CPD, CBL, EPA, and SSP –­ Say What?

Remember the first time you heard it? Its potential was thrilling on the one hand yet terrifying on the other. The first step was easy (supposedly), the second step was more complex to achieve (successfully), and the third step carried an aura of expertise (albeit a falsehood).

Figured it out? Of course, it’s: See One, Do One, Teach One.

Gives me the shivers just thinking about it actually. Being procedurally oriented as a surgeon, I recall many instances during training and in the early stages of my career when that scenario played itself out. Thankfully, I don’t remember experiencing any bad outcomes or significant errors, but I am aware of many unfortunate situations for others.

Most of us are able to progress along the trajectory from novice in our chosen clinical specialty to recognized expert. The timeframe to accomplish this gradual maturation varies for many reasons, but the average is usually about 10 years…or about 10,000 hours of focused effort on an area of specific talent, if you happen to believe that theory (see Figure 1).

Figure 1. Genesis of the expert. From Episode 8 of the Communication, Thinking, and Learning course “Creating Creation Companies” by Barry Mapp. https://gohighbrow​.com​/communication​-thinking​-and​-learning

And yet, just when you think you are a so-called master, something happens that reminds you that learning is a lifelong process. Humility can be a rude lesson to learn.

Can we harness similar principles for leadership? Is one individual able to become a master leader? It is a question that already has a deep, rich literature and a plethora of theories to debate.

Continuous Professional Development

As a professional association focused on continuous professional development (CPD) — the first acronym (and not that clinical CPD) — AAPL is committed to physician leadership. Our commitment to helping create significant positive change in healthcare is predicated on facilitating the growth and development of individual physicians. But, as we continue transforming our association, we also are engaged, purposefully and increasingly, with how to help create sustainable change by working with a host of clinical delivery systems and other professional organizations involved with the industry.

If we are going to improve healthcare, CPD cannot be just for individuals — it must include organizations as well. Working collaboratively across all the industry sectors is essential for success.

How is AAPL doing this? We continue to focus on high-quality education offerings, professional development/career services, robust information resources, expanded thought leadership, and an interactive peer community. This array is brought together by a sophisticated leading-edge technical platform that continues to mature at a rapid pace. CPD is the primary driving force in each of these strategic priorities (see https://app.physicianleaders.org).

Competency-Based Learning

Underpinning our efforts is the second acronym: CBL for competency-based learning. Competency-based learning has become an essential cornerstone not only in educational theory but also within educational practices. This type of learning is especially critical for professions such as medicine and has been integrated in both medical school curricula and residency training programs for some time, albeit not yet across all institutions.

According to The Business Dictionary, competence is a cluster of related abilities, commitments, knowledge, and skills that enable a person (or an organization) to act effectively in a job or situation. Competence indicates sufficiency of knowledge and skills that enable someone to act in a wide variety of situations. This can occur in any period of a person’s life or at any stage of his or her career (http://www.businessdictionary.com/definition/competence.html ).

In this context, AAPL’s approaches to competencies continue to evolve. We have followed the literature in this regard and have beta-tested different approaches during the past several years. In our earlier approaches, it was too challenging to align our competencies and effectively demonstrate measurable positive outcomes from the competencies within a specific AAPL program, product, or service. We now use defensible, industry-recognized competencies that are backed by scientific instrumentation and research.

AAPL has created a scalable, industry-relevant competency matrix that not only maps at a granular level across all current and future AAPL programs, products, and services, but also provides an opportunity for us to assess outcomes of those using our programs, products, and services. The net result from this research and testing is that we have embraced a set of validated competencies in which we strongly believe.

This complementary blend of leadership characteristics and technical skills combine to create AAPL’s holistic competency model for physician leadership:

Self-Management

• Self-Awareness

• Humility

• Resilience

• Self-Control

Professional Capabilities

• Integrity

• Judgment

• Accountability

• Influence

Team Building and Teamwork

• Team Building

• Develop Relationships

• Collaborative Function

• Working with and Through Others

Problem Solving

• Strategic Perspective

• Conflict Management

• Action Orientation

• Critical Appraisal Skills

Motivations and Thinking Style

• Motivate Others

• Adaptability

• Trust and Respect

• Comfort with Visibility

Operations and Policy

• Governance

• Communication Strategies

• Technology Integration

• People Management

Quality and Risk

• Quality Improvement

• Healthcare Process

• Risk Management

• Health Law

Finance

• Financial Management

• Economics

• Resource Allocation

• Payment Models

Strategy and Innovation

• Performance

• Systems Awareness

• Differentiation

• Environmental Influences

By using this combined approach, we more effectively apply a competency-based learning strategy within our AAPL curriculum design, enabling individuals to gradually move through the stages of professional development that mimics novice to expert. We have four AAPL leadership growth stages: fundamental, developmental, experiential, and transformational. This gradual growth also creates a progression in how leaders mature in their degree of influence as visualized in Figure 2.

Figure 2. AAPL spheres of leadership influence

In fact, the entire suite of AAPL programs, products, and services is gradually being organized to align with this competency-based leadership philosophy — whether that is the way to encourage mentorship, enable coaching, align and promote our thought leadership content— and certainly in keeping with our rich constellation of information resources and macro or micro content learning areas. All of these eventually will align closely to the same comprehensive set of competencies and instruments to measure accurately and consistently across all types of individual and organizational engagements.

Getting back to the core questions: Can we harness similar principles for leadership? Is one able to become a master leader? AAPL clearly is on that path as an association to help clarify how to do so, and we will contribute to the leadership literature as we gain more data from our association’s experience. Facilitating growth of master physician leaders is an AAPL priority and the Certified Physician Executive (CPE) credential is certainly a step in that direction.

But others have also begun heading down that path and their resources are useful when considering how AAPL can best approach this trajectory of thought leadership. The original CanMEDS Physician Competency Framework, developed by the Royal College of Physicians and Surgeons of Canada, has been embraced by many around the world, and it has inspired descriptions for the following roles of physicians (http://www.profilesmed.ch/canmeds ):

1. Medical Expert (EXP)

2. Communicator (COM)

3. Collaborator (COL)

4. Leader/Manager (LEA)

5. Health Advocate (ADV)

6. Scholar (SCH)

7. Professional (PRO)

Category 4, Leader/Manager, for example is described as: “as managers and individuals demonstrating leadership, physicians are engaged individuals who take the initiative to contribute in a collaborative way toward positive and sustainable change in health care, from the level of an individual patient to that of the healthcare system…” See page 10 for CanMEDS’ Leader/Manager Competencies.

Entrustable Professional Activity

An EPA — entrustable professional activity — is a unit of professional practice defined as a task or responsibility that a trainee is entrusted to perform unsupervised once he or she has attained sufficient competence in the activity. EPAs are context-dependent, which means they should be taught and applied in common professional situations. It is an essential task of a “discipline” that an individual can be trusted to perform independently in a given context. EPAs often are used for assessment purposes and encompass multiple milestones (http://www.profilesmed.ch/epas ).

Milestones are then defined as observable markers of an individual’s ability along a developmental continuum and can be used for planning or teaching the skills related to an EPA.

The key difference between EPAs and milestones is that EPAs are the tasks or activities that must be accomplished while learning, whereas milestones are the actual abilities of the individual being assessed while learning. The combination of milestones and EPAs allows educators to examine performance at both the micro (when needed) and macro levels, providing a balanced view of trainees’ abilities.

How do EPAs differ from competencies?

• EPAs are not an alternative for competencies but a means to translate competencies into practice.

• Competencies are descriptors of professionals; EPAs are descriptors of work.

• EPAs usually require multiple competencies in an integrative, holistic setting.

Confused? For those interested in developing EPAs, Figure 3 provides a useful framework.

Figure 3. Guidelines for full entrustable professional activities descriptions. From Olle ten Cate. Nuts and Bolts of Entrustable Professional Activities. J Grad Med Educ. 2013 Mar;5(1):157-8. https://www​.ncbi​.nlm​.nih​.gov​/pmc​/articles​/PMC3613304

While AAPL has embraced CPD and CBL, we still need to gain more experience with our competencies before we can begin to fully embrace how AAPL defines EPAs for physician leadership. In the coming months, as an initial step in the process, AAPL will be determining how best to offer the industry a more concrete definition of a physician leader, remembering that all physicians are leaders at some level. As we do so, we will consider a host of variables to ensure we construct a definition that is not overly vague, but also not overly restrictive — certainly a challenge in itself. EPAs and other related aspects will follow in due course.

Our commitment to becoming an expanded thought leader and influencing group in healthcare encompasses many facets. It is a responsibility of our association to further contribute to the academic development of the physician and interprofessional leadership discourse. In so doing, we welcome your thoughts, suggestions, and ideas for how best to evolve in this fashion.

Situations As Starting Points

Because we have been discussing lifelong learning principles, it is important to define situations as starting points (SSPs). They are “a set of generic situations which cover the common circumstances, symptoms, complaints, and findings that a physician should be able to manage clinically” (http://www.profilesmed.ch/ssps ).

For instance, jaundice may be a starting point for numerous situations such as neonatal jaundice, hepatitis, pancreatic cancer, or cirrhosis. Use of these situations clinically can help students develop their skills in clinical reasoning, increase their ability to integrate various options into their differential diagnosis, and maintain an interdisciplinary perspective. The situations are also intended to be used by faculty and teachers to illustrate lectures, to engage in problem-based learning sessions, and to facilitate bedside teaching — all clinical areas where AAPL is not focused as an association but is still part of the discussion.

Walking the Talk

The professional development field for physicians has its own set of intrigues (think MOC) and continues to remain murky at times. AAPL sits uniquely within the crossroads of opportunity to help create significant change in healthcare through the platform of leadership. We are committed to the proverbial “walking the talk.” Look for more developments along these lines in coming months as our approaches mature toward individual and organizational professional development.

AAPL maximizes the potential of physician leadership to create significant personal and organizational transformation. I encourage each of us to continue seeking deeper levels of professional development and to appreciate better how we can each generate positive influence at all levels.

As physician leaders, let us become more engaged, stay engaged and help others to become engaged. Creating a broader level of positive change in healthcare — and society — is within our reach. Our patients and their families will appreciate the eventual outcome.

CanMEDS 4 - Physician Leader/Manager Competencies

4.1 Understand the principles of population medicine and its strategies, and use the main tools which are used in epidemiology and public health. These include the gathering and use of health determinants and indicators, descriptive and explanatory statistics, risk and protective factors and the concepts of prevention and health promotion at individual, community and environmental levels.

4.2 Define and illustrate health promotion and health-enhancing strategies at various levels, such as the monitoring and promotion of a safe environment and the promotion of effective public health policies and interventions. In doing so, they take into account financial, material and staffing resources, at both community and public health levels.

4.3 Recognize and respond to disease outbreaks, epidemics and pandemics.

4.4 Identify and address the special needs of vulnerable populations, showing awareness of the importance of equity in the delivery of care. They seek collaboration with social services if appropriate.

4.5 Address the psychosocial, insurance, financial and environmental aspects of handicaps and chronic diseases.

4.6 Identify the roles and describe the functions of the health and invalidity insurance system and its impact on health and health care at both individual and collective levels.

4.7 Integrate the principles of economic effectiveness and efficiency in daily work and the planning of healthcare provision.

4.8 Identify and engage in opportunities for continuous improvement of the healthcare system, based on a critical understanding of the continuous transformation of medicine and society.