Education Columns

David R. Brown, MD, Abbas Hyderi, MD, MPH, and Jamie B. Warren, MD, MPH

Entrustable Professional Activities (EPAs) are observable and measurable tasks or responsibilities specific to a field of work that lead to recognized outcomes.¹ Olle ten Cate elucidated the concept of EPAs to facilitate clinical competency assessment. Completion of an EPA requires integration of both competencies and milestones. Entrustment is the act of granting permission for someone to perform a professional activity with a specific level of supervision (such as direct supervision, indirect supervision, or independent practice) based on assessment of trustworthiness as well as skills and abilities in that activity. Supporting this framework, the Association of American Medical Colleges (AAMC) charged a drafting panel that identified 13 core EPAs all graduating medical students are expected to perform without direct supervision by the time they begin residency.²

AAMC’s 13 Core Entrustable Activities for Entering Residency²

1. Gather a history and perform a physical examination
2. Prioritize a differential diagnosis following a clinical encounter
3. Recommend and interpret common diagnostic and screening tests
4. Enter and discuss orders and prescriptions
5. Document a clinical encounter in the patient record
6. Provide an oral presentation of a clinical encounter
7. Form clinical questions and retrieve evidence to advance patient care
8. Give or receive a patient handover to transition care responsibility
9. Collaborate as a member of an interprofessional team
10. Recognize a patient requiring urgent or emergent care and initiate evaluation
11. and management
12. Obtain informed consent for tests and/or procedures
13. Perform general procedures of a physician
14. Identify system failures and contribute to a culture of safety and improvement

To pilot-test the feasibility of organizing undergraduate medical education (UME) curricula, assessments, faculty development, and organizational systems to align with the EPA concept, the AAMC assembled the Core EPAs for Entering Residency Pilot (https://www.aamc.org/initiatives/coreepas/). Currently, the Core EPA Pilot is comprised of ten medical schools that are tasked to explore constructs of longitudinal student performance and integrate data from diverse sources into portfolios and dashboards to facilitate goal setting, coaching, and decision-making about entrustment. Additionally, the pilot group’s aim is to discover whether competency and trustworthiness can be reliably determined in large numbers of students by using digital solutions to aggregate multi-source data and support EPA-based assessment systems modeled on the residency clinical competency committee process.

In the short time since its launch, several important needs and challenges have emerged from the Core EPA Pilot’s focus on entrustment, one being the need for educators to create sufficient opportunities for students to assume graduated, progressive responsibility in the clinical setting. Other important needs include learner engagement in the entrustment process, portfolio/dashboard information system development, coaching, and educational handovers of learners between settings. Because EPAs align with discrete clinical tasks, the EPA framework has potential to allow educators to complete assessments more readily in the context of daily activities. However, large class sizes, multiple clinical venues, and supervision by a disparate cadre of clinical faculty make this challenging, and may result in students experiencing fewer sustained relationships with faculty. Additionally, the proliferation of rules related to safety, supervision, privacy, billing, and electronic documentation have put limits on participation of students in patient care.

In summary, developing undergraduate medical school competency-based curricula around an EPA framework has potential to enhance the assessment of the attitudes, skills, and medical knowledge trainees must have before beginning residency. While determining best approaches for creating UME outcome-based assessment systems utilizing EPAs is still under early investigation, this model holds great potential to impact the future of both medical education and care delivery in academic institutions.

References

1. Ten Cate O, Chen HC, Hoff RG, Peters H, Bok H, van der Schaaf M. Curriculum development for the workplace using entrustable professional activities (EPAs): AMEE guide no. 99. Medical teacher. 2015;37(11):983-1002.
2. Association of American Medical Colleges. Core Entrustable Activities for Entering Residency: Curriculum Developer’s Guide. Washington, DC: Association of American Medical Colleges; 2014.