Answer to "EPAs have been described in different ways: as diseases, as procedures, as organizational tasks and in other ways. What is the best way to describe an EPA?"

 

Three things should be kept in mind: (a) sometimes EPAs do not meet the definition of an EPA, (b) EPAs require specifications to make them clear and transparent for everyone and (c) EPA frameworks can be organized in different ways.

(a) Sometimes EPAs do not meet the definition of an EPA. The definition and the components of EPAs have been well defined since their introduction in the literature (ten Cate, 2005). Read FAQs #1, 2 and 3.

 

Not everything purported to be an EPA is always a strong EPA (ten Cate, 2014; Tekian, 2017). Two published instruments, the EQual (Taylor et al., 2017) and the Quepa (Post et al., 2016) can be used to measure the strength of an EPA. However, a first simple test to see whether a task is an EPA is to see if a supervisor can imagine completing the following sentences: "From tomorrow onwards, you will be allowed to practice [EPA title] with only indirect supervision" (Mulder et al., 2010) and "Tuesday you are scheduled to do [EPA title]".  For instance, "Managing falls in older patients" is not a very strong EPA. This sounds like an activity, but it is difficult to schedule someone for it; 'managing' should be very specifically elaborated before a certifying summative entrustment decision can be made. "Managing the older patient at risk for falls" would sound clearer as an EPA. The Association of American Medical Colleges (AAMC) core EPA #15, "Identify systems failures and contribute to a culture of safety and improvement" (Englander et al., 2016) or the Association of Faculties of Medicine of Canada (AFMC) EPA #12 "Participate in health quality improvement initiatives" (Touchie and Boucher, 2016) also are not easy to envision as strong EPAs, simply because it is difficult to envision a pivotal moment before which there is no permission to act and after which such permission is granted. The AAMC and AFMC do include other EPAs that are unquestionably strong: "Obtain/gather a history and perform a physical examination" or "Perform general procedures of a physician". These still require a clear description, as specified below in (b).

The EPA concept was conceived for postgraduate medical training, and has been applied to undergraduate training and other health professions. In general, postgraduate EPAs are stronger than undergraduate EPAs. UME EPAs (both US and Canadian) often contain vagueness in their titles: "prioritize a differential diagnosis", "form clinical questions", "recommend procedures", "formulate and communicate plans" (Englander et al., 2016; Touchie and Boucher, 2016). Each of these suggests that the trainee's contribution to health care is not serious, because prioritisations, question formulations, recommendations and plan formulations can all be overruled by supervisors. Using EPAs are meant to have learners gradually, but seriously, contribute to health care, without the need to check everything they do. This should also be possible, to some extent in undergraduate education (Chen, van den Broek and ten Cate, 2015; ten Cate et al., 2018)

(b) EPAs require specifications to make them clear and transparent for everyone. The description of an EPA should be more than a title.

EPAs are the currency to certification, so all involved (trainees, supervisors and other clinicians, nurses, examination committees, clinical competency committees, clinicians in a next rotation etc.) should understand exactly what the EPA is, or, in other words, what it is that learners are permitted to do (at a designated level of supervision). The recommended description contains seven features of each EPA (ten Cate et al., 2015), two of which are essential for this understanding: The title and the specification & limitations.

To make EPAs truly transparent for all involved, the specification should list all components (no more, no less) that belong to this EPA, at a level of detail that should make them sufficiently unambiguous. An EPA for undergraduate education that is quite common is "the general procedures of the physician", but, naturally, all students, teachers, nurses and others should be fully aware of what these are. A specification like "Examples of procedures that fit the above principles include: Suturing the skin including injection of local anesthetic agent; insertion of a nasogastric tube in an awake patient; vaginal speculum examination with pap smear" (Touchie and Boucher, 2016) may not suffice, as a list of examples is not definitive enough. In a program that lists all required procedures for this undergraduate medical education EPA (venepuncture; peripheral intravenous line placement and connection; participation in the OR; speculum/vaginal examination; insertion of urinary catheter; intramuscular, intra- and subcutaneous-injection; rectal examination; wound care) (ten Cate et al., 2018) provides more clarity. Some procedures may need further clarification (e.g. participation in the OR = standing sterile, adequate behavior when only observing)

(c) EPA frameworks can be organized in different ways, with all of the EPAs still meeting the definition.

EPAs have been described as specific or general (bundles of) procedures, as scheduled services/rotations, as activities not related to individual care, and as managerial activities.

 

The question of which is the best categorization of EPAs for an educational program does not have one single answer. In most cases, a program may use more than one categorization. In procedural specialties, it is likely that procedures or groups of them will prevail, in non-procedural specialties scheduled services may more readily be used.

Diseases as the unit of EPAs can create difficulty if undifferentiated patients visit the office, and diagnostic processes are required to determine the disease of the patients. The alternative approach, using clinical conditions as the basis of the EPA, can be complex too. A family doctor, certified for the EPA "Managing the patient with pain/swelling in the legs", may next face "patient with sleeping problems". It may not be practical to have EPAs and certifications for small EPAs based on small groups of symptoms. (See FAQ 4) The Dutch national postgraduate pediatric curriculum has chosen to limit their total number of EPAs to 9 broad EPAs, largely based on scheduled services. To monitor resident experiences with the necessary variety of frequent medical conditions and diseases, these are listed, and residents document patient encounters with each of these for regular review by the program director.

References

ten Cate, O. (2005) ‘Entrustability of professional activities and competency-based training’, Medical Education, 39(12), pp. 1176–1177. https://doi.org/10.1111/j.1365-2929.2005.02341.x.

ten Cate, O. (2014) ‘Trusting Graduates to Enter Residency: What Does It Take?’, Journal of Graduate Medical Education, 6(1), pp. 7–10. https://doi.org/10.4300/JGME-D-13-00436.1.

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. https://doi.org/10.3109/0142159X.2015.1060308.

ten Cate, O., Graafmans, L., Posthumus, I., Welink, L., et al. (2018) ‘The EPA-based Utrecht undergraduate clinical curriculum: Development and implementation’, Medical Teacher, 40(5), pp. 506–513. https://doi.org/10.1080/0142159X.2018.1435856.

Chen, H. C., van den Broek, W. E. S. and ten Cate, O. (2015) ‘The Case for Use of Entrustable Professional Activities in Undergraduate Medical Education’, Academic Medicine, 90(4), p. 431. https://doi.org/10.1097/ACM.0000000000000586.

Englander, R., Flynn, T., Call, S., Carraccio, C., et al. (2016) Toward Defining the Foundation of the MD Degree: Core Entrustable Professional Activities for Entering Residency. https://doi.org/info:doi/10.1097/ACM.0000000000001204.

Mulder, H., Cate, O. T., Daalder, R. and Berkvens, J. (2010) ‘Building a competency-based workplace curriculum around entrustable professional activities: The case of physician assistant training’, Medical Teacher, 32(10), pp. e453–e459. https://doi.org/10.3109/0142159X.2010.513719.

Post, J. A., Wittich, C. M., Thomas, K. G., Dupras, D. M., et al. (2016) ‘Rating the Quality of Entrustable Professional Activities: Content Validation and Associations with the Clinical Context’, Journal of General Internal Medicine, 31(5), pp. 518–523. https://doi.org/10.1007/s11606-016-3611-8.

Taylor, D. R., Park, Y. S., Egan, R., Chan, M.-K., et al. (2017) ‘EQual, a Novel Rubric to Evaluate Entrustable Professional Activities for Quality and Structure’, Academic Medicine, 92(11S), p. S110. https://doi.org/10.1097/ACM.0000000000001908.

Tekian, A. (2017) ‘Are all EPAs really EPAs?’, Medical Teacher, 39(3), pp. 232–233. https://doi.org/10.1080/0142159X.2016.1230665.

Touchie, C. and Boucher, A. (2016) ‘Entrustable professional activities for the transition from medical school to residency’, Ottawa, Ontario, Canada: Association of Faculties of Medicine of Canada.

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