Answer to "How many EPAs should a full program contain? "

 

This is one of the most frequently asked questions, and related to it is the question of how broad an EPA should be. Ten years ago, we had suggested that "50 to 100 EPAs should be able to cover the objectives of a full postgraduate medical course of five to six years" (ten Cate and Scheele, 2007). We now believe this recommendation needs to be reconsidered. While a single answer cannot be given, experiences over the past few years with programs that have begun implementing EPA-based curricula point to a reasonable number range.

EPAs can be broad and general or small and specific. They can actually contain and act as a bundle of multiple small EPAs (e.g. the EPA "The general procedures of the physician"; Englander et al., 2016). Some other broad EPAs are not bundles of parallel small EPAs, but encompass smaller EPAs in a more hierarchical fashion (e.g. the EPA "the patient consultation" contains "nested EPAs" of history-taking, physical examination, etc. – subordinate tasks that together make up the larger EPA).

Intuitively, it appears that one should simply first analyze the profession, determine what professional activities are common, need to be mastered and are suitable for EPAs. In practice, it is not so simple. EPAs can serve as objectives for training; these objectives can be small or big and as many as an educational program likes. Some specialties have identified many EPAs for a full program (e.g. 76 for Family medicine; Shaughnessy et al., 2013), and others only few (e.g. 9 EPAs for Pediatrics in the Netherlands; Gemke et al., 2017).

Schools/programs often use elaborate lists of objectives, local or national, framed as knowledge, skills and attitudes, or as competencies and sub-competencies (Pangaro and Cate, 2013; Frank, Snell and Sherbino, 2014). However, EPAs must also allow schools/programs to make important advancement or summative entrustment decisions (i.e. readiness for unsupervised practice; or for indirect supervision). These summative entrustment decision cannot be made every day. In a postgraduate program, residents may be reviewed approximately every three months or so to determine whether they may be ready to be entrusted with increased responsibilities for patient care. Such decisions are based on multiple data points/collected observations by teams of clinicians (e.g. in a performance portfolio), and the number of EPAs for which residents are ready for unsupervised practice may increase over time. These are major decisions that should be experienced by the trainee as significant advances in responsibility. If EPAs are small, each will be just a minor step and will not be felt as significant. Such small steps work well in ad hoc situations, when a supervisor weighs decisions to grant tailored responsibilities. However, an EPA summative decision of entrustment has the nature of a certification, and may lead to digital badges showing permission to perform a significant task with less supervision.

Experience so far seems to indicate that 20-40 EPAs are reasonable numbers for a multi-year program. More EPAs, if they are taken seriously in their requirements for documentation, may burden the organization and create bureaucracy. Anecdotally, several programs have reduced the initial number of EPAs during implementation phases of new EPA-based programs and created larger chunks to constitute reasonable units of professional practice lending themselves for meaningful summative entrustment decisions and Statements of Awarded Responsibility (STARs). STARs are like the driver's license, awarded when the trainee has demonstrated readiness for unsupervised practise.

References

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. https://doi.org/10.1097/ACM.0b013e31805559c7.

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’, Academic Medicine, 91(10), pp. 1352–1358. https://doi.org/10.1097/ACM.0000000000001204.

Frank, J. R., Snell, L. and Sherbino, J. (2014) ‘The draft CanMEDS 2015 physician competency framework–series IV’, Ottawa: The Royal College of Physicians and Surgeons of Canada.

Gemke, R., Brand, P., Semmekrot, B., Brus, F., et al. (2017) Toekomstbestendige Opleiding Pediatrie: TOP PDF. Available at: https://docplayer.nl/30993391-Toekomstbestendige-opleiding-pediatrie-top-2020.html (Accessed: 28 February 2019).

Pangaro, L. and Cate, O. ten (2013) ‘Frameworks for learner assessment in medicine: AMEE Guide No. 78’, Medical Teacher, 35(6), pp. e1197–e1210. https://doi.org/10.3109/0142159X.2013.788789.

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. https://doi.org/10.4300/JGME-D-12-00034.1.

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