requirements during our off service year. Also, they made the passing score higher than most preceptors are comfortable giving to off service R1s. 

[shikimate]

Honestly I just write that the resident meets the EPA because I have enough stuff to do already and don't need more work justifying them. 

It makes sense for PGY4 and PGY5 to have EPA to show they can function at a high level. It makes very little sense for PGY1 to have to do them. Like if you are a fresh PGY1 you just show up and try your best with no expectations.

Also I agree with the cherry picking thing. Like if today the resident saw 5 cases and decide to use 2 cases they knew the answers to do the EPA, then I have to write that they did well on those 2 cases. 

Also some of the older staff are refusing to do these EPA because they are not computer fluent and can't access ONE45 etc

[anonymouspls]

14 hours ago, rmorelan said:

Ha, we are starting that up right now. Why is does it happen to be despised so much where you are at?

Who doesnt like doing more meaningless busywork for a make work project designed by admin that otherwise would be out of a job.

Ha i dont feel quite as strongly about it as above but I dont know many people that are the subject of EPAs which enjoy or approve of them. At Western we unfortunately had EPAs and logbooks introduced as early as the clerkship level.

Im looking at my PGY1 EPAs as a rad onc resident and im seeing gems such as “complete a handover” and “gather a complete history.” Im sure glad ill have to bother my seniors or even staff to sign off on these, as if everyone isnt already extremely busy ha.

[rmorelan]

1 hour ago, anonymouspls said:

Who doesnt like doing more meaningless busywork for a make work project designed by admin that otherwise would be out of a job.

Ha i dont feel quite as strongly about it as above but I dont know many people that are the subject of EPAs which enjoy or approve of them. At Western we unfortunately had EPAs and logbooks introduced as early as the clerkship level.

Im looking at my PGY1 EPAs as a rad onc resident and im seeing gems such as “complete a handover” and “gather a complete history.” Im sure glad ill have to bother my seniors or even staff to sign off on these, as if everyone isnt already extremely busy ha.

That sort of thing just leads to massive sign offs happening all at once by bored senior people. They are supposed to be actual competencies, not low level or vague things. How do you even evaluate if handover was actually completed, or that the history is complete etc. 

and ha, good old one45. Still annoying people even after all this time. 

 

[zxcccxz]

1 hour ago, anonymouspls said:

Who doesnt like doing more meaningless busywork for a make work project designed by admin that otherwise would be out of a job.

Ha i dont feel quite as strongly about it as above but I dont know many people that are the subject of EPAs which enjoy or approve of them. At Western we unfortunately had EPAs and logbooks introduced as early as the clerkship level.

Im looking at my PGY1 EPAs as a rad onc resident and im seeing gems such as “complete a handover” and “gather a complete history.” Im sure glad ill have to bother my seniors or even staff to sign off on these, as if everyone isnt already extremely busy ha.

At UofC we had EPAs introduced at the clerkship level too. Most of my classmates didn't complain too much, because we only had to do 40-something across the entirety of clerkship & as other posters pointed out, it was super cherry-picked who/when you sent them out (I think I only had one EPA that was ever rated as "required supervision" rather than "able to do independently" because I only ever sent them to residents who were happy to fill them out without even looking at them, rather than sending them to staff).

Starting off as a new R1 though, I've heard that my program in particular has some crazy EPA requirements (you need to complete several per week on average) and that's something I'm really not looking forward to. Thankfully my specialty/program allows for a lot of 1-on-1 time with staff physicians without a more senior resident present, so hopefully that'll make it easier to get them. 

Completely agree that EPAs are something that was devised by out of touch academics and admin with the ultimate goal of justifying their positions and publishing "the incredible gains made by medical learners" as a part of a series of esoteric scientific papers in some shitty journal. Noone really likes them or sees them as anything more than an administrative hurdle.

[rmorelan]

4 hours ago, zxcccxz said:

At UofC we had EPAs introduced at the clerkship level too. Most of my classmates didn't complain too much, because we only had to do 40-something across the entirety of clerkship & as other posters pointed out, it was super cherry-picked who/when you sent them out (I think I only had one EPA that was ever rated as "required supervision" rather than "able to do independently" because I only ever sent them to residents who were happy to fill them out without even looking at them, rather than sending them to staff).

Starting off as a new R1 though, I've heard that my program in particular has some crazy EPA requirements (you need to complete several per week on average) and that's something I'm really not looking forward to. Thankfully my specialty/program allows for a lot of 1-on-1 time with staff physicians without a more senior resident present, so hopefully that'll make it easier to get them. 

Completely agree that EPAs are something that was devised by out of touch academics and admin with the ultimate goal of justifying their positions and publishing "the incredible gains made by medical learners" as a part of a series of esoteric scientific papers in some shitty journal. Noone really likes them or sees them as anything more than an administrative hurdle.

I do like the concept of them- it is the execution that is the problem at many sites. Ultimately the problem may be that to do it correctly truly does take an extremely large amount of work that no one has or it rewarded for doing (the busy work people are describing here isn't even close to what is actually required). It is easier to just dump it all on the learner with a long list of requirements, ignoring the fact that it is the instructors that are actually supposed to be evaluating for those and providing feedback - otherwise it just breaks down and become an academic scavenger hunt for getting check marks. 

 

 

[hero147]

21 hours ago, rmorelan said:

Ha, we are starting that up right now. Why is does it happen to be despised so much where you are at?

People in my program are foregoing learning opportunities to pick cases and staff that will fill out EPAs over cases that interest them. Plus talking to a lot of residents, they frequently say that one of the biggest stressors to residency is finishing your EPAs. Residency is stressful enough without adding useless evaluations to make resident lives even more difficult. A lot of staff don't fill them out and it's a pain to chase staff to do them. Never mind that there are so many of them. At  my program, its about 350 more evaluations over 5 years that you have to send and pass in addition to the ITERs.