In an effort to create a more meaningful way for gastroenterologists to continue ongoing professional education, the American Gastroenterological Association is proposing an alternative to the American Board of Internal Medicine’s Maintenance of Certification program.
The alternative pathway, dubbed “G-APP” (Gastroenterologist: Accountable Professionalism in Practice), “represents individualized needs, supports lifelong learning and accountability, is based on performance levels using the EPA [Entrustable Professional Activities] framework [and] provides an adaptive learning module with reinforcement for competencies achieved and direction for continued learning where gaps are uncovered,” Dr. Suzanne Rose of the University of Connecticut in Farmington, and colleagues said in an article in the November issue of Gastroenterology (2015. doi: 10.1053/j.gastro.2015.08.009) and Clinical Gastroenterology and Hepatology outlining the proposal.
Dr. Suzanne Rose
“The benefits of G-APP are many: it is personalized, flexible, includes learning as part of the assessment and is not high stakes,” the authors note. “The challenges will lie in building a framework for tracking and customizing a system for implementation and follow-up.”
G-APP is built upon three foundational concepts. The first is EPAs – the practice domains for gastroenterology and hepatology have already been outlined by the 13 existing EPAs – defined to describe the core activities of the profession to aid in assessment of trainees to meet Accreditation Council for Graduate Medical Education (ACGME) requirements.
Next is Individual Practice Divergence. After fellowship training, Dr. Rose and colleagues note that “most clinical practitioners diverge from a pattern of uniform exposure to, and depth of experience with, the full range of EPAs. They become more focused and selective in their practice domains across a narrower range of EPAs, according to their interests, abilities, and the needs of their practice environment.
Finally, Performance Levels, which are “reasonable parameters” that can be established for “assessment to be personalized to reflect a practitioner’s self-described competence within each of their domains of practice, termed a ‘Performance Level.’ ”
There are three Performance Levels for each EPA – Level 1 indicates a basic working knowledge with limits, under which a practitioner would know those limits and would appropriately identify and refer to someone with a higher level of expertise as needed. Level 2 indicates the ability to apply expertise to a competent level of general patient management. Level 3 indicates the ability to apply expertise to state-of-the-art management of complex issues.
Upon completion of initial training, all GI fellows should be at Level 2 for all 13 EPAs. To obtain recognition as a “competent gastroenterologist,” the practitioner must self-designate at least seven or more EPA practice domains at Level 2 with all remaining EPA practice domains at Level 1 (an option commonly associated with a general gastroenterology practice) or at least one or more EPAs at Level 3 with all remaining EPAs at either Level 1 or Level 2 (an option for subject matter clinical or research experts in a highly focused practice).
For Level 1 assessments, practitioners can use three different types of assessments: One being a low-stakes adaptive modular assessment taken at home and if competency is achieved, the level is complete; the second is point-of-care educational activities or completion of self-directed learning modules; and the third a series of assessments sent to the practitioner every 3 months to be completed within 3 months, with wrong answers prompting direction to learning modules that must be completed.
Assessments for Level 2 EPAs would entail adaptive, modular assessments at home and online, with ongoing testing until the practitioner demonstrates competency. Two EPAs – No. 6 (perform upper and lower endoscopic evaluation of the luminal gastrointestinal tract for screening, diagnosis, and intervention) and No. 7 (perform endoscopic procedures for the evaluation and management of gastrointestinal bleeding) - would require either a short answer examination or perhaps a peer observation skills-based assessment.
Level 3 assessments will require that the practitioner is an expert, with examples such as documentation to show that at least 75% of patients have a particular diagnosis. Testing may be short answer or in a different format and would be of greater difficulty and could encompass some degree of peer review examination. The authors note this will be “particularly rigorous, as the purpose of Performance Level 3 assessment is not to recognize special expertise for the general practitioner with areas of special interest, but rather to provide a fair assessment for those practitioners with practices limited to distinct areas of special expertise.”
G-APP also includes the creation of a Quality Improvement (QI) and Patient Safety Portal, with the stated goals being to “(1) promote the importance of QI and patient safety in a manner that recognizes QI efforts already in place, and (2) provide tools to enable those in need of QI initiatives to meet the requirements.”
