Answer to "Many residents supervise medical students on an EPA before they have reached level 5. Should 'providing supervision' not be an EPA in itself?"

The EPA concept is linked with entrustment decisions. Those decisions pertain to the level of supervision that a trainee should receive. These levels have been formulated in a 5-step framework (ten Cate and Scheele, 2007; ten Cate et al., 2015):

  1. Not allowed to practice this EPA,

  2. Allowed to practice this EPA only under proactive, full supervision,

  3. Allowed to practice this EPA only under reactive/on-demand supervision,

  4. Allowed to practice this EPA unsupervised,

  5. Allowed to supervise others in the practice of this EPA.

While there are variations with more detailed in-between levels (Chen and ten Cate, 2018), for this question, we will just refer to this simple framework.

Most levels seem to relate to the same dimension (i.e. the more proficient you become, the less supervision you need), but level 5 is something different. Providing supervision can seem more like a teaching than a clinical task. Some authors have pointed to the difficulty of seeing and using the scale as a one-dimensional construct (Krupat, 2018; Schwartz, 2018). They may be right from a standpoint of traditional psychometrics and classical test theory. However, it is important to remember what level 5 really means. Supervision is not just 'teaching' or 'advising' junior learners, it truly means having and executing the role of supervisor. That means having the role and power of the primary responsible physician for the patient for whom the trainee is also taking responsibility. It includes assessment of patient safety and risk of an EPA within the context at hand, and determining how much supervision to provide a trainee undertaking the EPA. Psychometricians could still object and say this is not one dimension, but at least the scale is an ordinal scale, in which every step higher implies a higher level of responsibility.

So teaching, guiding, coaching junior trainees, from the perspective of the old surgical adage of "see one - do one - teach one", may be definitely useful to a certain extent for activities that are not too critical, but it is NOT similar to Level 5 of the supervision scale. Teaching junior trainees is often very productive and beneficial for both parties (ten Cate and Durning, 2007), but that is not supervision in the strict sense. For instance, it is the attending who assumes ultimate responsibility for the patient and who makes the decision about what activity the student can do and under what level of supervision, and then assigns the resident to be the coach. The teaching then pertains to an EPA that this coach has previously mastered. No one should supervise anyone else on an EPA on which they have not themselves reached level 4.

Providing supervision is indeed a skill that is different from patient care, and aspects of it can be trained. It may indeed be an EPA in itself, and would then be a teaching-EPA. Some have suggested these should be developed (Dewey et al., 2017; Iqbal and Al-Eraky, 2018). It should include, next to having patient care responsibilities, monitoring trainees, assessing trainees, creating learning opportunities and possibly required general clinical teacher skills (Kilminster et al., 2007; Sutkin et al., 2008). One option is to only certify a trainee for Level 5 of supervision if a senior educator has attested to his/her ability to supervise.


ten Cate, O., Chen, H. C., Hoff, R. G., Peters, H., et al. (2015) ‘Curriculum development for the workplace using Entrustable Professional Activities (EPAs): AMEE Guide No. 99’, Medical Teacher, 37(11), pp. 983–1002.

ten Cate, O. and Durning, S. (2007) ‘Dimensions and psychology of peer teaching in medical education’, Medical Teacher, 29(6), pp. 546–552.

ten Cate, O. and Scheele, F. (2007) ‘Viewpoint: Competency-Based Postgraduate Training: Can We Bridge the Gap between Theory and Clinical Practice?’, Academic Medicine, 82(6), p. 542.

Chen, H. C. and ten Cate, O. (2018) ‘Assessment through Entrustable Professional Activities’, in Learning and Teaching in Clinical Contexts: A Practical Guide. 2nd edn. Chatswood: Elsevier Health Sciences.

Dewey, C. M., Jonker, G., ten Cate, O. and Turner, T. L. (2017) ‘Entrustable professional activities (EPAs) for teachers in medical education: Has the time come?’, Medical Teacher, 39(8), pp. 894–896.

Iqbal, M. Z. and Al-Eraky, M. M. (2018) ‘Using entrustable professional activities (EPAs) to assess teaching competence and transfer of training: A personal view’, Medical Teacher, 0(0), pp. 1–2.

Kilminster, S., Cottrell, D., Grant, J. and Jolly, B. (2007) ‘AMEE Guide No. 27: Effective educational and clinical supervision’, Medical Teacher, 29(1), pp. 2–19.

Krupat, E. (2018) ‘Critical Thoughts About the Core Entrustable Professional Activities in Undergraduate Medical Education’, Academic Medicine, 93(3), pp. 371–376.

Schwartz, A. (2018) ‘What should we mean by “allowed to supervise others” in entrustment scales?’, Medical Teacher, 40(6), pp. 642–642.

Sutkin, G., Wagner, E., Harris, I. and Schiffer, R. (2008) ‘What Makes a Good Clinical Teacher in Medicine? A Review of the Literature’, Academic Medicine, 83(5), p. 452.