The Key Literature in Medical Education podcast tackles a hot topic in health professions education this week – Entrustable Professional Activities (EPAs).
The article under discussion is one of the early descriptions of implementing an EPA-based programmatic assessment.
The abstract is below… but as usual, there is a lot more to be discussed/debated on the podcast.
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KeyLIME Session 91 – Article under review:
View/download the abstract here.
Schultz K, Griffiths J, Lacasse M. The Application of Entrustable Professional Activities to Inform Competency Decisions in a Family Medicine Residency Program. Academic Medicine. 2015 Feb 23. [ePub ahead of print]
Reviewer: Jonathan Sherbino
Entrustable professional activities (EPAs) are the talk of competency-based medical education (CBME) specifically and medical education generally. Coined by a friend of the show Olle ten Cate, they describe the essential or representative task (i.e. work) that an individual can be assigned responsibility (i.e. trusted) to perform in a specific clinical context. EPAs are made up of multiple competencies from multiple Roles.
Perhaps the uptake of EPAs in medical education reflects the fact that they focus on “work,” which is concrete, in contrast to competencies (i.e. abilities) that may be more challenging to assess or articulate as an observable behaviour. Or perhaps it is the incorporation of “trust,” as a scale of ability, which links to the history of medical education that makes EPAs so popular.
This article is part of the first wave of publications describing the actual implementation of EPAs in training programs.
“…the authors describe the development of 35 EPAs for a Canadian family medicine residency program…”
Type of paper
Report of an innovation
Key Points on the Methods
The authors indicate that a literature review was performed and that they conducted a quasi- needs assessment; however, minimal details are provided.
Representatives from four Canadian family medicine residency programs in three provinces formed an expert panel.
The expert panel developed 35 EPAs that encompass all/most patient presentations and included some additional EPAs that describe physician work indirect to patient care (e.g. “taking on a teaching role”).
EPAs were subdivided into “phases of the clinical encounter” (e.g. history, physical exam, diagnosis, treatment, etc.). The scale of entrustability ranged from “close supervision” to “minimal supervision” to “ready for independence; supervision for refinement.” Generic behavioural anchors described each phase. Anticipated progression is “minimal supervision” by start of PGY2 and “ready for independence; supervision for refinement” by completion of training.
EPAs were linked to current field notes assessment program (narrative description of a resident’s performance including a description of verbal feedback given). This focused a random process to describe performance according to entrustability and to ensure adequate mapping across all essential activities/competencies.
EPA reports were incorporated into a learner’s portfolio. Every three months the portfolio (which includes other assessment elements is reviewed.) is reviewed with a faculty advisor. The faculty advisor makes competency declarations that are forwarded to the program director.
Introduction of EPAs increased field note completion by 10% from baseline.
Faculty development sessions were important in the change initiative. EPAs were refined with user feedback.
The authors conclude “…we translated our multiple objectives and important but unwieldy, nonintegrative competencies into practical, manageable, measurable activities that allow us to formatively and summatively assess competency development.”
Spare Keys – other take home points for clinician educators
One of the ongoing challenges is how to process multiple data points of various elements to determine collective competence. For example, if one EPA requires “close supervision” while the others meet “minimal supervision” does a learner progress in training? Suggested options include: a jury model (balance of evidence), a red flag model (key competencies that are not achieved require a halt in progression until remediated), and a competence model (every competence must be achieved). This program did not articulate explicitly the model selected, but suggests that the jury model was used.
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