Annual Meeting 2018 Presentations - The Association for Surgical Education

PS1 - 04: THE SURGICAL CONSULT EPA: DEFINING COMPETENCE AS A BASIS FOR EVALUATION
Ryland Stucke, MD¹, Sarah Sullivan, PhD²; ¹Dartmouth-Hitchcock Medical Center, ²University of Wisconsin - Madison

Background: The American Board of Surgery has proposed a residency redesign, which relies on entrustable professional activities (EPAs). No data exist to define competence for surgical consultation, one of five proposed trial EPAs.

Methods: Cognitive task analysis and semi-structured interviews were conducted with 7 key surgical faculty at a moderately sized academic institution. Interview content was independently reviewed by 2 surgical researchers for procedural steps and themes.

Results:

Table 1. Procedural steps for consultation with key themes
Procedural Step	Key Themes
1.Receiving information	- triage consult urgency - review existing data
2.Bedside evaluation	- history/physical exam - obtain pertinent social details/patient preferences
3.Obtaining additional information	- initial differential diagnosis - obtain additional tests/diagnostics
4.Decision making	- final diagnosis - action plan/recommendations
5.Communication/documentation	- closed loop communication to all stakeholders - concise/organized presentation to attending - thorough documentation in a timely manner

No explicit framework was used to evaluate competence. Nearly all surgeons said, “I just know competence when I see it”. Competent versus developing residents were differentiated by performance traits including: 1. situational awareness, 2. thoroughness and thoughtfulness, 3. incorporating extenuating circumstances, 4. ability to proceed when uncertainty exists, 5. comfort synthesizing and editing clinical details, and 6. developing a safe plan within acceptable practice standards. Agreement of the resident’s and attending’s final plan was not important if the other factors were met.

A consult was considered a “failure” if any of the following were displayed: 1. lying/deception, 2. missing critical details of the evaluation, work-up, or presentation, 3. refusing to see the consult, and 4. rudeness/disrespect.

Conclusions: A competent consultation includes 5 key steps and multiple performance traits involving interpersonal, psychosocial, clinical, and administrative skills. This proposed framework creates the basis for development of an evaluation tool, which can be used to establish EPA standards for consultation.