The Entrustable Professional Activities (EPAs) of Geriatric Medicine part 1

Core Competencies of Healthcare Professionals involved in Older People’s care

Entrustable Professional Activities (EPAs)

Professor Tahir Masud

Professor of Geriatric Medicine, Nottingham, UK

Past President of the British Geriatrics Society (BGS)

Director of Education and Training,

European Geriatric Medicine Society (EuGMS) Executive Board

Joint Report 2011: WHO

National Institute of Health

National Institute of Ageing

“Oldest Old” (>85 years) are projected to increase globally by 351% between 2010 and 2050

Report: Ageing in the European Union Rechel et al 2013 Lancet

“Workforce providing healthcare for older people should be expanded and that health workers should be trained appropriately”

Silver Paper: Report of a European summit on Age Related Disease

Ageing Clin Exp Res 2009

Cruz-Jentoft AJ, Franco A, Sommer P, Baeyens JP, Jankowska E, Maggi A, Ponikowski P, Rys A, Szczerbinska K, Michel JP, Milewicz A

“The research literature suggests that support for geriatrics in national undergraduate curricula is key to delivery of teaching in the speciality”

European Union of Medical Specialists

(UEMS)- Geriatric Medicine Section

Updated Lit Review

2009-2012 (TM)

First draft Pre-Delphi

European Undergraduate Geriatric Medicine Curriculum

Dec 2012 (TM,AS)

•A.Stuck

•T.Masud

•K.Mulpeter

•A.Blundell

•A.Gordon

•K.Singler

•R.Roller-Wirnsberger

UEMS Subgroup + Experts

Final draft Pre-Delphi

European Undergraduate Geriatric Medicine

Curriculum Jan 2013

12 paragraphs/domains

DELPHI PROCESS

3 rounds

Feb-April 2013 (AS)

Delphi Process

Austria Thomas Frühwald

Austria Georg Pinter

Belgium Margareta Lambert

Belgium Jean Petermans

Bulgaria Toni Staykova

Czech Republic Eva Topinková

Denmark Ellen Holm

Denmark Susanne van der Mark

Estonia Helgi Kolk

Finland Maria Nuotio

Finland Jaakko Valvanne

France Alain Franco

Germany Dieter Lüttje

Greece George C. Spatharakis

Hungary Gyula Bakó

Iceland Pálmi V. Jónsson

Ireland Ken Mulpeter

Israel A. Mark Clarfield

Italy Mario Barbagallo

Italy Renzo Rozzini

Lithuania Jūratė Macijauskienė

Malta Anthony Fiorini

Malta Mark A. Vassallo

Netherlands Jaap Krulder

Norway Thomas Svendsen

Poland Katarzyna Wieczorowska-Tobis

Portugal Gorjão Clara

Romania Gabriel-Ioan Prada

Serbia Mladen Davidovic

Serbia Predrag Erceg

Slovakia Stefan Krajcik

Slovenia Gregor Veninsék

Spain Sergio Ariño-Blasco

Sweden Anne Ekdahl

Sweden Maria Eriksdotter

Switzerland Christophe J. Büla

Switzerland Andreas E. Stuck

Turkey Mustafa Cankurtaran

Turkey Asli Curgunlu

United Kingdom Tahir Masud

Expert Adrian Blundell

Expert Adrian Goeldlin

Expert Adam Gordon

Expert Regina Roller-Wirnsberger

Expert Katrin Singler

Expert Arturo Vilches-Moraga

29 countries

Ten Broad Domains

1. Respect for Older Patients

2. Principles of Ageing

3. Common Medical Conditions in Older People

4. Geriatric Assessment

5. Medication Use in Older People

6. Older peoples Response to Illness: Impairments/Disabilities/Handicaps

7. Ethical and Legal Issues

8. Role of other Healthcare and Social Care Professions

9. Healthcare in Different Settings

10. Specific Regional Health and Social Care Aspects

Curricular Mapping/Surveys and Audits

Relaunch of Plan: Update of European Undergraduate Curriculum in

Updated Literature Search

1. Scoping review on literature

2. Scoping review on EPAs and how they applied in other specialities

Curriculum Development Panel reviews literature search and produces first version of Revised Curriculum

Delphi rounds (2 or 3) with a separate Delphi Panel

Prepare Publication of Revised Curriculum for submission to Age and Ageing

Future Plans

• Translation into languages

• Implementation into Medical schools / Curriculum Mapping / Audits

1st Scoping Review

Results

Records identified through database searching

(18th May, 2021), n = 2,503

Records after removal of duplicates, conference abstracts, nursing or pediatric titles, n = 1,136

Records screened, n = 1,136

Excluded, n = 743

Studies included in the review, n = 367

Major themes

Six major themes were identified:

• Curricula

• Curricular topics

• Teaching methods

• Teaching settings

• Medical students’ skills

• Medical students’ attitudes

Curricular topics

Curricular topics:

• Delirium

• Pharmacotherapeutics (e.g. deprescribing)

• Healthy ageing and health promotion (e.g. vaccinations)

• Frailty

• Malnutrition

• Elder abuse

• Social gerontology

• Telemedicine

Curricular topics: healthy ageing

Intervention to promote healthy ageing:

• Deprescribing

• Exercise prescription

• Management of cardiovascular risk factors

• Vaccinations

• Nutrition

Teaching methods

Teaching methods:

• Clinical placements

• Interprofessional education

• Senior mentor programmes, intergenerational contact

• Simulation games, Serious games

• E-learning

• Service learning

• Short-term research training programs

• Student journaling

Vertical Integration

Teaching settings

Teaching settings:

• Acute-care hospitals (geriatric wards versus non-geriatric wards)

• Rehabilitation settings

• Home visits

• Nursing homes (empathy, more holistic approach)

2nd Scoping Review

• Entrustable Professional Activities” (EPAs) have become a popular component of competency-based medical education as a new approach for operationalising learning outcomes

• Originally, EPAs were mainly used for postgraduate medical education [9], including geriatric postgraduate specialty training (AGS, UEMS)

• There is a growing interest in the use of EPAs in undergraduate medical education

• In this context, EPAs are defined as units of professional activities, which medical students can be entrusted to perform with distant supervision alone

AIM

• to evaluate whether, and if so how, current undergraduate curricula including EPAs address geriatric learning objectives

(by mapping to the 2014 European Undergraduate Geriatric Medicine Curriculum)

Search

• Of 1311 hits, we found 9 undergraduate curricula that met the inclusion criteria

Section 4—Multidisciplinary team-working and services

4a: Graduates should understand and respect the roles and expertise of other health and social care professionals by:

4b: Graduates should know about care of older patients in different settings and about specific aspects of health and social care in their region/country by:

Section 5—Prescribing in geriatric medicine

5: Graduates should understand the principles of treatment, including the appropriate and safe use of medicines as a basis for prescribing , by:

Section 6—Ethicolegal aspects of geriatric medicine

6: Graduates should understand the main ethical and legal issues arising in the care of older patients by:

Section 7—Research in ageing and geriatric medicine

7: Graduates should understand the intricacies of undertaking and interpreting research in older people by:

Section 5—Prescribing in geriatric medicine

5: Graduates should understand the principles of treatment, including the appropriate and safe use of medicines as a basis for prescribing , by:

i. Describing the effect of ageing upon pharmacodynamics and pharmacokinetics.

ii. Defining the concept of polypharmacy in older people.

iii. Engaging in medicines optimisation with older patients, accounting for physiological differences, drug–drug interactions, multi-morbidity, frailty, adverse drug reactions and patient preference, and considering objective assessment tools available for medication reviews where appropriate (e.g. STOPP/START, STOPPFall, anti-cholinergic calculators and levodopa equivalence calculators).

iv. Discussing the factors affecting medication concordance with older patients and the detection and management of drug underuse/overuse.

v. Prescribing safely for the conditions defined in section 3, and to manage symptoms occurring at the end of life.

Competency-Based Medical Education

“Copyright © 2015 The Royal College of Physicians and Surgeons of Canada. https://www.royalcollege.ca/rcsite/canmeds/canmeds-framework-e Reproduced with permission.”

Entrustable Professional Activity EPA

… Is a unit of professional practice that can be fully entrusted to a resident, as soon as he or she has demonstrated the necessary competence to execute this activity unsupervised

1. Managing community liaison and practice

• Performs a comprehensive assessment (which includes physical, functional, social, environmental, psychological and spiritual concerns) of older people in community settings

• Manages acute illness, comorbidities (including dementia) and other problems safely in community settings, including in patient’s homes and care homes (with or without a hospital at home service)

• Able to discuss uncertainty and balance benefits/burdens of hospital versus home treatment

• Manages rehabilitation in community settings, including patient’s homes, care homes and community inpatient rehabilitation.

• Performs an assessment of mental capacity

• Performs a medication review

• Formulates an appropriate differential diagnosis, problem list, and individualised management plan taking into account patient preferences

• Understands the various agencies involved in community care, (including voluntary, social prescribing and third sector)

• Promotes multidisciplinary team working

• Demonstrates a flexible approach to care which crosses the traditional division between primary and secondary car

• Identifies patients with limited reversibility of their medical condition, is able to discuss end of life, undertake advance care planning conversations (including community DNACPR) and determine palliative care needs

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Level 1

Level 2

Level 3

Level 4

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Subspecialty Training: Themed for Service Geriatric Medicine CiPs (EPAs)

1. Able to manage older patients presenting with fracture and is able to provide a comprehensive ortho-geriatric and bone health service

2. Able to assess patients with urinary and faecal incontinence and is able to provide a continence service for a specific patient group in conjunction with specialist nursing, therapy and surgical colleagues

3. Able to manage ill or disabled older people in a hospital at home, intermediate care and community setting and is able to provide a comprehensive community geriatric medicine service

4. Able to manage patients with a wide range of movement disorders at any stage and is able to develop a movement disorders service for older people

Overall Project lead: Marina Kotsani

Rational

• Geriatric Medicine (GM) skills and competencies are increasingly required

• Heterogeneous historical GM development among countries

• Pragmatic and feasible solutions should be investigated for countries with emerging GM (training of existing workforce)

• Need for core GM competencies across all settings (and a standardized approach in all countries?)