Answer to "Must, or should, EPAs and STARs be acknowledged across departments, hospitals,    nationally and internationally?"


EPAs, the units of professional practice that constitute the core activities of the profession, are usually conceived by a small group of educators, and then vetted again by obtaining opinions of other experts in the field (see FAQs # 3, 4 and 5). While this process can be done locally, regionally, nationally or internationally, there is merit in small scale development, as educators can 'own' and shape the process and product. However, physicians tend to move to new locations from time to time and apply their skills at places different than where they were trained. New employers generally understand what the medical degree and a specialty board registration means.

However, EPAs are new, and not everyone may readily understand what they are. As the concept becomes clearer, there are now examples of different lists of EPAs for the same specialty, developed at different locations (e.g. family medicine (Shaughnessy et al., 2013; Schultz, Griffiths and Lacasse, 2015), internal medicine (Hauer et al., 2013; Caverzagie et al., 2015) and psychiatry (Boyce et al., 2011; Weiss et al., 2016; Young et al., 2018)). If EPAs extend beyond training periods into the continuum of training and professional practice, for instance as a 'dynamic portfolio of validated EPAs' (see FAQ #13), it is more than worth the effort to create universal, workable EPAs. The time may not be right yet, as programs are now implementing EPAs-based curricula, and the experience is that implementation processes lead to adaptations of EPA frameworks, but it is very likely that uniform standards for EPAs will be developed. For undergraduate education, the proposed EPAs in the USA and in Canada look very similar, even in a case of implementations that will take some years. The titles of some early publications suggest a desire to at some point have EPAs reflect the objectives of undergraduate education, bridge the transition to postgraduate education and ultimately define specialties (Leipzig et al., 2014; Brown et al., 2016; Deitte et al., 2016).

To start with, STARs for agreed-upon EPAs should be acknowledged across units within a system. Taking the program or institution as the smallest system, at the very least, for undergraduate medical education (UME), this requires acknowledgement across departments in the same UME program.  At the next level, STARs could be recognized and, therefore, ideally portable within the same region or country.

Challenges may rise with EPA definitions and STAR acknowledgments across national borders.  Health systems are set up differently in different countries, and each system may have different practice requirements.  For instance, in the United States, medical school graduates may not practice without completing at least one year of residency training.  This allows the EPAs for which STARs are awarded in UME to be at a lower level of autonomy.  In some other countries, medical school graduates are expected to practice independently in the community for one or two years before entering residency; in these cases, the UME EPAs and STARs awarded would necessarily need to be at a higher level of autonomy. Another example is the definition of a pediatrician. In the United States, pediatricians are primary care physicians, and need to be entrustable for primary care and care coordination.  In the United Kingdom, pediatricians are subspecialists who receive referrals from primary care physicians.

Of course, this is the current challenge with licensing and certification across countries. In fact, EPAs may offer a potential solution via an "a la carte" approach.  If we agreed on a palette of EPAs required for a specified level of patient care, each country could define a profession by choosing EPAs from that palette.  In this case, the constellation of EPAs for pediatricians in the United States (US) and the United Kingdom (UK) would overlap but not be the same. If a UK pediatrician came to the US, the US could accept the STARs for the relevant EPAs and request that additional EPAs be added to the portfolio to match the US definition of pediatrician.

One must realize that, while in most of the western countries, undergraduate medical education does not lead to unsupervised medical practice, many other countries it does. If UME EPAs must lead to primary care responsibilties without supervision, their EPAs should reflect this higher level of autonomy.


Boyce, P., Spratt, C., Davies, M. and McEvoy, P. (2011) ‘Using entrustable professional activities to guide curriculum development in psychiatry training’, BMC Medical Education, 11(1), p. 96.

Brown, C. R., Criscione‐Schreiber, L., O’Rourke, K. S., Fuchs, H. A., et al. (2016) ‘What Is a Rheumatologist and How Do We Make One?’, Arthritis Care & Research, 68(8), pp. 1166–1172.

Caverzagie, K. J., Cooney, T. G., Hemmer, P. A. and Berkowitz, L. (2015) ‘The Development of Entrustable Professional Activities for Internal Medicine Residency Training: A Report From the Education Redesign Committee of the Alliance for Academic Internal Medicine’, Academic Medicine, 90(4), p. 479.

Deitte, L. A., Gordon, L. L., Zimmerman, R. D., Stern, E. J., et al. (2016) ‘Entrustable Professional Activities:: Ten Things Radiologists Do’, Academic Radiology, 23(3), pp. 374–381.

Hauer, K. E., Kohlwes, J., Cornett, P., Hollander, H., et al. (2013) ‘Identifying Entrustable Professional Activities in Internal Medicine Training’, Journal of Graduate Medical Education, 5(1), pp. 54–59.

Leipzig, R. M., Sauvigné, K., Granville, L. J., Harper, G. M., et al. (2014) ‘What Is a Geriatrician? American Geriatrics Society and Association of Directors of Geriatric Academic Programs End-of-Training Entrustable Professional Activities for Geriatric Medicine’, Journal of the American Geriatrics Society, 62(5), pp. 924–929.

Schultz, K., Griffiths, J. and Lacasse, M. (2015) ‘The Application of Entrustable Professional Activities to Inform Competency Decisions in a Family Medicine Residency Program’, Academic Medicine, 90(7), p. 888.

Shaughnessy, A. F., Sparks, J., Cohen-Osher, M., Goodell, K. H., et al. (2013) ‘Entrustable Professional Activities in Family Medicine’, Journal of Graduate Medical Education, 5(1), pp. 112–118.

Weiss, A., Ozdoba, A., Carroll, V. and DeJesus, F. (2016) ‘Entrustable Professional Activities: Enhancing Meaningful Use of Evaluations and Milestones in a Psychiatry Residency Program’, Academic Psychiatry, 40(5), pp. 850–854.

Young, J. Q. M., Hasser, C., Hung, E. K., Kusz, M., et al. (2018) ‘Developing End-of-Training Entrustable Professional Activities for Psychiatry:  Results and Methodological Lessons’, Academic Medicine, 93(7), pp. 1048–1054.

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