Defining Entrustable Professional Activities: Helping to Inform a Medical Licensing Examination Practice Analysis

• In Event: Developing a Blueprint for a National Medical Licensing Examination Program: From Soup to Nuts

Abstract

Purpose

The purpose of this research is to illustrate how entrustable professional activities (EPAs) can better inform a practice analysis for a large-scale national medical licensing examination program.

Perspective

A practice analysis should be undertaken to ensure that content included on licensing examinations adequately reflects professional practice. Traditionally, this is done by performing a task analysis or a job inventory.

However, the latter analysis may be insufficient to properly define the activities of a complex profession such as medicine.

EPAs are key observable activities that together constitute the mass of critical elements that operationally define a profession. EPAs are intended to help supervisors determine whether a postgraduate trainee is ready to perform an activity without supervision. Consequently, defining EPAs and surveying PGY-1s and clinical supervisors (CSs) on expectation as to these EPAs should provide information about complex activities in a practice analysis and further inform alignment of the content of a medical licensing examination aimed at PGY-1 with actual practice.

Methods

Entrustable professional activities (EPAs) were identified by a multi-specialty educator group using a nominal group technique as activities to be performed independently by the end of the PGY-1 year by all residents, regardless of specialty. A web-based survey was then sent to PGY-1s and CSs inquiring about levels of supervision expected/received for these EPAs. PGY-1s were also asked whether the activity had been performed as a medical student.

Results

Ten EPAs were identified (e.g.: patient handover, obtaining informed consent). Forty-eight PGY-1s and 113 CSs responded to the survey. Eight EPAs were performed by greater than 88% of PGY-1s in the first four months of residency. Additionally, more than 75% of PGY-1s reported performing six of these eight EPAs as an undergraduate medical student. Three of the EPAs, including, (1) recognizing and initiating management of a critically-ill patient, (2) obtaining informed consent, and (3) obtaining advanced directives, were performed by less than 70% of respondents at the undergraduate level. Two of these EPAs were performed by 90% of residents early in residency. Over 95% of CSs expected PGY-1s to be able to perform six of the EPAs with some level of supervision. Twenty-six percent of CSs did not expect PGY-1s to perform one of the EPAs (disclosing medical errors).

Finally, the majority of residents (65%) reported not performing this activity, even with supervision.

Scholarly Significance

In conducting a practice analysis, it is important to reflect what it is that professionals do. EPAs provide a process to define complex activities which are performed by PGY-1s in early residency. Surveying PGY-1s and clinical supervisors confirmed that the majority of EPAs are being performed early in residency. These findings provide useful additional evidence in the development of the blueprint and accompanying test specifications for medical licensing examinations aimed at that level of training.

Author

• Claire Touchie, Medical Council of Canada