Answer to "What is the best procedure to arrive at a valid set of EPAs for an educational program?"


As experience builds across many programs around the world, and curriculum developers share best practices, similar approaches begin to emerge. The following is a summary of recommended procedures for schools and postgraduate programs identifying EPAs and developing EPA-based curricula from scratch.

  1. Often, a core group of faculty members meet first to begin the identification of EPAs. There may be examples in the literature - many undergraduate medical education (Chen et al., 2016; Englander et al., 2016; Touchie and Boucher, 2016; Cate et al., 2018) and postgraduate medical program EPAs have been published. Whether informed by available EPAs or starting from scratch, it is useful to structure the initial process of EPA identification. One or more focus group sessions (Stalmeijer, McNaughton and Mook, 2014) using nominal group technique (O’Neil and Jackson, 1983) can be a sensible approach.

  2. When there is an initial set of EPAs, a validation process is useful, to make sure there will be consensus among stakeholders. Delphi or modified Delphi techniques have been used to arrive at agreed-upon EPAs and to support their validity for medical educational programs (Fessler et al., 2014; Hauer et al., 2015; van Houwelingen et al., 2016; Wisman-Zwarter et al., 2016; Hamui-Sutton et al., 2017; Parker, Guiton and Jones Jr, 2017).

  3. The identified set of EPAs is an excellent starting place with which to build the curriculum. However, be aware that implementation will necessarily lead to adaptation, as only in practice will the feasibility of the EPAs be established (see also FAQ #5).

  4. Finally it is good to realise that sets of EPAs may have different structures: broad EPAs may include smaller nested ones to be mastered earlier (ten Cate et al., 2015) and EPAs may link across UME and GME (Carraccio et al., 2017).


Carraccio, C., Englander, R., Gilhooly, J., Mink, R., et al. (2017) ‘Building a Framework of Entrustable Professional Activities, Supported by Competencies and Milestones, to Bridge the Educational Continuum’, Academic Medicine, 92(3), p. 324.

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.

Cate, O. ten, 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.

Chen, H. C., McNamara, M., Teherani, A., Cate, O. ten, et al. (2016) ‘Developing Entrustable Professional Activities for Entry Into Clerkship’, Academic Medicine, 91(2), pp. 247–255.

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.

Fessler, H. E., Addrizzo-Harris, D., Beck, J. M., Buckley, J. D., et al. (2014) ‘Entrustable Professional Activities and Curricular Milestones for Fellowship Training in Pulmonary and Critical Care Medicine: Report of a Multisociety Working Group’, Chest, 146(3), pp. 813–834.

Hamui-Sutton, A., Monterrosas-Rojas, A. M., Ortiz-Montalvo, A., Flores-Morones, F., et al. (2017) ‘Specific entrustable professional activities for undergraduate medical internships: a method compatible with the academic curriculum’, BMC Medical Education, 17(1), p. 143.

Hauer, K. E., Boscardin, C., Fulton, T. B., Lucey, C., et al. (2015) ‘Using a Curricular Vision to Define Entrustable Professional Activities for Medical Student Assessment’, Journal of General Internal Medicine, 30(9), pp. 1344–1348.

van Houwelingen, C. T. M., Moerman, A. H., Ettema, R. G. A., Kort, H. S. M., et al. (2016) ‘Competencies required for nursing telehealth activities: A Delphi-study’, Nurse Education Today, 39, pp. 50–62.

O’Neil, M. J. and Jackson, L. (1983) ‘Nominal Group Technique: A process for initiating curriculum development in higher education’, Studies in Higher Education, 8(2), pp. 129–138.

Parker, T. A., Guiton, G. and Jones Jr, M. D. (2017) ‘Choosing entrustable professional activities for neonatology: a Delphi study’, Journal of Perinatology, 37(12), pp. 1335–1340.

Stalmeijer, R. E., McNaughton, N. and Mook, W. N. K. A. V. (2014) ‘Using focus groups in medical education research: AMEE Guide No. 91’, Medical Teacher, 36(11), pp. 923–939.

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.

Wisman-Zwarter, N., van der Schaaf, M., ten Cate, O., Jonker, G., et al. (2016) ‘Transforming the learning outcomes of anaesthesiology training into entrustable professional activities: A Delphi study’, European Journal of Anaesthesiology (EJA), 33(8), p. 559.

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