Advertisement

Mastery Learning, Milestones, and Entrustable Professional Activities

  • Eric S. HolmboeEmail author
  • David H. Salzman
  • Joshua L. Goldstein
  • William C. McGaghie
Chapter
Part of the Comprehensive Healthcare Simulation book series (CHS)

Abstract

Competency-based medical education (CBME) has developed strong roots in many professional education systems worldwide. The CBME movement is driven by concern and evidence of significant challenges in the quality and safety of healthcare. Medical education can be viewed as a translational science intervention because the competencies acquired by learners must transfer directly to the care of patients and families. Mastery learning specifically incorporates this critical outcomes-based philosophy into its design and application. Milestones and entrustable professional activities (EPAs) have emerged as developmental educational strategies and approaches to advance the implementation of CBME. However, implementation of competencies through milestones and EPAs has been challenging and is still in its infancy.

The logical, and necessary, next step is to integrate mastery learning into all developmental models. Health professions education is a highly experiential process involving vulnerable patients, families, and communities. A mastery mindset can help accelerate the evolution, if not transformation, now occurring in medical education. This chapter explores how mastery-based methods can substantially advance CBME and enhance the utility of milestones and EPAs. Mastery learning provides the roadmap to achieve the ultimate aims of medical education to improve the healthcare of patients and families.

Keywords

Mastery learning Competency-based medical education Competencies Milestones Entrustable professional activities Shared mental models Shared mental representations Quality Patient safety Outcomes 

References

  1. 1.
    Sullivan RL. The competency-based approach to training. Strategy Paper No 1. Baltimore, MD: JHPIEGO Corporation; 1995.Google Scholar
  2. 2.
    Elam S. Performance-based teacher education: what is the state of the art? Washington, DC: American Association of Colleges for Teacher Education; 1971.Google Scholar
  3. 3.
    McGaghie WC, Miller GE, Sajid AW, Telder TV. Competency-based curriculum development in medical education. Public Health Paper No. 68. Geneva: World Health Organization; 1978.Google Scholar
  4. 4.
    Carraccio C, Wolfstahl SD, Englander R, et al. Shifting paradigms: from Flexner to competencies. Acad Med. 2002;77:361–7.CrossRefGoogle Scholar
  5. 5.
    Frank JR, Snell LS, Cate OT, et al. Competency-based medical education: theory to practice. Med Teach. 2010;32(8):638–45.CrossRefGoogle Scholar
  6. 6.
    Frank J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010;376:1923–58.CrossRefGoogle Scholar
  7. 7.
    McGaghie WC. Medical education research as translational science. Sci Transl Med. 2010;2:19cm8.CrossRefGoogle Scholar
  8. 8.
    Schroedl CJ, Corbridge TC, Cohen ER, et al. Use of simulation-based education to improve resident learning and patient care in the medical intensive care unit: a randomized trial. J Crit Care. 2012;27:219.e7–219.e13.CrossRefGoogle Scholar
  9. 9.
    McGaghie WC, Issenberg SB, Barsuk JH, Wayne DB. A critical review of simulation-based medical education with translational outcomes. Med Educ. 2014;48(4):375–85.CrossRefGoogle Scholar
  10. 10.
    Cook DA, Brydges R, Zendejas B, et al. Mastery learning for health professionals using technology-enhanced simulation: a systematic review and meta-analysis. Acad Med. 2013;88(8):1178–86.CrossRefGoogle Scholar
  11. 11.
    Griswold-Theodorson S, Ponnuru S, Dong C, et al. Beyond the simulation laboratory: a realist synthesis of clinical outcomes of simulation-based mastery learning. Acad Med. 2015;90(11):1553–60.CrossRefGoogle Scholar
  12. 12.
    Holmboe ES, Sherbino J, Long DM, et al. The role of assessment in competency-based medical education. Med Teach. 2010;32(8):676–82.CrossRefGoogle Scholar
  13. 13.
    Kogan JR, Holmboe ES. Realizing the promise and importance of performance-based assessment. Teach Learn Med. 2013;25(Suppl 1):S68–74.CrossRefGoogle Scholar
  14. 14.
    Ericsson KA. An expert-performance perspective of research on medical expertise: the study of clinical performance. Med Educ. 2007;41:1124–30.CrossRefGoogle Scholar
  15. 15.
    Frank JR, Snell L, Sherbino J, editors. CanMEDS 2015 physician competency framework. Ottawa: Royal College of Physicians and Surgeons of Canada; 2015.Google Scholar
  16. 16.
    Batalden P, Leach D, Swing S, et al. General competencies and accreditation in graduate medical education. Health Aff (Millwood). 2002;21(5):103–11.CrossRefGoogle Scholar
  17. 17.
    Holmboe ES, Durning SJ, ten Cate O, Hawkins RE. Assessment challenges in the era of outcomes-based education. In: Holmboe ES, Durning SJ, Hawkins RE, editors. Practical guide to the evaluation of clinical competence. Philadelphia: Elsevier; 2018.Google Scholar
  18. 18.
    Holmboe ES, Edgar RE, Hamstra S. Milestones Guidebook. Available at: http://www.acgme.org.
  19. 19.
    Dreyfus HL, Dreyfus SE. Mind over machine: the power of human intuition and expertise in the era of the computer. New York: Free Press; 1986.Google Scholar
  20. 20.
    Carraccio CL, Benson BJ, Nixon LJ, Derstine PL. From the educational bench to the clinical bedside: translating the Dreyfus developmental model to the learning of clinical skills. Acad Med. 2008;83(8):761–7.CrossRefGoogle Scholar
  21. 21.
    Messick S. Standards of validity and the validity of standards in performance assessment. Educ Meas Issues Pract. 1995;14(4):5–8.CrossRefGoogle Scholar
  22. 22.
    Ericsson KA, Pool R. Peak: secrets from the new science of expertise. Boston: Houghton Mifflin Harcourt; 2016.Google Scholar
  23. 23.
    ten Cate O. Entrustability of professional activities and competency-based training. Med Educ. 2005;39(12):1176–7.CrossRefGoogle Scholar
  24. 24.
    Englander R, Flynn T, Call S, et al. Toward defining the foundation of the MD degree: core entrustable professional activities for entering residency. Acad Med. 2016;91(10):1352–8.CrossRefGoogle Scholar
  25. 25.
    Pangaro L, ten Cate O. Frameworks for learner assessment in medicine: AMEE Guide No. 78. Med Teach. 2013;35(6):e1197–210.CrossRefGoogle Scholar
  26. 26.
    Ten Cate O, Hart D, Ankel F, et al. for the International Competency-Based Medical Education Collaborators. Entrustment decision making in clinical training. Acad Med. 2016;91(2):191–8.Google Scholar
  27. 27.
    Kogan JR, Holmboe ES. Direct observation. In: Holmboe ES, Durning SJ, Hawkins RE, editors. Practical guide to the evaluation of clinical competence. Philadelphia: Elsevier; 2018.Google Scholar
  28. 28.
    Lypson ML, Frohna JG, Gruppen LD, Woolliscroft JO. Assessing residents’ competencies at baseline: identifying the gaps. Acad Med. 2004;79(6):564–70.CrossRefGoogle Scholar
  29. 29.
    ten Cate O. Trust, competence, and the supervisor’s role in postgraduate training. BMJ. 2006;333(7571):748–51.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Andolsek K, Padmore J, Hauer KE, Holmboe ES. Clinical competency guidebook. Available at: www.acgme.org.
  31. 31.
    Deming WE. The new economics for industry, government, education. Cambridge, MA: MIT Center for Advanced Engineering Study; 1993.Google Scholar
  32. 32.
    Lockyer J, Carraccio C, Chan MK, et al. for the ICBME Collaborators. Core principles of assessment in competency-based medical education. Med Teach. 2017;39(6):609–16.Google Scholar
  33. 33.
    Kogan JR, Hatala R, Hauer KE, Holmboe E. Guidelines: the do’s, don’ts and don’t knows of direct observation of clinical skills in medical education. Perspect Med Educ. 2017;6(5):286–305.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Kogan JR, Hess BJ, Conforti LN, Holmboe ES. What drives faculty ratings of residents’ clinical skills? The impact of faculty’s own clinical skills. Acad Med. 2010;85(10 Suppl):S25–8.CrossRefGoogle Scholar
  35. 35.
    Barsuk JH, Cohen ER, Nguyen D, et al. Attending physician adherence to a 29-component central venous catheter bundle checklist during simulated procedures. Crit Care Med. 2016;44(10):1871–81.CrossRefGoogle Scholar
  36. 36.
    Apramian T, Cristancho S, Sener A, Lingard L. How do thresholds of principle and preference influence surgeon assessments of learner performance? Ann Surg. 2018;268(2):385–90.CrossRefGoogle Scholar
  37. 37.
    Gingerich A, Regehr G, Eva KW. Rater-based assessments as social judgments: rethinking the etiology of rater errors. Acad Med. 2011;86(10 Suppl):S1–7.CrossRefGoogle Scholar
  38. 38.
    Gingerich A, van der Vleuten CP, Eva KW, Regehr G. More consensus than idiosyncrasy: categorizing social judgments to examine variability in mini-CEX ratings. Acad Med. 2014;89(11):1510–9.CrossRefGoogle Scholar
  39. 39.
    Gingerich A, Kogan J, Yeates P, et al. Seeing the ‘black box’ differently: assessor cognition from three research perspectives. Med Educ. 2014;48(11):1055–68.CrossRefGoogle Scholar
  40. 40.
    Kogan JR, Conforti LN, Iobst WF, Holmboe ES. Reconceptualizing variable rater assessments as both an educational and clinical care problem. Acad Med. 2014;89(5):721–7.CrossRefGoogle Scholar
  41. 41.
    Fortin AHVI, Dwamena F, Frankel R, Smith RC. Smith’s patient-centered interviewing: an evidence-based method. 3rd ed. New York: McGraw-Hill; 2012.Google Scholar
  42. 42.
    Stein T, Frankel RM, Krupat E. Enhancing clinician communication skills in a large healthcare organization: a longitudinal case study. Pat Educ Couns. 2005;58:4–12.CrossRefGoogle Scholar
  43. 43.
    Légaré F, Witteman HO. Shared decision making: examining key elements and barriers to adoption into routine clinical practice. Health Aff (Millwood). 2013;32(2):276–84.CrossRefGoogle Scholar
  44. 44.
    Agency for Healthcare Research and Quality. The SHARE Approach. Available at: http://www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/index.html.
  45. 45.
    Baile WF, Buckman R, Lenzi R, et al. SPIKES-a six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4):302–11.CrossRefGoogle Scholar
  46. 46.
    Kogan JR, Holmboe ES. Preparing residents for practice in new systems of care by preparing their teachers. Acad Med. 2014;89(11):1436–7.CrossRefGoogle Scholar
  47. 47.
    Conforti LN, Ross KM, Holmboe ES, Kogan JR. Do faculty benefit from participating in a standardized patient assessment as part of rater training? A qualitative study. Acad Med. 2016;91(2):262–71.CrossRefGoogle Scholar
  48. 48.
    Kogan JR, Conforti LN, Bernabeo E, et al. How faculty members experience workplace-based assessment rater training: a qualitative study. Med Educ. 2015;49(7):692–708.CrossRefGoogle Scholar
  49. 49.
    Asch DA, Nicholson S, Srinivas S, et al. Evaluating obstetrical residency programs using patient outcomes. JAMA. 2009;302(12):1277–83.CrossRefGoogle Scholar
  50. 50.
    Epstein AJ, Srinivas SK, Nicholson S, et al. Association between physicians’ experience after training and maternal obstetrical outcomes: cohort study. BMJ. 2013;346:f1596.CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Asch DA, Nicholson S, Srinivas SK, et al. How do you deliver a good obstetrician? Outcome-based evaluation of medical education. Acad Med. 2014;89(1):24–6.CrossRefGoogle Scholar
  52. 52.
    Chen C, Peterson S, Phillips R, et al. Spending patterns in region of residency training and subsequent expenditures for care provided by practicing physicians for Medicare beneficiaries. JAMA. 2014;312(22):2385–93.CrossRefGoogle Scholar
  53. 53.
    Sirovich BE, Lipner RS, Johnston M, Holmboe ES. The association between residency training and internists’ ability to practice conservatively. JAMA Intern Med. 2014;174(10):1640–8.CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Phillips RL Jr, Peterson SM, Bazemore AW, al e. The effects of training institution practice costs, quality, and other characteristics on future practice. Ann Fam Med. 2017;15(2):140–8.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Dall’Alba G, Sandberg J. Unveiling professional development: a critical review of stage models. Rev Educ Res. 2006;76(3):383–412.CrossRefGoogle Scholar
  56. 56.
    Batalden M, Batalden P, Margolis P, et al. Coproduction in healthcare service. BMJ Qual Saf. 2016;25(7):509–17.CrossRefGoogle Scholar
  57. 57.
    Gruppen LD, ten Cate O, Lingard LA, et al. Enhanced requirements for assessment in a competency-based, time-variable medical education system. Acad Med. 2018;93:S17–21.CrossRefGoogle Scholar
  58. 58.
    Dreyfus HL. On the Internet. Thinking in action series. New York: Routledge; 2001.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Eric S. Holmboe
    • 1
    • 2
    Email author
  • David H. Salzman
    • 3
  • Joshua L. Goldstein
    • 4
  • William C. McGaghie
    • 5
  1. 1.Accreditation Council for Graduate Medical Education, Chief Research, Milestone Development, and Evaluation Officer, Department of MilestonesChicagoUSA
  2. 2.Northwestern University Feinberg School of Medicine, Adjunct Professor of Medical EducationChicagoUSA
  3. 3.Northwestern University Feinberg School of Medicine, Departments of Emergency Medicine and Medical EducationChicagoUSA
  4. 4.Northwestern University Feinberg School of Medicine, Departments of Pediatrics, Medical Education, and NeurologyChicagoUSA
  5. 5.Northwestern University Feinberg School of Medicine, Departments of Medical Education and Preventive MedicineChicagoUSA

Personalised recommendations