By: David Turner
Competency-based education starts with the end in mind, and education priorities are then developed to meet those desired outcomes. In health professions education, we are increasingly addressing these outcomes by bringing the patient into the assessment equation using entrustable professional activities (EPAs).1 EPAs represent the critical tasks of a profession that individuals are expected to be able to execute to meet the needs of our patients. These patient focused activities, when taken as a whole, can serve to define the activities of a profession overall.2
As EPAs continue to be developed and integrated into competency-based health professions education programs, the main focus is often primarily on assessment. As learners progress and move from training to unsupervised practice, assessment is clearly an important aspect of a competency-based approach to education, but the role that EPAs have in informing curriculum is often underemphasized. EPAs should contribute to informing curriculum at multiple levels in health professions education, including, for individuals, for programs, and for disciplines/specialties as a whole.
Individual Level Curricula (i.e., Individualized Learning Plans)
Individualized curricula often go by many different names, but they are critical to competency-based education and assessment. A well-structured individualized curriculum has the potential to address at least three of the 5 core components3 of CBME through inclusion of progressive sequencing, tailored learning experiences, and competency-focused instruction. These three elements ideally build on a core framework of EPAs, competencies, and milestones in a way that optimizes both teaching and learning for an individual as part of an overall program of assessment.
Program Level Curricula
When integrating EPAs and the needs of patients in a fully realized competency-based approach to education, an often underrecognized value for EPAs is identifying and helping address curricular gaps at the program level. As an example, in a recent study published by Schumacher and colleagues in pediatrics in the United States, only 53% of residents graduating from general pediatrics residency training were deemed ready for unsupervised practice for the EPA focused on the care of patients with behavioral and mental health conditions.4 For the programs involved in this investigation, and for many others for which these data clearly resonated, these data served as a prompt for them to step back and determine what was needed programmatically to address this curricular deficiency.
Specialty/Discipline Level Curricula
As EPAs can be used to define a profession, they in turn can contribute to curricula on a larger scale. In another example from pediatrics, one of the EPAs was recently revised to address racism, discrimination, and inequities in the care of children.5 Many programs realized that they were not addressing this EPA adequately, which has prompted a group of education leaders from the Association of Pediatric Program Directors to develop and collate curricula at the national level that will be available for training programs to use in the development of their program curricula and their individualized learning plans.6 This framework can also be used for curricular development beyond training as part of the lifelong learning process. As disciplines and medical specialties more clearly define the activities that our patients need from all of us as health professionals, these activities can be used to develop curricula and drive education on a broad scale.
In summary, when we discuss informing curricula using EPAs, the focus most often is (appropriately) on the individual. For example, if a learner is not ready for unsupervised practice for a given EPA, what competencies need to be addressed to help them advance to the next level? What support and resources do they need to grow and further their development? Developing an individualized curriculum is one of the benefits of a fully realized model of competency-based education, but it is important to remember that these plans for individuals arise from program and national curricula that should also be based on the activities and outcomes that our patients need.
ABOUT THE AUTHOR: David A. Turner, MD is the Vice President of Competency-Based Medical Education at the American Board of Pediatrics, as well as a Consulting Professor in the Division of Pediatric Critical Care in the Department of Pediatrics at the Duke University School of Medicine.
1. Ten Cate O. Entrustment Decisions: Bringing the Patient into the Assessment Equation. Academic Medicine. 2017; 92(6): 736-738.
2. Ten Cate O et al. The recommended description of an entrustable professional activity: AMEE Guide No. 140. Medical Teacher. 2021;43(10: 1106-1114.
3. Van Melle E et al. A core components framework for evaluating implementation of competency-based education. Academic Medicine. 2019; 94:1002-1009.
4. Schumacher D et al. Longitudinal Assessment of Resident Performance Using Entrustable Professional Activities. Jama Network Open. 2020;3(1).
5. Unaka et al. An Entrustable Professional Activity Addressing Racism and Pediatric Health Inequities. Pediatrics. 2022; 149 (2).
6. Association of Pediatric Program Directors. Curricula for Anti-Racism. https://www.appd.org/about/curricula-for-anti-racism/
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