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Northwestern University Feinberg School of Medicine
MD Education

EPA

 EPA 1: Gather a history and perform a physical examination

What does this EPA mean?   Physicians perform accurate and appropriately complete history and physical examinations in a prioritized, organized manner without supervision and with respect for the patient (both during and after the encounter).  The history and physical examination will be tailored to the clinical situation and specific patient encounter.  Physicians integrate the scientific foundations of medicine with clinical reasoning skills to guide their information gathering, incorporating alternate sources of information such as family members or the EHR as appropriate.  Physicians also acknowledge limitations in their skills, obtaining assistance when needed and reporting findings exactly as performed.

What behaviors may be observed?

FSM Competency

Pre-entrustable behaviors

Entrustable behaviors

ECIS 1: Listen empathetically and effectively

When taking a history, the student may look at the computer or their notes and not make adequate eye contact with the patient.  They may focus on obtaining the history and miss verbal or nonverbal cues from the patient where empathy is indicated. The student may interrupt the patient, repeat questions or rely on mostly closed-ended questions.

The student maintains appropriate eye contact with the patient.  The student responds to patient’s verbal and nonverbal cues and offers empathic statements or other nonverbal indications of understanding.  The student encourages the patient to tell their story and elicits the patient’s perspective.

PCMC 1: Elicit complete medical histories using questions appropriate for the presenting concerns

The history taking does not demonstrate hypothesis-driven questioning but appears to follow rote memorization of a series of questions. This history may be missing key components in the HPI, medical history, social history, medication list, or other aspects.  The history-taking does not attend to the clinical scenario and is either too exhaustive or too succinct. =.  The student does review information available in the chart to guide their questions.

An appropriate history is taken, using hypothesis-driven techniques to obtain all relevant information for the presenting concern and setting.  All relevant information is included in the HPI, medical history, social history, medication list, and allergies.  The student elicits appropriate detail given the clinical scenario. The student performs necessary chart review to understand patient history and help guide their questions.  

PCMC 2: Perform the physical exam with sensitivity to patient comfort; select techniques appropriate to the complexity and acuity of the patient.

The student may not communicate with the patient in a clear, well-timed manner during the physical exam. Student may fail to drape or otherwise attend to patient comfort.  Relevant physical examination maneuvers may be excluded or performed incorrectly. The physical examination may be overly brief or overly detailed for the patient concern and setting.  The student may be unable to interpret physical exam findings.

The physical examination is performed correctly, with clear, well-timed communication with the patient and attention to patient comfort.  All relevant maneuvers are done without extraneous examination maneuvers.  The student is able to accurately interpret physical exam findings.

PBMR 3: Display honesty integrity, respect, & compassion toward others regardless of gender, race, religion, ideology, socioeconomic status, disability, age, national origin, sexual orientation, or ability to pay.

The student may have lapses in respect toward the patient during or after the interview and examination such as failing to acknowledge the patient beyond the chief concern or dismissing the patient’s concerns.  The student may show lack of respect in describing the patient’s case to other members of the healthcare team.  The student may report portions of the history or physical examination findings they did not elicit. 

The student maintains respect for the patient during the history and physical and during all discussions of the patient with others on the healthcare team.   The student is honest and forthright with respect to their portrayal of history and examination findings.

 

When can this EPA be assessed?

  • History taking can be observed during initial patient admission or when a patient has a new concern during admission and a new history of present illness is asked.
  • Physical examination can be observed at any point during admission, including morning bedside rounds as the student leads the team in the encounter.
  • Both the standard “History and Physical Direct Observation” long form assessment and the “ad hoc” mobile assessment app can be used as tools to record attending assessments and feedback to students.

 EPA 2: Prioritize a differential diagnosis following a clinical encounter

What does this EPA mean?  Physicians synthesize data from multiple sources and utilize this data to develop a prioritized differential diagnosis.  Then, as additional data becomes available—from other historical sources, exam changes, and studies—physicians must continuously revise the differential diagnosis, avoiding common errors of clinical reasoning such as premature closure.  A well-reasoned differential diagnosis will incorporate the scientific foundations of medicine along with evidence of critical thinking to support and refute each possibility.

What behaviors are observed when assessing this skill?

FSM Competency

Pre-entrustable behaviors

Entrustable behaviors

PCMC 1: Elicit complete medical histories using questions appropriate for the presenting concerns

The medical history is missing critical elements or students fail to identify the key features from the history. The student does not review or does not understand the patient’s past history found in the medical record.

The medical history is complete and nuanced, making clear the student’s clinical reasoning. The history includes all data needed to help prioritize a differential diagnosis.   The student does necessary EMR review, and then integrates information acquired from the patient and from the medical record.

PCMC 2: Perform the physical exam appropriately and select techniques appropriate to the complexity and acuity of the patient; interpret findings correctly.

The physical exam is incomplete, incorrectly performed, or misinterpreted.  The student may do a rote exam that is not tailored to the presenting concern.

The physical examination is complete, accurate, and interpreted correctly.  All exam maneuvers relevant to the differential diagnosis are performed.

PCMC 3: Display clinical reasoning skills regarding a patient case verbally and in writing.

The differential diagnosis is missing key diagnoses and/or justification applied is incorrect. 

The differential diagnosis is prioritized and includes all expected diagnoses, including most likely diagnoses, and appropriate “cannot miss” diagnoses.  The differential is well-justified and includes appropriate information from history, physical examination, and studies already obtained. 

PBMR-7: Demonstrate initiative and responsibility in and patient care.

The differential diagnosis is missing one or more critical conditions that would typically be found with background reading about the chief concern.

The differential diagnosis demonstrates application of background reading, including key signs or symptoms of less common diagnoses when appropriate.

 

When can this skill be assessed?

  • Written notes or conversations serve as sources of data to assess differential diagnosis
  • Assessment can occur anytime a differential diagnosis is being created or revised:
    • after initial discussion between a student and team resident while working up a new admission
    • after a presentation of a patient on rounds
    • after a conversation about the patient that occurs between an assessor and student after new data is collected and leads to the need to revise a differential diagnosis.
    • After presentation of a patient in the ambulatory setting
    • In a phone conversation where a student revises a differential diagnosis using new data that was ordered during an ambulatory visit

 

 EPA 3: Recommend and interpret common diagnostic and screening tests

What does this EPA mean?  Physicians must appropriately recommend tests for both diagnostic and screening purposes and interpret these results. When recommending tests, one must consider the evidence supporting the use of the test, the value of the test, and the expenses that patients may incur by obtaining the test.  Physicians must also follow-up on all test results in a timely fashion and communicate results to patients.

What behaviors are observed when assessing this skill?

FSM Competency

Pre-entrustable behaviors

Entrustable behaviors

MKS 3a: Apply knowledge to diagnose illness and solve clinically relevant problems.

The student may not recommend or interpret basic diagnostic tests accurately; justification for tests may be incomplete or inaccurate.

The student consistently recommends or interprets basic diagnostic tests accurately, providing appropriate justification for each test.

MKS 1f: Demonstrate knowledge of epidemiology, biostatistics and the principles of disease prevention to make medical decisions.

 

The student does not apply or demonstrate understanding of the concepts of pre-test probability and test-performance characteristics. The student does not recommend patient-specific procedures for health maintenance unless instructed to do so.

The student attempts to apply pre-test probability and test-performance characteristics when choosing and interpreting diagnostic tests.  The student usually recommends patient-specific procedures for health maintenance.

PBMR 7

Demonstrate initiative and responsibility in daily professional tasks including participation in learning activities, class presentations and patient care.

 

The student must be prompted to follow-up on diagnostic test results and may not try to provide their own assessment of the results before seeking team input. The student’s work does not show evidence of reading about a given test interpretation when appropriate.

The student follows-up promptly on results for all diagnostic tests and interprets the results for themselves before looking to the team for guidance.  When necessary, the student does additional reading to best interpret the results of the studies and apply to the patient case. 

SATBC-1

Describe healthcare finance and delivery in various healthcare systems, and demonstrate the ability to effectively call on system resources to provide care that is of optimal value.

 

When recommending diagnostic or screening tests, the student does not consider costs and/or value of the test in decision making. The student may not demonstrate awareness of the financial implications of ordering the tests/procedures for patient, Examples include: recommending “routine daily labs” during a hospital stay without justification, duplicate tests because of incomplete review of medical records, or low-value tests in the outpatient setting. 

The student considers the value of tests and procedures when recommending their use, appropriately justifying a given test or procedure using evidence-based principles. The student also considers expenses for patients when recommending tests and procedures. The student uses information technology to support decision-making and adopts strategies to decrease cost and risk to individuals.

ECIS 3 Communicate information clearly to patients, colleagues and teams. Demonstrate closed loop communication skills.

 

The student communicates results in a manner that is unclear, uses jargon, or does not confirm patient understanding.

The student communicates results without using jargon and confirms understanding from the patient.

 

When can this skill be assessed?

  • Written notes or conversations serve as sources of data about how the student recommends and interprets common diagnostic and screening tests
  • Assessment can occur any time labs and studies are being ordered or interpreted:
    • initial discussion between a student and team resident while working up a new admission
    • after a presentation of a patient on rounds
    • after a conversation about the patient that occurs between an assessor and student after new data is collected and leads to the need to obtain or interpret additional data.
    • During discussion of the plan in the ambulatory setting
    • In a phone call/email/EPIC message where a student discusses his/her interpretation of labs and studies ordered during an ambulatory visit.

 EPA 4: Enter and discuss orders and prescriptions

What does this EPA mean?  Writing safe and appropriately-indicated orders and prescriptions is a critical skill for practicing physicians.  A number of patient-safety structures are in place in the EHR to aid in this endeavor and physicians should use this guidance to ensure that orders and prescriptions are written clearly in a manner that all team members and patients can understand.  Even practicing physicians will sometimes need guidance regarding how to write orders correctly when systems change or new orders become available—recognizing one’s limitations, doing additional reading, and asking for help are key skills to ensure orders are safe and accurate.

What behaviors are observed when assessing this skill?

FSM Competency

Pre-entrustable behaviors

Entrustable behaviors

ECIS 2   Write clearly at an appropriate level for patients, colleagues and teachers.

 

Orders lack adequate detail to guide those completing orders or interpreting results (i.e. radiology studies, pathology). The student does not use standard language when writing orders and prescriptions.  Prescriptions for patients may include jargon (i.e. BID, TID, etc.) or other errors. 

Orders are written succinctly but with adequate detail for all users.  Prescriptions are written without jargon and use standard language for frequency and dosage.  Free text is used sparingly and only when necessary.

CLQI 5  Articulate and effectively apply relevant patient safety principles, practices and appropriate patient safety-related behaviors.

The student clicks through decision-support alerts without reading, fails to consider adjusting medication doses for BSA or GFR, inadequately completes order justification templates, or otherwise dismisses or does not apply EMR-based patient safety tools when writing orders or prescriptions.

All decision support prompts are read and attended to, taking care to adjust doses for renal disease or in pediatric patients.  EMR-based patient-safety tools and Best Practice Alerts are noted and acted upon.

MKS 3b & PCMC 3 Apply knowledge to prevent and treat illness and improve quality of life.  Display clinical reasoning skills regarding a patient case verbally and in writing.

Suggested orders or prescriptions lack appropriate rational or justification.  At times, the correct orders or prescriptions are suggested but the reasoning that supports them is incorrect or not provided. 

Suggested orders and prescriptions are justified and prioritized appropriately for the patient case, setting, and indication.

PBMR 6 Demonstrate respect for privacy, protect confidentiality, and maintain security of the data of patients and families.

The student frequently enters orders or prescriptions for the incorrect patient.  Requires frequent reminders to lock/log-off computer when not in use. 

The student double-checks the patient’s name, DOB, or other identifier when entering orders and prescriptions.  The student always locks or logs off the EHR appropriately. 

SATBC-1  Describe healthcare finance and delivery in various healthcare systems, and demonstrate the ability to effectively call on system resources to provide care that is of optimal value.

 

The student does not consider costs and/or value when writing orders or prescriptions. The student does not demonstrate awareness of the financial implications for the patient or utilize strategies to reduce out-of-pocket costs. 

The student considers the value of orders and prescriptions when recommending their use, using evidence-based principles to justify use. The student also considers out-of-pocket expenses for patients and recommends ways to ameliorate costs (i.e. GoodRx, assistance from SW, pharmaceutical programs).

 

When can this skill be assessed?

  • Assessment can occur anytime orders or prescriptions are written:
    • During initial admission for inpatients when residents co-sign orders
    • During outpatient visits when attendings co-sign orders
    • At the time of discharge when prescriptions are written for patients and residents co-sign

 EPA 5: Document a clinical encounter in the patient record

What does this EPA mean?  Physicians must write accurate, focused, and context-specific documentation of clinical encounters across a number of settings: office visits, admissions, daily notes, discharge summaries, phone calls, and patient email messages.  Documentation serves both to help the writer to organize one’s thoughts and to communicate one’s data gathering and reasoning to other care team members.  Notes may serve as hand-offs to share anticipatory guidance as well.  Physicians must truthfully document work and verify the information in notes for accuracy.  Documentation must be completed in a timely manner.

What behaviors are observed when assessing this skill?

FSM Competency

Pre-entrustable behaviors

Entrustable behaviors

ECIS 2   Write clearly at an appropriate level for patients, colleagues and teachers.

 

The note may be too brief or overly wordy, with errors in organizing, and prioritizing the information. The note may not be appropriate for the clinical setting (e.g. a full inpatient H&P style note for an acute outpatient visit for a viral URI). Written patient instructions are unclear or inaccurate.    

Notes are clear, well-organized, appropriately succinct, and are appropriate for the setting.  Patient insructions are clear and accurate.

PCMC 1 Elicit complete medical histories using questions appropriate for the patient’s presenting concerns.

 The medical history is missing critical elements, or the student fails to identify the key features from the history. The student does not incorporate data from multiple sources, such as the medical record.

The documented history is appropriately detailed for the presenting concern and setting. It incorporates data from multiple sources including the medical record

PCMC 2 Perform both comprehensive and focused physical exams with sensitivity to patient comfort. Select techniques appropriate to the complexity and acuity of the patient.

The documented physical exam is overly brief, overly long, and/or is not hypothesis-driven.  Key maneuvers may be missing, and irrelevant physical examination maneuvers may be noted.

 A relevant and hypothesis-driven physical examination appropriate for the given setting and patient complaint is documented.

PCMC 3 Display clinical reasoning skills regarding a patient case verbally and in writing.

Patient notes may have errors in structure (objective findings in history, missing relevant information, excessive “data dump” that is not relevant to the current encounter) or in the reasoning laid out in the assessment and plan.  The differential diagnosis may be too limited, mis-prioritized, or have errors in justification.

Patient notes show proper structure, demonstrate sound reasoning, and advance the care of the patient. Reasoning is complete and correct even in challenging cases with justification for the prioritization of the differential diagnosis and the next steps in the diagnostic work-up and plan.

PCMC 5 Demonstrate proficiency in navigating the electronic health record (EHR) to obtain and document information needed for patient care.

Data from prior relevant encounters may not be appropriately included in the current note or may be incorporated when not relevant to the current encounter. There may be excessive reliance on copy-paste or “copy forward.” 

Relevant information from prior encounters (including history and prior testing) that is pertinent to the presenting situation is extracted, synthesized, and reworded (when appropriate) to succinctly convey information. 

PBMR 5  Display accountability and dependability.

Notes are not completed on time and/or contain inaccurate data.

Notes are completed in a timely manner.

PBMR 3: Display honesty & integrity.

 

Notes contain data copied from other providers without attribution or document data that was not obtained by the student.

Notes are responsibly documented, never copied from other providers unless appropriately attributed, and document only information that was elicited or confirmed by the student.

SATBC-3 Demonstrate skills in transitioning care from one clinical team member to another within and between healthcare systems, paying particular attention to unique patient needs.

Notes written in transitional care (e.g. discharge summaries, off service notes, urgent care visits) fail to document anticipatory guidance or next steps for the providers assuming care of the patient.  Relevant information is missing or poorly synthesized.  A clear “to-do” list is missing.

Notes carefully document next steps in care and anticipatory guidance using “if…then…” guidance when appropriate.  Relevant studies or clinical data is clearly synthesized. 

 

When can this skill be assessed?

  • Any written note can be assessed.
    • Notes can be assessed centrally in some cases (i.e. by physicians who are not part of the care team)
    • Inpatient notes or outpatient notes can be used
    • A variety of note types can be assessed (i.e. H&Ps, daily notes, outpatient notes, discharge summaries)

 EPA 6: Provide an oral presentation of a clinical encounter

What does this EPA mean?  Physicians must succinctly summarize patient encounters with one or more members of the healthcare team in many settings.  A proper oral presentation requires the efficient synthesis of gathered data with a goal of helping all participants to have a shared understanding of the patient’s current condition.  The style of the presentation will be tailored to the setting to meet the needs of the receiver of the information.   

What behaviors are observed when assessing this skill?

FSM Competency

Pre-entrustable behaviors

Entrustable behaviors

ECIS 3 Communicate information clearly to patients, colleagues and teams. Demonstrate closed loop communication skills.

 

The presentation is poorly organized, making it difficult for the listener to follow the information.  The presentation is not be appropriate for the clinical setting (i.e. a full inpatient H&P style presentation for an acute outpatient visit for a viral URI). Speech may be difficult to understand.      

The presentation is clearly organized, clinically meaningful and follows established oral presentation conventions, and is tailored to the setting.  The student speaks clearly.

PCMC 1 Elicit complete medical histories using questions appropriate for the patient’s presenting concerns.

 The history is disorganized, does not contain all relevant information for the presenting concern and setting, or contains extraneous information.

The history is prganized and appropriately detailed for the presenting concern and setting.

PCMC 2 Perform both comprehensive and focused physical exams with sensitivity to patient comfort. Select techniques appropriate to the complexity and acuity of the patient.

The physical exam is overly brief, overly long, and/or does not demonstrate attention to the hypothesis-driven exam.  Key maneuvers may be missing and irrelevant physical examination maneuvers may be noted.

Arelevant and hypothesis-driven physical examination appropriate for the given setting and patient complaint is shared in the oral presentation.

PCMC 3 Display clinical reasoning skills regarding a patient case verbally and in writing.

The presentation may have errors in reasoning laid out in the assessment and plan.  The differential diagnosis may be too limited, mis-prioritized, or have errors in justification.

Oral presentations demonstrate reasoning that is complete and correct even in challenging cases with justification for the prioritization of the differential diagnosis and the next steps in the diagnostic work-up and plan.

PCMC 5 Demonstrate proficiency in navigating the electronic health record (EHR) to obtain and document information needed for patient care.

Data from prior relevant encounters may not be appropriately included or may be incorporated in a disorganized way.

Relevant information (including historical information and data/studies) from prior encounters is extracted, synthesized, and succinctly conveyed.

PCMC 7 Demonstrate initiative and responsibility in daily professional tasks.

The oral presentation does not show evidence of application of additional reading to the interpretation of data, assessment, or plan.

The oral presentation shows evidence of additional reading applied to the interpretation of data, assessment, or plan.

 

When can this skill be assessed?

  • Any oral presentation can be assessed.

 EPA 7: Form clinical questions and retrieve evidence to advance patient care

What does this EPA mean? Physicians must be able to identify key clinical questions in caring for patients, identify information resources, and retrieve quality information and evidence that can be used to address these questions.  Physicians must be able to appropriately critique the information obtained utilizing principles of evidence-based medicine and communicate their findings and the applicability of the information to the team caring for the patient.

What behaviors are observed when assessing this skill?

FSM Competency

Pre-entrustable behaviors

Entrustable behaviors

CLQI 3: Construct clinical and research questions and apply information to solve them. Retrieve, analyze and critically appraises literature.

The student is unable or requires significant help to construct a searchable clinical question pertinent to patient care, utilizes outdated or irrelevant resources and cannot appropriately critique the evidence or its applicability to the patient.

The student independently develops a well formed, searchable clinical question relevant to the care of a patient, retrieves high quality resources that they can appropriately critique using the principles of evidence -based medicine and applies the results of the literature to the patient.

ECIS 2 and 3: Communicate information clearly to patients, colleagues and teams verbally and/or in writing.

The student is unable to or requires significant help advising or educating the team regarding the information obtained to answer a clinical question pertinent to patient care.

The student independently advises and educates the team with nuanced findings from the evidence and/or shares the limitations of available evidence for a given clinical question pertinent to patient care. The student presents the information clearly and efficiently.

PCMC 3: Display clinical reasoning skills regarding a patient case verbally and in writing.

The student does not understand the most relevant clinical care issues that would drive the identification of a question pertinent to the clinical care of the patient.

The student has a deep understanding of and is able to prioritize the most critical diagnoses and management issues that need to be addressed in the care of a particular patient.

 

When can this skill be assessed?

  • Written notes or conversations with the team serve as sources of data to assess the ability to form appropriate clinical questions, search and critique quality evidence that informs the care of the patient.
    • Examples of written notes include admission H&Ps and progress notes.
  • Assessment can occur anytime that information is being brought back to the team to answer a clinical question.
    • after a presentation of a patient on rounds
    • after a conversation about the patient that occurs between an assessor and student after new data is collected and leads to a change or confirmation of the diagnostic and/or management plan.
    • After presentation of a patient in the ambulatory setting

 

 EPA 8: Give or receive a patient handover to transition care responsibility

What does this EPA mean?  Effective and efficient handover communication ensures that patients continue to receive high quality and safe care through transitions of responsibility from one healthcare team or provider to another.  Handovers may occur between settings (ICU to inpatient ward, inpatient to rehabilitation unit, inpatient care to outpatient primary care physician) or within settings (shift changes). Physicians must be able to utilize structured tools and documents that provide critical information for the handoff. They must provide succinct verbal and/or written communication that conveys illness severity, situation awareness, action planning and contingency planning.

What behaviors are observed when assessing this skill?

FSM Competency

Pre-entrustable behaviors

Entrustable behaviors

ECIS 2 and 3: Communicates information clearly verbally and in writing to colleagues and teams.  Utilizes closed loop communication skills.

Communication is rigid and fact based without synthesis or prioritization. Transition handoff is disorganized and confusing. No confirmation of understanding from recipient of handoff.

Communication is clear, efficient, and appropriate for type of transition of care.  Displays understanding and prioritization of patient acuity, problems and outstanding issues that need follow up.

Closed loop communication is utilized to confirm understanding from recipient.

PCMC 5: Demonstrate proficiency in navigating the electronic health record (EHR) to obtain and document information needed for patient care

Inconsistent use of available information in the EHR (care everywhere, outpatient notes) to provide critical patient information during transitions of care.

Obtains all important information from EHR utilizing available EHR tools effectively and efficiently.

PCMC 3: Display clinical reasoning skills regarding a patient case verbally and in writing.

Handoff demonstrates poor understanding and prioritization of pertinent patient problems in terms of acuity and complexity.

Handoff demonstrates exceptional understanding and prioritization of pertinent patient problems in terms of acuity and complexity.  Anticipates which patients may deteriorate and why and provides appropriate steps for management.

PBMR-6: Demonstrate respect for privacy, protect confidentiality and maintain security of the data of patients.

Student inconsistently considers patient privacy and confidentiality (eg. Discussing patients in public areas or leaving handoff documents in freely available areas)

Student respects and helps others maintain the privacy and confidentiality of patients in every situation.

SATBC 2a and 2b:

Demonstrate  positive teamwork attitudes and skills during clinical care and work effectively with all members of the interprofessional team to provide best patient care.

 

Limited participation in team activities around transitions of care.

Focused on own needs and not those of other team members. Allows distractions and interruptions to interfere with team tasks during transitions. Engages poorly with non-MD members of the team.

Fully engaged in team activities around transitions of care.  Understands the roles of all team members and interacts effectively.  Puts own needs behind those of the patient and team during transitions of care activities.

SATBC 3:

Demonstrate skills in transitioning care from one clinical team member to another within and between healthcare systems, paying particular attention to patient needs

Unable to provide appropriate information during care transitions (content, accuracy, efficiency and synthesis). Does not utilize structured approaches to patient handoffs. Demonstrates little understanding of patient safety implications of care transitions.

Utilizes effective, standardized approaches to care transitions reliably which contain appropriate information and anticipatory guidance during handoffs. Engages all team members effectively and creates environment where patient safety

 

When can this skill be assessed?

  • Written/verbal handoffs, discharge summaries or transfer notes serve as sources of data to assess transitions of care.
  • Assessment can occur anytime a transition of care occurs:
    • Observation of student during shift change handoff conversation
    • Upon transfer of patient from one care setting to another (ICU transfer, conversation with PCP at time of patient discharge)
    • Discussion with ED or admitting team when sending a patient to these settings from an ambulatory visit.

 

 EPA 9: Collaborate as a member of an interprofessional team

What does this EPA mean? Physicians must be able to effectively work in inter-professional teams to provide safe, equitable and effective patient care. Physicians must understand the roles and responsibilities of various team members and must be able to communicate with respect and appreciation for each team member. The needs of the team must supersede personal needs in order to provide best patient care.

What behaviors are observed when assessing this skill?

FSM Competency

Pre-entrustable behaviors

Entrustable behaviors

ECIS 1 and 3: Listens empathically and effectively to all team members. Shares information clearly, demonstrating closed loop communication skills

Does not anticipate or read team members’ emotions in verbal and nonverbal communication. Is disengaged or disruptive to conversation.  Does not contribute information clearly and may disregard communication barriers.

Listens actively and encourages ideas and opinions from other team members. Tailors communication to audience, purpose and content in most situations. Checks understanding of the recipient of communication.

PBMR 3: Display honesty, integrity, respect and compassion toward others.

Demonstrates lapses in professional conduct, such as through disrespectful interactions or lack of truth-telling.

Is respectful, compassionate and demonstrates integrity in interactions with all team members.  Practices truthfulness. 

SATBC 2a and 2b: Demonstrate positive teamwork attitudes and skills during clinical care activities.

Does not understand the roles and value of inter-professional team members. Limited participation in team discussion. Passively follows the lead of others. Little initiative to interact with team members. Limited acknowledgement of the work of others.

Demonstrates an understanding of the roles of various team members by seeking out, engaging and interacting with all relevant members to achieve best clinical outcomes. Puts needs of team ahead of personal needs.

 

When can this skill be assessed?

  • Interactions with the team serve as sources of data to assess the ability to work effectively with all members of the team.
  • Assessment can occur anytime that team interactions occur.
    • Encounters where students interact and multiple team members are present (i.e. inpatient rounds, OR, L and D, outpatient team huddles, interdisciplinary rounds)
    • Encounters where students interact 1:1 with non-physician team members (i.e. SW, PT, pharmacy etc.
    • Observing students calling consults, interacting with consulting teams, or communicating with a primary team when on rotations serving as a consultant

 EPA 10: Recognize a patient that requires urgent/emergent care & initiate evaluation and management

What does this EPA mean?  The ability to promptly recognize a patient who requires urgent or emergent care, initiate evaluation and management, and seek help is essential for all physicians. Interns are often the first responders in an acute care setting, or the first to receive notification of an abnormal lab or deterioration in a patient’s status. Early recognition and intervention is essential to optimize patient outcomes. Simultaneously recognizing the need, calling for assistance and initiating care is important.

What behaviors are observed when assessing this skill?

FSM Competency

Pre-entrustable behaviors

Entrustable behaviors

PCMC 1: Elicit complete medical histories for the presenting concern

The student is unable to efficiently elicit information relevant to understanding the change in patient status from multiple sources including the patient, the medical record and other members of the team.

The student quickly gathers pertinent information from relevant sources (even in the setting of a non-responsive patient) that helps to accurately understand the change in a patient’s clinical status.

PCMC 2: Perform focused physical exam appropriate to the complexity and acuity of the patient; interpret findings correctly.

The student fails to recognize concerning trends in vital signs. Key aspects of the physical exam which would help pinpoint the underlying cause for a change in the patient’s condition are not performed. The student spends too much time on extraneous maneuvers. The students misinterprets or overlooks the relevance of key findings.

The student quickly and efficiently performs a focused exam relevant to the specific change in the patient’s status.  Key findings are recognized and correctly interpreted to accurately describe the patient’s condition.

PCMC 3: Display clinical reasoning skills

The student does not recognize the severity and acuity of the patient’s condition and does not escalate care appropriately. The student does not interpret or connect important pieces of information to quickly develop a differential diagnosis and plan next steps. The differential is not accurately prioritized and/or is missing key diagnoses (those most common and essential not to miss given the acuity of the situation). The student requires supervisors and/or other members of the team to initiate correct interventions and testing.

The student correctly interprets the urgency of the patient’s condition, escalates care and initiates next steps. The differential diagnosis includes all expected diagnoses, including both “most likely” and “cannot miss” diagnoses.  The student is able to anticipate the appropriate next steps to evaluate, intervene and manage the situation in a timely manner.

PCMC 4: Demonstrate proficiency in performing select clinical procedures.

 

 

The student is unable to call a code and apply basic and advanced life support as indicated.

The student is able to utilize proper procedures to escalate care, and initiate/ apply basic and advanced life support as indicated.

ECIS 3: Communicate information clearly to patients, colleagues and teams.

The provides superfluous and/or incomplete patient information to responding members of the health care team and omits information when documenting the clinical encounter in the medical record.

The student provides timely, focused and accurate patient information to responding members of the health care team and completely documents essential information in the

medical record

CLQI 1a:

Accept, seek and implement feedback.

The student is not reflective , does not seek feedback and is defensive and/or argumentative during debriefing sessions of the clinical encounter.

The student understands and recognizes personal limitations, emotions, and personal biases and seeks help when needed as well guidance and feedback about their performance.

 

When can this skill be assessed?

  • Assessment can occur anytime a patient’s condition deteriorates and necessitates an immediate/urgent response.
  • Review of written notes, patient rounds and debriefing conversations with the team serve as sources of data to assess the ability of a student to identify and intervene in urgent/emergent situations.

 

 EPA 11: Obtain informed consent for tests and/or procedures

What does this EPA mean? Physicians must be able to obtain informed consent for interventions, tests, or procedures they order or perform (e.g., immunizations, central lines, contrast and radiation exposures, blood transfusions). Informed consent presumes knowledge of the indications, contraindications, alternatives, risks, and benefits of the procedure and requires an understanding of its importance in shared decision-making.

What behaviors are observed when assessing this skill?

Pre-entrustable behaviors

Entrustable behaviors

• The student does not understand or does not include key elements of informed consent (indications, contraindications, alternatives, risks, and benefits) or provides incorrect information.

• Uses medical jargon, unidirectional communication strategies, does not elicit questions or patient preferences and is unable to read emotional cues of others.

• Does not recognize personal bias, knowledge limitations or need for interpretive services.

• Documentation of consent contains errors

• The student demonstrates an understanding of the key elements and provides complete information specific to the procedure.

• Avoids medical jargon, uses bidirectional communication strategies, elicits questions and patient preferences, and recognizes/addresses emotional needs of the patient.

•Demonstrates confidence commensurate with knowledge and skills, seeks guidance from superiors, and uses an interpreter as indicated.

• Documentation is complete and timely.

 

When can this skill be assessed?

  • Assessment can occur when consent is being obtained for any test or procedure.
  • Review of written notes can serve as sources of data to assess the ability of a student to correctly document all key elements of informed consent in a timely fashion.

 EPA 12: Perform general procedures of a physician

What does this EPA mean?  All physicians need to demonstrate competency in performing core procedures on completion of medical school in order to provide basic patient. These procedures may include: basic cardiopulmonary resuscitation (CPR), bag and mask ventilation, venipuncture, obtaining an arterial sample and other clerkship-specific procedures.

What behaviors are observed when assessing this skill?

FSM Competency

Pre-entrustable behaviors

Entrustable behaviors

MKS 1a : Demonstrate clinically relevant knowledge of the normal structure and function of the body

Unaware of the necessary anatomical landmarks and regional anatomy necessary to safely perform the procedure.

Demonstrates good understanding of anatomy and possible variations in order to safely perform the procedure

MKS 1e: Demonstrate knowledge of pharmacology and other therapeutic modalities.

Unaware of indications, contraindications, risks, benefits, and alternatives of the procedure.

Demonstrates awareness of indications, contraindications, risks, benefits, and alternatives of the procedure.

PCMC 4: Demonstrate proficiency in performing select clinical procedures.

The student uses poor technical skills or demonstrates a lack of dexterity.

Utilizes proper technique and is able to complete the procedure.

ECIS 3: Communicate information clearly to patients, colleagues and teams.

Does not demonstrate patient-centered skills (uses medical jargon, does not confirm patient understanding or engage the patient in decision-making, unable to read emotional cues from the patient, touches without warning)

Demonstrates patient-centered skills (avoids medical jargon, insures patient understanding and shared decision-making, pays attention to the patient’s emotional response, puts patient at ease, talks before touch)

CLQI 1a:

Accept, seek and implement feedback.

Lacks judgement and self-awareness either in over or under-confidence; does not seek feedback and is defensive and/or argumentative during debriefing sessions after the procedure

Has confidence commensurate with knowledge and skill level; self-regulates during the performance of the procedure; seeks feedback.

 

CLQI 4: Demonstrate quality improvement knowledge and skill.

Demonstrates limited knowledge of complications of the procedure and does not know how to minimize them. Inconsistently uses universal precautions and aseptic technique when needed.

Knows and takes steps to mitigate complications of the procedure. Consistently uses universal precautions and aseptic technique.

PCMC 5: Demonstrate proficiency in navigating the electronic health record (EHR) to obtain and document information.

Documents the procedure incompletely or not in a timely manner in the EHR.

Thoroughly documents the procedure in a timely manner.

 

 

When can this skill be assessed? Assessment of this EPA can occur whenever a student will be directly observed performing a procedure on a real patient.  This can include bedside procedures (i.e. arterial line placement, NG tube placement, CPR, dressing changes, venipuncture, urinary catheter placement, skin laceration repair, pap smear etc) or procedures in the OR (i.e. wound closure tends to be most common, but any other OR procedural task is appropriate). 

Pre and de-briefing along with review of the medical record can assist with assessment of entrustable behaviors.