Phase 4 - Integration Into Practice
Class of 2024
Academic Year 2022-2024

Phase 4 Overall Assessment Plan
 
Regular aggregate assessments of learners across all courses in Phase 4 are designed to track the longitudinal progression of each learner towards competence prior to residency.  EPA is defined as Entrustable Professional Activity. EPAs are units of professional practice, defined as tasks or responsibilities that learners are entrusted to perform without direct supervision by the end of Phase 4.
 
Entrustable Professional Activities (EPAs)
EPA 1:            Obtain a history and perform a physical examination adapted to the patient’s clinical situation.
EPA 2:            Formulate and justify a prioritized differential diagnosis.
EPA 3:            Formulate an initial plan of investigation based on the diagnostic hypotheses.
EPA 4:            Interpret and communicate results of common diagnostic and screening tests.
EPA 5:            Formulate, communicate and implement management plans.
EPA 6:            Present oral and written reports that document a clinical encounter.
EPA 7:            Provide and receive the handover in transitions of care.
EPA 8:            Recognize a patient requiring urgent or emergent care, provide initial management and seek help.
EPA 9:            Communicate in difficult situations.
EPA 10:          Participate in health quality improvement initiatives.
EPA 11:          Perform general procedures of a physician.
EPA 12:          Educate patients on disease management, health promotion and preventative medicine.
EPA 13:          Collaborate as a member of an inter-professional team.
EPA 14*: Incorporate the relevant social determinants of health (SDoH) and cultural safety in relation to patient’s illness and management planning.
 
*pilot introduction of EPA 14
 
Phase Structure
Phase 4 consists of the following courses:
 
MED 8710: Core Experiences – Block Rotation-based or Longitudinal Integrated Clerkship (LIC)
MED 8720: Clinical Skills IV
MED 8730: Electives
MED 8740: Advanced Practice Integration (Selectives/P2P)
MED 8750: Physician Competencies IV
 
Phase 4 Assessment
Assessment is administered within each course but collated and monitored by the Undergraduate Medical Education (UGME) office to ensure progression through Phase 4. Learners will receive their grades from the Undergraduate Medical Education (UGME) office via One45.

The Phase 4 Management Team performs a comprehensive review of learner performance and plans remediation specific to a learner's requirements as per the results of assessments throughout Core Experiences.  The Phase 4 committee recommends to the Promotions Committee the promotion of the learners who have met all competency requirements by the end of Phase 4.
 
Core Experiences Assessment
Assessment data is combined into an aggregate assessment profile for each learner at 6, 9 and 12 months. This process will be repeated at 18 months for any learner requiring remediation after the review of the 12 month aggregate assessment profile. 
 
Progress Testing (formative and summative)
Learners will write the NBME Comprehensive Clinical Science examination at 0 (beginning of Phase 4), 4, 8 months, and in the last month of core clerkship as a progress test. This multiple-choice question examination assesses clinical knowledge. The first three examinations will be formative and learners will be provided with feedback on their performance. The final examination will be summative but will not be reported on the MSPR. Learners who fail the final examination will write a reassessment examination prior to the beginning of their fourth year.
           
Exam dates for Class of 2024
            Baseline/0 months
            (beginning of Phase 4):     August 19, 2022
            4 month:                            December 2, 2022
            8 month:                            April 6, 2023
            Final:                                 July 28, 2023
            Reassessment:                  August 11, 2023
 
Progress Testing Scores
The pass score for the final progress test will be determined using a norm-referenced standard setting method. This will be based on the summative progress examination performance of previous cohorts. The pass score is 156 and will be used for the final progress as well as the reassessment test.
 
For the formative (0, 4 and 8 month) tests, the mean and standard deviation for each test will be used to determine a Z-score for each learner’s score on the test. The Z- score indicates how well the learner has performed relative to the mean score for all learners writing that test. The following benchmarks for performance will be used:

Satisfactory:                Z-score -1.5 or greater
Borderline:                  Z-score -2.0 or greater; less than -1.5
Unsatisfactory:            Z-score less than -2.0
 
All learners with an unsatisfactory score will be required to meet with a member or members of the Phase 4 Management Team to develop a learning plan to address their educational needs. This does not apply for the baseline (0 month) test.
 
All learners with a borderline score will be offered the opportunity to meet with a member or members of the Phase 4 Management Team to develop a learning plan to address their educational needs.
 
Learners with a satisfactory score may also request a meeting with a member or members of the Phase 4 Management Team if they are interested in further coaching.

 
Phase 4 Comprehensive Review
At 6, 9 and 12 months: An assessment profile will be created for each learner by the UGME office and reviewed by the Phase 4 Management Team. The performance of any learner not progressing as expected (i.e. not meeting the criteria below) will be discussed at the related comprehensive review.
 
Block Rotation-Based Stream
 
A learner must meet the following criteria for continued progress through Phase 4 at the 6-month comprehensive review:
 

1. Documented entrustability in a majority of all EPAs within at least one rotation,
2. At least 2 assessments entrustable for at least one EPA,
3. All summative ITARs to date indicate the learner is “progressing as expected”,
4. Satisfactory score in most recent progress test,
5. Completion of all discipline-specific assignments to date at a satisfactory level, and
6. No documented concerns with professionalism.

 
A learner must meet the following criteria for continued progress through Phase 4 at the 9-month comprehensive review:
 

1. Documented entrustability in a majority of all EPAs within at least one rotation.
2. At least 2 assessments entrustable for the majority of EPAs for which there are 3 or more assessments ,
3. All summative ITARs to date indicate the learner is “progressing as expected”,
4. Satisfactory score in most recent progress test,
5. Completion of all discipline-specific assignments to date at a satisfactory level, and
6. No documented concerns with professionalism.

 
A learner must meet the following criteria for continued progress through Phase 4 at the 12-month comprehensive review:
 

1. Documented entrustability in a majority of all EPAs within at least four rotations, with at least the last two rotations excluding Anesthesia and Emergency Medicine having documented entrustability in a majority of all EPAs,
2. At least 2 assessments entrustable for any one EPA,
3. All summative ITARs indicate the learner is “progressing as expected”,
4. Passing grade in the final progress test,
5. Completion of all discipline-specific assignments at a satisfactory level, and
6. No documented concerns with professionalism.

 
Longitudinal Integrated Clerkship (LIC) Stream
 
A learner must meet the following criteria for continued progress through Phase 4 at the 6-month comprehensive review:

1. Documented entrustability in EPAs 1, 4, 6, and 13, based on most recent formative ITAR for Family Medicine and formative discipline ITARs completed to date
2. At least 2 assessments entrustable for each EPA,
3. All formative ITARs to date indicate the learner is “progressing as expected”,
4. Satisfactory score in most recent progress test,
5. Completion of all discipline-specific assignments to date at a satisfactory level, and
6. No documented concerns with professionalism.

A learner must meet the following criteria for continued progress through Phase 4 at the 9-month comprehensive review:

1. Documented entrustability in EPAs 1, 2, 3, 4, 5, 6, 8, 10, and 13, based on most recent formative ITAR for Family Medicine and formative discipline ITARs completed to date
2. At least 2 assessments entrustable for each EPA,
3. All formative ITARs to date indicate the learner is “progressing as expected”,
4. Satisfactory score in most recent progress test,
5. Completion of all discipline-specific assignments to date at a satisfactory level, and
6. No documented concerns with professionalism.

 
A learner must meet the following criteria for continued progress through Phase 4 at the 12-month comprehensive review:

1. Documented entrustability in a majority of EPAs within at least four disciplines based on the summative discipline ITARs
2. At least 2 assessments entrustable for EPA 1-13,
3. All summative ITARs indicate the learner is “progressing as expected”,
4. Passing grade in the final progress test,
5. Completion of all discipline-specific assignments at a satisfactory level, and
6. No documented concerns with professionalism

To inform the decision about progression for each learner, each course/discipline/LIC coordinator will present documentation of pre-entrustability or entrustability for each EPA in the form of the various discipline- and course-specific assessment methods.
 
Remediation and Reassessment
All discipline- and course-specific assignments must be completed at a satisfactory level as determined by each discipline or course. Learners failing a discipline- or course-specific assignment must be reassessed. A learner may be reassessed only once for each failed assignment.
 
The performance of any learner with an unsatisfactory or borderline score in the initial NBME progress test, the 4 month NBME progress test, or the 8 month NBME progress test; or failing the final NBME progress test will be discussed during the comprehensive review. Learners who fail the final progress test will write the NBME progress test as a reassessment prior to the beginning of their fourth year. Reassessment, including repeating MED 8710, will be at the discretion of the Phase 4 Management Team. The Phase 4 Management Team will review progress test performance in conjunction with the clinical assessment for the Core Experiences course.
 
Documented professionalism concerns for any learner will be discussed at the comprehensive review. Remediation and reassessment will be at the discretion of the Phase 4 Management Team.
 
The final promotion decision for Phase 4 courses occurs during comprehensive review by the Phase 4 Management Team and will be made via consensus decision.  In the absence of a consensus, the decision will be made via anonymous vote amongst the Phase 4 Management Team.  In this case final decision requires a majority vote.
 
As outlined in the MD program objectives, the Faculty of Medicine at Memorial University values professionalism as a core competency and a requirement of the MD program. Recognizing that medical learners are developing their professional identity, professionalism lapses will be remediated where possible and appropriate. Unsuccessful remediation will result in failure of the Phase.  Professionalism lapses may render a learner incompatible with continuation in the MD program (as outlined in the Memorial University Calendar Regulation 10.5 Promotion).

As outlined in Section 10.5.2 and 10.5.3 of the Regulations for the Degree of Doctor of Medicine in the University calendar, learners with a Fail grade in any course cannot be promoted to graduation. Even in the absence of any Fail grades, a learner for whom substantial concerns about performance have been expressed may either be required to repeat the Phase or required to withdraw conditionally or unconditionally.
 
 
Version date: August 24, 2022
Reviewed by SAS: April 27, 2022
Approved by UGMS: May 18, 2022