Answer to "Does working with EPAs lead to time variability in clinical training with training length tailored to individual trainees, and if so, how can that be organized?"

The short answer to the first question is: yes. It is a principle of competency-based medical education (CBME) that finishing the pre-planned duration of a training program should not be the only, or maybe not even the main, criterion that determines whether a trainee is ready for unsupervised practice. This principle has been reiterated many times in the past 50 years, but only in the 21st century have educators started to create programs that allow for such flexibility (McGaghie et al., 1978; Carraccio et al., 2002; ten Cate, 2005; Frank et al., 2010; Lucey, Thibault and ten Cate, 2018). This would mean that those who meet the standards of the profession within the projected time complete the program at the expected moment, those who need more time are given more time, and those who are very proficient may complete the program earlier. One way of operationalizing CBME is by using EPAs (ten Cate, 2005; ten Cate et al., 2015).

So far, however, only very few examples have demonstrated the feasibility of some variability (Long, 2000; Nousiainen et al., 2018). One reason is that an academic degree or diploma is a comprehensive license that includes successful completion of all curricular activities and assessments as a proxy for competence and a requisite for what a licensed person is allowed to do. Variations in the moment that a diploma is awarded, based on successful completion of in all these curricular activities, is difficult. If, instead, each of the EPAs that together comprise the foundation of the license or diploma is observed and assessed, training, assessment and progress can be individualized much more easily. Individualisation can lead to time justified variations.

When considering adapting time-variability in training, there is a number of things to keep in mind.

  1. Time variability is not a purpose in itself, but only a measure to ensure that graduates meet standards. It is illogical to think that some learners should take twice as long and some could finish in half the time. While there is no hard criterion, a variation beyond 20% plus or minus the program duration would be rare. In more extreme cases, either the trainee should have not been accepted into the program, or one should worry that the trainee has not had sufficient experience and exposure to clinical situations despite excellent assessment results.

  2. Much of the exposure to patients and clinical situations, including working interprofessionally, cannot be planned, but is essential for workplace learning (Teunissen et al., 2018). In addition, dwell time is not always unproductive; even during sleep, brain development continues and learning becomes anchored. Time, in itself, is a resource, and not merely something to be minimized (ten Cate et al., 2018).

  3. Time variability forces a program to assess competence more rigorously (Gruppen et al., 2018). However, there are limitations to what can be objectively stated as 'meeting standards' in the assessment of trainees (ten Cate and Regehr, 2018). Workplace-based assessment must necessarily rely on expert judgment. Not only do clinicians differ in their perception of competence, contexts vary greatly and arriving at valid entrustment decisions (Chen and ten Cate, 2018) requires collective subjective judgments and sometimes team negotiations in clinical competency committees (Hauer et al., 2015, 2016).

  4. Finally, to come back to the second question: frankly, it is not easy to transition from a time-fixed program to a time-variable program. There are many hurdles to overcome, most of which have a regulatory, legal or organizational nature (Kogan et al., 2018). But flexibility is not impossible (Wiersma, Berkvens and ten Cate, 2017; Hoff et al., 2018), and even without the adaptation of variable training duration, the content of training and certification can be more flexible in EPA-based programs. While there may be core EPAs that are mandatory for all trainees, adding elective EPAs may create flexibility for more proficient learners (Chen et al., 2016; ten Cate et al., 2018).


Carraccio, C., Wolfsthal, S. D., Englander, R., Ferentz, K., et al. (2002) ‘Shifting Paradigms: From Flexner to Competencies’, Academic Medicine, 77(5), p. 361.

ten Cate, O. (2005) ‘Entrustability of professional activities and competency-based training’, Medical Education, 39(12), pp. 1176–1177.

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. 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.

ten Cate, O., Gruppen, L. D., Kogan, J. R., Lingard, L. A., et al. (2018) ‘Time-Variable Training in Medicine: Theoretical Considerations’, Academic Medicine, 93(3S), p. S6.

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.

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.

Frank, J. R., Snell, L. S., Cate, O. T., Holmboe, E. S., et al. (2010) ‘Competency-based medical education: theory to practice’, Medical Teacher, 32(8), pp. 638–645.

Gruppen, L. D., ten Cate, O., Lingard, L. A., Teunissen, P. W., et al. (2018) ‘Enhanced Requirements for Assessment in a Competency-Based, Time-Variable Medical Education System’, Academic Medicine, 93(3), pp. S17–S21.

Hauer, K. E., Cate, O. ten, Boscardin, C. K., Iobst, W., et al. (2016) ‘Ensuring Resident Competence: A Narrative Review of the Literature on Group Decision Making to Inform the Work of Clinical Competency Committees’, Journal of Graduate Medical Education, 8(2), pp. 156–164.

Hauer, K. E., Chesluk, B., Iobst, W., Holmboe, E., et al. (2015) ‘Reviewing Residents’ Competence: A Qualitative Study of the Role of Clinical Competency Committees in Performance Assessment’, Academic Medicine, 90(8), p. 1084.

Hoff, R. G., Frenkel, J., Imhof, S. M. and ten Cate, O. (2018) ‘Flexibility in Postgraduate Medical Training in the Netherlands’, Academic Medicine, 93(3), pp. S32–S36.

Kogan, J. R., Whelan, A. J., Gruppen, L. D., Lingard, L. A., et al. (2018) ‘What Regulatory Requirements and Existing Structures Must Change If Competency-Based, Time-Variable Training Is Introduced Into the Continuum of Medical Education in the United States?’, Academic Medicine, 93(3), pp. S27–S31.

Long, D. M. (2000) ‘Competency-based Residency Training: The Next Advance in Graduate Medical Education’, Academic Medicine, 75(12), p. 1178.

Lucey, C. R., Thibault, G. E. and ten Cate, O. (2018) ‘Competency-Based, Time-Variable Education in the Health Professions: Crossroads’, Academic Medicine, 93(3S), p. S1.

McGaghie, W. C., Miller, G. E., Sajid, A. and Telder, T. V. (1978) Competency-Based Curriculum Development in Medical Education. Geneva, Switzerland: World Health Organization.

Nousiainen, M. T., Mironova, P., Hynes, M., Takahashi, S. G., et al. (2018) ‘Eight-year outcomes of a competency-based residency training program in orthopedic surgery’, Medical Teacher, 40(10), pp. 1042–1054.

Ten, O. C. and Regehr, G. (2018) ‘The Power of Subjectivity in the Assessment of Medical Trainees.’, Academic medicine : journal of the Association of American Medical Colleges.

Teunissen, P. W., Kogan, J. R., ten Cate, O., Gruppen, L. D., et al. (2018) ‘Learning in Practice: A Valuation of Context in Time-Variable Medical Training’, Academic Medicine, 93(3), pp. S22–S26.

Wiersma, F., Berkvens, J. and Cate, O. ten (2017) ‘Flexibility in individualized, competency-based workplace curricula with EPAs: Analyzing four cohorts of physician assistants in training’, Medical Teacher, 39(5), pp. 535–539.