Entrustable Professional Activities in Medical Education: Placing Public Good at the Center of Competency-Based Education

• In Event: Competency-Based Education in the Health Professions: Using Applied Research to Improve Learner and Societal Outcomes

Abstract

Objective/Purpose: Outcomes of health professions training necessitates the expectation for safe and effective care of patients. Entrustable professional activities (EPAs) offer a framework for working with competencies that places them explicitly and squarely in the context of public safety. The purpose of this paper is to introduce the concept of EPAs, describe its application in advancing competency-based education in medicine and provide a frame for the subsequent papers in this session.

Perspectives/Theoretical Framework: The competency-based education movement has been gaining momentum internationally and calling for greater emphasis on learner outcomes in curricular implementation and learner assessment.1 In medicine, a variety of competency frameworks have been adopted to define performance expectations for physician training. However, concerns have arisen about the potential reductionist approach with the lack of expectation for integration across domains of competence, application to patient care, and consideration of context.2,3 The EPA framework was introduced in an attempt to address some of these concerns. It integrates multiple competency domains, translates them into clinical practice, and accounts for context.4

Most importantly, the EPA framework focuses attention on the care of patients rather than the mere achievement of competencies as an end goal. The clinical workplace is an essential site of learning within health professions education, where learners develop the knowledge and skills required for the profession through participation in the delivery of patient care.5 This learning-as-participation necessitates an approach to learning and assessment that includes an expectation of safe and effective patient care.6 In practice, clinical teachers balance learner participation and autonomy with supervision on a daily basis to ensure both learner development and patient safety. The EPA framework asks clinical teachers to use these routine supervision decisions they already make to provide information about learner competence. The EPA framework defines competencies as the concrete activities, or entrustable professional activities, that a competent health professional performs. Assessments within the framework focus on the clinical teacher’s entrustment decisions about how much supervision to provide a learner performing one of these activities.7,8

Multiple learner factors impact entrustment or supervision decisions. A key factor is the learner’s capability (the required knowledge, skills, and experience) to perform the activity. This assessment of competence is consistent with traditional workplace-based assessments. However, entrustment decisions require clinical teachers to take into consideration additional factors such as integrity (truthfulness), reliability (conscientiousness, consistency), humility (recognition of limits, willingness to ask for help), and agency (self-direction, motivation).8

In medicine, EPAs have been defined for key transition points (e.g. medical school to residency, residency to practice, etc.) and for various specialties by individual institutions, national societies, and regulatory bodies. Most processes have engaged stakeholders via consensus methods such as the Delphi technique. Many of these EPAs are currently being piloted and implemented to different degrees. Emerging evidence on the use of entrustment/supervision scales for assessment support their ability to generate more reliable information and useful feedback to learners than typical performance rating scales.8 National, international, and interprofessional collaborations have arisen to implement and study EPAs within various health professions.

Author

• Huiju Carrie Chen, Georgetown University School of Medicine