by Tomoko Sairenji, MD, MS, Sarah Stumbar, MD, MPH; Kirby Clark, MD; Kristen Hood Watson, MD; Danielle Bienz, MEd; Stephen Scott, MD, MPH; Javad Keyhani, MD; Suzanne Minor, MD; Franklyn Babb, MD; Magdalena Pasarica, MD, PhD; Christine Savi, PhD

The Association of American Medical Colleges (AAMC)’s Core Entrustable Professional Activities (EPAs) for Entering  Residency encompass 13 activities that medical students should perform upon entering residency. Medical schools must re-evaluate teaching and assessment methods to prepare students in the competency domain. At the 2019 Society of Teachers of Family Medicine Conference on Medical Student Education, seven schools discussed institutional EPA implementation at their institutions in the presentation "Symposium on Incorporating EPAs into Medical School Curricula." We offer a summary of the SWOT analysis (Strengths-Weaknesses-Opportunities-Threats) completed by participants regarding EPA curricular incorporation. 

Strengths:
Interest/buy-in. It is critical to have faculty and leadership support to champion EPAs; working together across clerkships is necessary for broader implementation. Community preceptor interest and motivation to carry out the requirements of the curriculum helps to facilitate successful implementation. 
Assessment. Medical institutions value EPA assessments because they are objective, longitudinal, formative, and summative. EPAs align with schools’ educational program objectives (EPOs) and provide measurable criteria for assessing competence across a developmental continuum. Because they are modeled after the GME residency milestones, EPAs facilitate a seamless transition from undergraduate medical education to graduate medical education.
New schools/curriculums. New schools have opportunities to allow just-in-time integration, where alignment and integration can be spiraled throughout the curriculum at the onset.
Required status. There are indications that AAMC will require schools to integrate EPAs.
Central location. Offering one central location for the education of medical learners can facilitate easier integration.

Weaknesses:
Faculty development. Teaching preceptors how to use the EPAs across multiple clerkship sites takes time and can be a challenge as few resources exist in this area. 
Getting buy-in from key stakeholders. EPA assessment and gathering multiple data-points can be difficult. Student disengagement with EPA assessment is often associated with its impact on residency applications. Incorporating EPAs requires additional time and effort from clerkship directors, already burdened by administrative tasks. Gaining buy-in from preceptors and students to engage in this process is key.
Working with other clerkships and tracking performance over time. Financial and technological resources are necessary to incorporate and assess EPAs across settings. Standard technologies that institutions can utilize is lacking.

Opportunities: 
Transition. Opportunities exists during times of transition. Change in leadership may impact change for the clerkship director, department chair, or dean. Curriculum changes may include transitioning to student portfolios or changing from a block structure to a longitudinal integrated clerkship.  
Liaison Committee on Medical Education (LCME). Leveraging upcoming LCME visits to implement EPA assessments in curriculum can be helpful. 
Feedback. EPAs can facilitate feedback for learners and educators. Clerkship directors can provide faculty development to preceptors about how to give formative feedback to learners. A common language for delivering feedback can be gained by using the assessment anchors. 
Growing as educators. This is an opportunity for preceptors to grow as teachers, connect with the learning community, and possibly earn CME credit.  

Threats:
Time and complexity. Teaching EPA concepts to busy students and community preceptors across a region is difficult. Creating efficient means to do this via text, audio, video, and live or virtual meeting takes time and effort. 
Preceptor buy-in/burn out. Preceptors must find time to utilize the EPA tool, which may prevent preceptors from taking medical students. Creating efficient methods to use EPAs, providing incentives, and offering electronic dashboards to track student improvement may help with engagement.
Institutional buy-in. Institutions may be excited to have EPAs, but must commit to providing resources, time and money to the people involved.
Student buy-in. Asking students to be the front line of EPAs is a hard sell. Awarding students credit for participation may mitigate this risk. 
Lack of objective evidence: EPAs have literature-based origins, however there is little evidence that they create better-prepared residents. Tracking Step 2-CS scores and intern milestone ratings may offer correlation with performance.

Conclusion:
The SWOT activity facilitated reflection about EPA implementation from participating institutions. Our collective experiences provided rich fodder for consideration which we hope will be useful to others as they implement the EPAs.