Internal Medicine Residency Program Directors' Views of the Core Entrustable Professional Activities for Entering Residency: An Opportunity to Enhance Communication of Competency Along the Continuum

An internal medicine residency preparatory curriculum for fourth-year medical students

BACKGROUND

Intern preparation courses are often broad in scope; there are few published specialty-specific programs outside of General Surgery and Obstetrics. We designed an internal medicine (IM) residency preparatory course at the University of Maryland School of Medicine, which aimed to prepare graduating medical students for the rigours of IM residency training, mapped to Entrustable Professional Activities (EPAs).

METHODS

Fourteen fourth-year medical students who were matriculating into IM residency programs enrolled in a 4-week long residency preparation course. The course was designed to teach skills using case-based learning modules, specialty topic seminars, simulation laboratories, procedure laboratories and clinical practice. Participants were surveyed before and after the course on their perceived knowledge and ability with the skills tested.

RESULTS

With the exception of 'giving signout to a colleague', there was a significant difference in the participant's perceived ability for each skill taught within the course (P < 0.03 for each), with mean pre-course scores of 1.4-3.7 (SD = 0.5-1.2) and mean post-course scores of 3.2-4.2 (SD = 0.5-1.3). A second survey on course evaluation and perceived impact, completed 3 months after starting intern year, resulted in all respondents reporting that the information learned during the course had directly affected their care of patients on a daily or weekly basis. The modified Ottawa scale was the primary assessment means for the EPAs, with participants approaching entrustment at the conclusion of the course.

CONCLUSIONS

Implementation of an IM-specific residency preparation course is a useful adjunct in the fourth year of medical school.

TaskMaster: The Subintern Adventure Game-Game-Based Learning for Medical Subintern Task Prioritization

Introduction

The medical subinternship (also known as an acting internship) offers postclerkship medical students an opportunity for significant professional development. However, the skills required of a successful subintern-efficiency, patient triage, and advanced organization-are distinct from skills generally refined during the medicine clerkship. Few published curricula exist to prepare postclerkship students for success in this new role. To address this training gap, we introduced a novel tabletop role-playing game to equip medical subinterns with the necessary skills to deliver safe and efficient patient care.

Methods

We created an hour-long game-based learning session for rising internal medicine and family medicine subinterns. Led by a single facilitator, students worked together to triage and complete tasks in a gamified simulated environment of a morning on the wards. To assess the session, we surveyed participants (N = 130) immediately after activity completion.

Results

Eighty-three participants completed the postactivity survey, for a response rate of 64%. A majority of students agreed that TaskMaster: The Subintern Adventure Game met its educational goals of increasing comfort with task prioritization, organization, and patient triage. Ninety-three percent of respondents (77 of 83) either agreed or strongly agreed that they felt more prepared to be a covering provider for patients after the activity. Participants also reported high engagement with the activity.

Discussion

Leveraging the interactivity, teamwork, and contextualized practice of game-based learning can offer low-cost and adaptable opportunities to teach higher-order clinical skills and increase preparedness for the subinternship.

An assessment of the simulated performance of basic clinical procedures by junior doctors during the first year of clinical practice

BACKGROUND

Upon entering the healthcare system, junior doctors may lack the skills required to care for patients, and feel unprepared for their role, with considerable variation in the level of proficiency in the performance of particular clinical procedures.

OBJECTIVE

To compare the performance and proficiency (self-report and observed) of the performance of nine basic clinical procedures.

METHODS

Seventeen interns were observed performing nine clinical procedures in a simulated setting in June 2021 (Assessment 1) and January 2022 (Assessment 2). The observers identified whether each step in the procedure was performed correctly, and provided an overall assessment of proficiency. The participants also rated their own level proficiency.

RESULTS

At Assessment 1 the number of steps performed correctly ranged from a mean of 41.9-83.5%. At Assessment 2 the number of steps performed correctly ranged from a mean of 41.9-97.8%. The most common median proficiency rating for Assessment 1 was 'close supervision', and was 'indirect supervision' at Assessment 2. There was a significant and large effect size in the improvement in performance from Assessment 1 to Assessment 2. Low correlations were found between observer and self-reported proficiency in performance of the procedures.

CONCLUSIONS

The large improvement in performance across the two assessments is encouraging. However, there is a need to address the variability in performance on graduation from medical school, and to ensure that any assessment of proficiency is not only reliant on self-report.

Filling the Core EPA 10 assessment void: A framework for individual assessment of Core Entrustable professional activity 10 competencies in medical students

Objectives

The goal of this study was to develop and evaluate a novel curriculum and assessment tool for Core Entrustable Professional Activity (EPA) 10 competencies and entrustment scoring in a cohort of medical students in their emergency medicine (EM) clerkship using a framework of individualized, ad hoc, formative assessment. Core EPA 10 is an observable workplace-based activity for graduating medical students to recognize a patient requiring urgent or emergent care and initiate evaluation and management.

Methods

This is a prospective, pretest-posttest study of medical students during their EM clerkship. Using the Thomas and Kern framework, we created a curriculum of simulation cases about chest pain/cardiac arrest and respiratory distress, which included novel assessment checklists, and instructional videos about recognizing and managing emergencies. Students were individually pretested on EPA 10 competencies using the simulation cases. Two raters scored students using standardized checklists. Students then watched instructional videos, underwent a posttest with the simulation cases, and were scored again by the two raters using the checklists. Differences between pretest and posttest scores were analyzed using paired t-tests and Wilcoxon signed-rank tests.

Results

Seventy-three out of 85 (86%) students completed the curriculum. Mean scores from pretest to final posttest in the chest pain/cardiac arrest and respiratory distress cases significantly improved from 14.8/19 (SD 1.91), to 17.1/19 (SD = 1.00), t(68) = 10.56, p < 0.001, and 8.5/13 (SD 1.79), to 11.1/13(SD 0.89), t(67) = 11.15, p < 0.001, respectively. The kappa coefficients were 0.909 (n = 2698, p < 0.001) and 0.931 (n = 1872, p < 0.001). Median modified Chen entrustment scores improved from 1b (i.e., "Watch me do this") to 2b (i.e., "I'll watch you") for the chest pain/cardiac arrest case (p < 0.001) and 1b/2a (i.e., "Watch me do this"/ "Let's do this together") to 3a (i.e. "You go ahead, and I'll double-check all of your findings") for the respiratory distress case (p < 0.001).

Conclusion

A new directed curriculum of standardized simulation cases and asynchronous instructional videos improved medical student performance in EPA 10 competencies and entrustment scores. This study provides a curricular framework to support formative individualized assessments for EPA 10.

Core Entrustable Professional Activities for Entering Residency: A National Survey of Graduating Medical Students' Self-Assessed Skills by Specialty

BACKGROUND

The Association of American Medical Colleges described 13 Core Entrustable Professional Activities (EPAs) that graduating students should be prepared to perform under indirect supervision on day one of residency. Surgery program directors recently recommended entrustability in these Core EPAs for incoming surgery interns. We sought to determine if graduating students intending to enter surgery agreed they had the skills to perform these Core EPAs.

STUDY DESIGN

Using de-identified, individual-level data collected from and about 2019 Association of American Medical Colleges Graduation Questionnaire respondents, latent profile analysis was used to group respondents based on their self-assessed Core EPAs skills' response patterns. Associations between intended specialty, among other variables, and latent profile analysis group were assessed using independent sample t -tests and chi-square tests and multivariable logistic regression methods.

RESULTS

Among 12,308 Graduation Questionnaire respondents, latent profile analysis identified 2 respondent groups: 7,863 (63.9%) in a high skill acquisition agreement (SAA) group and 4,445 (36.1%) in a moderate SAA group. Specialty was associated with SAA group membership (p < 0.001), with general surgery, orthopaedic surgery, and emergency medicine respondents (among others) overrepresented in the high SAA group. In the multivariable logistic regression models, each of anesthesiology, ophthalmology, pediatrics, psychiatry, and radiology (vs general surgery) specialty intention was associated with a lower odds of high SAA group membership.

CONCLUSION

Graduating students' self-assessed Core EPAs skills were higher for those intending general surgery than for those intending some other specialties. Our findings can inform collaborative efforts to ensure graduates' acquisition of the skills expected of them at the start of residency.

Program Directors' Selection Criteria for General Surgery and Internal Medicine Residency Programs: A Cross-Sectional Study

Background and aims General surgery is a specialty that calls for a variety of abilities such as strong hand-eye coordination, the ability to function well under pressure, and the ability to make quick, informed decisions. On the other hand, internal medicine focuses on diagnosing, treating, and preventing adult non-surgical disorders. The present study aims to investigate the commonly used selection criteria employed by program directors (PDs) for general surgery and internal medicine residency programs. It also identifies how PDs value those criteria in the western and central regions of Saudi Arabia. Methods A retrospective cross-sectional study was conducted using a questionnaire adopted from the literature and modified following expert opinion. It was distributed to PDs in both the central and the western regions of Saudi Arabia. Results In total, 34 PDs completed the questionnaire, of which 32 (94.1%) were men. The mean age of participants was 42.53 ± 5.05 years; 21 (61.8%) PDs were general surgeons, and 47.1% were from the Jeddah region. Conclusion The study showed that the most selected criterion for both specialties was communication skills followed by clinical rotation in the same hospital; leadership skills were also highly considered by PDs.

Comparing Entrustment Decision-Making Outcomes of the Core Entrustable Professional Activities Pilot, 2019-2020

IMPORTANCE

Gaps in readiness for indirect supervision have been identified for essential responsibilities encountered early in residency, presenting risks to patient safety. Core Entrustable Professional Activities (EPAs) for entering residency have been proposed as a framework to address these gaps and strengthen the transition from medical school to residency.

OBJECTIVE

To assess progress in developing an entrustment process in the Core EPAs framework.

DESIGN, SETTING, AND PARTICIPANTS

In this quality improvement study in the Core EPAs for Entering Residency Pilot, trained faculty made theoretical entrustment determinations and recorded the number of workplace-based assessments (WBAs) available for each determination in 2019 and 2020. Four participating schools attempted entrustment decision-making for all graduating students or a randomly selected subset of students. Deidentified, individual-level data were merged into a multischool database.

INTERVENTIONS

Schools implemented EPA-related curriculum, WBAs, and faculty development; developed systems to compile and display data; and convened groups to make theoretical summative entrustment determinations.

MAIN OUTCOMES AND MEASURES

On an EPA-specific basis, the percentage of students for whom an entrustment determination could be made, the percentage of students ready for indirect supervision, and the volume of WBAs available were recorded.

RESULTS

Four participating schools made 4525 EPA-specific readiness determinations (2296 determinations in 2019 and 2229 determinations in 2020) for 732 graduating students (349 students in 2019 and 383 students in 2020). Across all EPAs, the proportion of determinations of "ready for indirect supervision" increased from 2019 to 2020 (997 determinations [43.4%] vs 1340 determinations [60.1%]; 16.7 percentage point increase; 95% CI, 13.8-19.6 percentage points; P < .001), as did the proportion of determinations for which there were 4 or more WBAs (456 of 2295 determinations with WBA data [19.9%] vs 938 [42.1%]; 22.2 percentage point increase; 95% CI, 19.6-24.8 percentage points; P < .001). The proportion of EPA-specific data sets considered for which an entrustment determination could be made increased from 1731 determinations (75.4%) in 2019 to 2010 determinations (90.2%) in 2020 (14.8 percentage point increase; 95% CI, 12.6-16.9 percentage points; P < .001). On an EPA-specific basis, there were 5 EPAs (EPA 4 [orders], EPA 8 [handovers], EPA 10 [urgent care], EPA 11 [informed consent], and EPA 13 [patient safety]) for which few students were deemed ready for indirect supervision and for which there were few WBAs available per student in either year. For example, for EPA 13, 0 of 125 students were deemed ready in 2019 and 0 of 127 students were deemed ready in 2020, while 0 determinations in either year included 4 or more WBAs.

CONCLUSIONS AND RELEVANCE

These findings suggest that there was progress in WBA data collected, the extent to which entrustment determinations could be made, and proportions of entrustment determinations reported as ready for indirect supervision. However, important gaps remained, particularly for a subset of Core EPAs.

Roles and Responsibilities of Medicine Subinternship Directors : Medicine Subinternship Director Roles

BACKGROUND

The internal medicine (IM) subinternship (also referred to as acting internship) plays a crucial part in preparing medical students for residency. The roles, responsibilities, and support provided to subinternship directors have not been described.

OBJECTIVE

We sought to describe the current role of IM subinternship directors with respect to their responsibilities, salary support, and reporting structure.

DESIGN

Nationally representative, annually recurring thematic survey of IM core clerkship directors with membership in an academic professional association as of September 2017.

PARTICIPANTS

A total of 129 core clinical medicine clerkship directors at Liaison Committee on Medical Education fully accredited U.S./U.S.-territory-based medical schools.

MAIN MEASURES

Responsibilities, salary support, and reporting structure of subinternship directors.

KEY RESULTS

The survey response rate was 83.0% (107/129 medical schools). Fifty-one percent (54/107) of respondents reported overseeing both core clerkship inpatient experiences and/or one or more subinternships. For oversight, 49.1% (28/53) of subinternship directors also reported that they were the clerkship director, 26.4% (14/53) that another faculty member directed all medicine subinternships, and 18.9% (10/53) that each subinternship had its own director. The most frequently reported responsibilities for the subinternship directors were administration, including scheduling, and logistics of student schedules (83.0%, 44/53), course evaluation (81.1%, 43/53), and setting grades 79.2% (42/53). The modal response for estimated FTE per course was 10-20% FTE, with 33.3% (16/48) reporting this level of support and 29.2% (14/54) reporting no FTE support.

CONCLUSIONS

The role of the IM subinternship director has become increasingly complex. Since the IM subinternship is critical to preparing students for residency, IM subinternship directors require standard expectations and adequate support. Future studies are needed to determine the appropriate level of support for subinternship directors and to define essential roles and responsibilities.

Essential yet Ill-defined: leadership roles to support fourth-year medical students in pediatrics

BACKGROUND

Few studies have been published about specialty-specific fourth-year medical student leadership in any discipline. This paper provides insight from pediatric educators about the current status and recommendations for pediatric-specific fourth-year leaders.

OBJECTIVE

To identify the prevalence of pediatric fourth-year medical student directors across the US and Canada and to compare current and ideal responsibilities for this role.

METHODS

Five multi-part questions were written and submitted for the 2019 Council on Medical Student Education in Pediatrics (COMSEP) Annual Survey and subsequently disseminated to all COMSEP member physicians. Anonymous responses were collected and results analyzed. The study was IRB exempt.

RESULTS

The program-level survey response rate was 79%. Of 115 respondent medical schools, 37% reported having a pediatric fourth-year director separate from the clerkship director, with an average of 9.8% full-time equivalent (FTE) protected time for the role. In contrast, individuals indicated 20% FTE would be ideal for fourth-year director responsibilities. The most common role identified for pediatric fourth-year directors was directing sub-internships. Respondents indicated it would be ideal for pediatric fourth-year directors to have an increased level of involvement in all areas queried in the survey, especially directing a pediatric residency preparatory course/boot camp, faculty development for educators of fourth-year students, and remediating fourth-year students.

CONCLUSIONS

As specialty-specific experiences have grown in the fourth year of medical school, there is an increasing demand for faculty leadership separate from direction of the pediatric clerkship. In this national survey, pediatric educators expressed a need for additional protected time to lead fourth-year specific activities. Similar findings in other disciplines would support advocating for more protected time and expanded roles for specialty-specific fourth-year directors nationally.

Transition-to-residency: pilot innovative, online case-based curriculum for medical students preparing for pediatric internships

Background: There is increasing recognition in medical education that greater emphasis must be placed on preparing graduating medical students for their new roles as interns. Few publications in the literature have described transition-to-residency curricula specifically for students interested in pediatrics or pediatric-related fieldsApproach: We developed novel online pediatric cases, embedded within an innovative, hybrid transition-to-residency course, to address high yield, multi-disciplinary topics within the context of several of the AAMC's identified Entrustable Professional ActivitiesEvaluation: The pilot cases were evaluated over two academic years (2018, 2019) at a single academic medical center as part of routine student course evaluation (N = 18/35) with the 2019 evaluation containing additional retrospective pre-post survey questions (N = 9/18) assessing self-reported changes in knowledge. Almost all students were very satisfied or satisfied with the modules overall (94%), the quality of the resources provided (100%), and the structure and clarity of the presentation of the material (100%). Among the students who completed the retrospective pre-post survey after participation in the online modules, significant self-reported improvements were noted in writing orders to the pediatrics floor (Z = -2.07, p = 0.04), providing anticipatory guidance (Z = -2.0,p = 0.046), formulating a differential diagnosis for common pediatric conditions (Z = -2.24, P = 0.03), and preparedness for managing common pediatric floor emergencies (Z = -2.33, P = 0.02).Reflection: We demonstrated feasibility of implementation of an interactive, online case-based curriculum, medical student satisfaction with content and delivery, and increased self-reported knowledge after completion of the pilot pediatric cases on the online, asynchronous learning platform.

Entrustable professional activities in entry-level health professional education: A scoping review

Entrustable professional activities (EPAs) are a recent enhancement to competency-based health professional education that describe the observable work done by a competent health professional. Through defining education outcomes in a work-based context, EPAs offer potential to identify skill gaps in individual or student cohorts and focus improvements. Entrustable professional activities have been pioneered and gained rapid acceptance in postgraduate medical education; however, less is known about their application and use in undergraduate or entry-level health professional education. The Joanna Briggs Institute scoping review methodology was used to explore how and in what context EPAs are being used in entry-level health professional education. Databases searched include CINAHL, EMBASE, MEDLINE, Web of Science and PsycINFO. A total of 748 abstracts were returned after duplicates removed, and 127 full-text articles were screened with 30 included for data extraction. Publications in this area have recently accelerated with disciplines of professions of medicine, pharmacy, dietetics and physician assistants reporting on EPA development, implementation and evaluation. EPA use has been reported in the United States, Canada, Europe Australia and Central America. Major motivation reported for EPA use is to improve patient safety by aligning performance and expectations and to improve student assessment. Several studies report on the use of EPAs to evaluate different curriculum models or identify curriculum gaps representing potential application in education research.

Revisiting the Core Entrustable Professional Activities for Entering Residency

The Core EPAs for Entering Residency Pilot project aimed to test the feasibility of implementing 13 entrustable professional activities (EPAs) at 10 U.S. medical schools and to gauge whether the use of the Core EPAs could improve graduates' performance early in residency. In this manuscript, the authors (members of the pilot institutions and Association of American Medical Colleges staff supporting the project evaluation) describe the schools' capacity to collect multimodal evidence about their students' performance in each of the Core EPAs and the ability of faculty committees to use those data to make decisions regarding learners' readiness for entrustment. In reviewing data for each of the Core EPAs, the authors reflected on how each activity performed as an EPA informed by how well it could be assessed and entrusted. For EPAs that did not perform well, the authors examined whether there are underlying practical and/or theoretical issues limiting its utility as a measure of student performance in medical school.

Handoffs and Nurse Calls: Overnight Call Simulation for Fourth-Year Medical Students

INTRODUCTION

Interns must be able to give and receive handoffs and use handoff information to respond to calls from nursing staff regarding patient concerns. Medical students may not receive adequate instruction in these tasks and often feel unprepared in this aspect of transitioning to residency. This program simulated an overnight call experience for fourth-year medical students emphasizing handoffs, nurse calls, and medical emergency response.

METHODS

The program utilized a combination of traditional didactics and simulated handoffs, nurse calls, and patient scenarios to allow groups of fourth-year medical students to independently manage a simulated overnight call. The program was designed for students as part of a larger Transition to Residency capstone course.

RESULTS

We ran four sessions over 3 years, with a total of 105 medical student participants. All students reported increased confidence or comfort in their ability to manage handoffs and respond to nurse calls. Students reported that the sessions were helpful and realistic.

DISCUSSION

This program provided fourth-year medical students with a realistic and useful opportunity to simulate handoffs and response to nurse calls, which increased their confidence and comfort. Minor changes were made between iterations of the course with continued positive feedback from medical students. The course is generalizable and can be adapted to the needs and resources of different institutions.

A Survey of Internal Medicine Interns Regarding the Most Useful Topics to Include in an Internal Medicine Track of a "Get Ready for Residency Boot Camp" Course

In the last decade, boot camp residency preparatory courses for fourth-year medical students have become increasingly popular in medical schools across the USA; however, the curricular content of these courses varies widely. The authors surveyed internal medicine interns at a large academic medical center regarding clinical and non-clinical topics that would be useful for an internal medicine residency preparatory curriculum. The response rate was 79% (64/81). A rational approach to antibiotics (42%) and electrolyte management (41%) were the most frequent clinical topics and cross-cover (69%) was the most frequent non-clinical topic selected by interns.

Development of an entrustable professional activities (EPAs) framework for small group facilitators through a participatory design approach

Background: Recent reports suggest that faculty development (FD) programs need a structured framework to design training and assess improvement in teaching performance of participants. Entrustable professional activities (EPAs) can serve as a novel framework to plan and conduct structured FD programs, and to assess the proficiency of small group facilitators after training. Objective: The researchers aimed to develop an EPAs framework for small group facilitators. Design: In March 2019, three workshops were organized to develop the EPAs framework by using a participatory action design approach. An orientation workshop was conducted to train the participating students and teachers. Then, a design workshop was conducted to develop the EPA framework, where data were collected from three sources: scribe notes, audio recordings, and field charts. Thematic analysis was performed, and consensus was sought from participants on the extracted professional tasks and competencies in the consensus workshop. In the third workshop, the participants also mapped professional tasks with relevant competencies. Results: A total of 15 teachers and 15 studentsf participated in the co-design process. Through a robust thematic analysis of multisource data, 57 professional tasks and 52 competencies emerged, which were converged into 11 tasks and 17 competencies after removing duplicating and non-qualifying professional tasks and competencies. Finally, a consensus was achieved on nine tasks and 12 competencies. Conclusions: The proposed EPAs framework can serve as a road map for longitudinal training and entrustment of small group facilitators. It can also guide small group facilitators in their continuous professional development and in building their teaching portfolios.

Identifying essential procedural skills in Canadian undergraduate medical education

INTRODUCTION

We conducted a national survey to characterize current Canadian procedural skills training in Undergraduate Medical Education (UGME). The goals were to identify the most important procedures students should know upon graduation and assess clinician-educator perceptions regarding implementation of a pre-clerkship procedural program.

METHODS

We distributed the survey to physician-educators across Canada's 17 medical schools. Respondents were directed to an individualized survey that collected demographic data, physician-educator responses on essential procedural skills, as well as physician-educator opinions on the value of a pre-clerkship procedural training program.

RESULTS

The response rate for this survey was 21% (42 out of 201 distributed surveys were completed). The top 10 most important procedures identified by physician-educators included IV Access, Airway Management, Local anesthesia/field block, Casting, Spontaneous Vaginal Delivery, Testing for STIs, Phlebotomy, Suturing of Lacerations, Nasogastric Tube Insertion, and Venipuncture. Physician-educators supported a pre-clerkship procedural program.

CONCLUSIONS

Identifying the most crucial procedural skills is the first step in implementing a competency-based procedural skills training program for Canadian medical students. With the list of essential skills, and the support for physician-educators in developing a pre-clerkship procedural skills curriculum, hopefully there can be future development of formalized curricula.

The development of a framework of entrustable professional activities for the intern year in Ireland

BACKGROUND

Entrustable Professional Activities (EPAs) are units of professional practice that capture essential competencies in which trainees must become proficient before undertaking them independently. EPAs provide supervisors with a solid justification for delegating an activity to trainees. This study aimed to develop and ensure face validity of a set of EPAs for junior doctors in the first year of clinical practice in the Republic of Ireland.

METHODS

An iterative eight stage consensus building process was used to develop the set of EPAs. This process was based on international best practice recommendations for EPA development. A series of surveys and workshops with stakeholders was used to develop a framework of EPAs and associated competencies. An external stakeholder consultation survey was then conducted by the Irish Medical Council. The framework of EPAs was then benchmarked against the 13 core EPAs developed by the Association of American Medical Colleges (AAMC).

RESULTS

A framework of seven EPAs, and associated competencies resulted from this study. These EPAs address all core activities that junior doctors should be readily entrusted with at the end of the intern year, which is the first year of clinical practice in the Republic of Ireland. Each EPA contains a series of defined competencies. The final EPAs were found to be comparable to the AAMC core EPAs for entering residency.

CONCLUSIONS

A framework of EPAs for interns in Ireland that are appropriate for the intern year has been developed by key stakeholders. The implementation of the EPAs in practice is the next step, and is likely to result in an improved intern training process and increased patient safety.

Creating a culture of communication in undergraduate medical education

Quality communication improves outcomes across a wide variety of health care metrics. However, communication training in undergraduate medical education remains heterogeneous, with real-life clinical settings notably underutilized. In this perspective, the authors review the current landscape in communication training and propose the development of communication-intensive rotations (CIRs) as a method of integrating communication training into the everyday clinical environment. Despite its importance, communication training is often relegated to a "parallel curriculum." Through integration, CIRs can provide opportunities for real-life skills training, decrease parallel curriculum burden, and provide specialty-specific training in preparation for residency. Clear, efficient communication and human connection remain central in a physician's practice. CIRs reinforce these crucial principles. Potential benefits of a CIR model include role modeling of expert communication techniques; real-time, specific feedback on communication behaviors; development of relationship-centered communication skills and human connection, thereby decreasing burnout; and the opportunity for quality communication practices to become habits in a medical student's daily routine.

Evaluation of an undergraduate nursing entrustable professional activities framework: An exploratory qualitative research

BACKGROUND

Entrustable professional activities (EPA) are mainly used in graduate medical education and professional development and have not been widely implemented in nursing undergraduate settings. Nursing EPAs were therefore developed by the Alice Lee Centre of Nursing to translate theoretical nursing competencies into clinical practice and as forms of standardized clinical assessment tools. Feedback from various stakeholders is required to further refine the framework.

OBJECTIVES

To explore the perceptions and experiences of using the new EPA framework in nursing students and hospital and university clinical instructors.

DESIGN

An exploratory qualitative study using focus group interviews.

PARTICIPANTS

Seven year-one nursing undergraduates, 12 year-two undergraduates, seven university clinical instructors, and 18 hospital clinical instructors participated in this study.

METHODS

The students formed five groups, while the clinical instructors formed seven groups, each consisting of three to four participants. Semi-structured interviews were conducted to explore stakeholders' experiences and perceptions of the EPA assessment framework. Thematic analysis was used to analyze the data.

RESULTS

Despite initial mixed reactions of confusion and relief, many students and clinical instructors commended the comprehensive and structured EPA framework and its emphasis on holistic patient-centered care. EPAs also allow flexible assessment methods, encourage critical thinking among students, and promote team-based care and peer teaching. However, the assessment using a two-dimensional matrix with multiple competencies for the EPAs, subjective assessment criteria, the lack of standardization using checklists, subjective assessment criteria, and the lack of, manpower, and time may potentially affect the accuracy of the clinical assessments. The effectiveness of the EPA framework was also dependent on the quality of feedback, students' intrinsic motivations, and learning environments. The refinement of EPAs and entrustment levels, a physical checklist, and an incorporation of EPAs into school curricula were recommended to improve practitioners' learning experiences.

CONCLUSIONS

The use of EPAs in nursing education continues to be a novel and evolving process. There remains a need for a further refinement of the EPA framework to tailor to instructors' expectations and students' capabilities.

Assessing medical student performance of Entrustable Professional Activities: A mixed methods comparison of Co-Activity and Supervisory Scales

Introduction: Observations of medical student participation in entrustable professional activities (EPAs) provide insight into the student's ability to synthesize competencies across domains and effectively function in different clinical scenarios. Both Supervisory and Co-Activity Assessment Scales have been recommended for use with medical students.Methods: Students were assessed on EPAs during Acting Internships in Medicine and Pediatrics. Two rating scales were modified based on expert review and included throughout the 2017-18 academic year. Statistical analysis was conducted to clarify relationships between the scales. Raters were interviewed to explore their interpretations and response processes.Results: The results of the McNemar test suggest that the scales are different (p-value <.01). Co-activity and Supervisory EPA ratings are related, but not interchangeable. This finding concurs with themes that emerged from response process interviews: (1) the scales are not directly parallel (2) rater preference depends on diverse factors and (3) rater comments are crucial for guiding students' future learning.Conclusion: The modified Chen Supervisory Scale and the modified Ottawa Co-Activity Scales are measuring different aspects of the entrustable professional activity landscape. Both scales can provide useful information to the learner and the assessment system, but they should not be treated as interchangeable assessments.

Senior-Year Curriculum in U.S. Medical Schools: A Scoping Review

Phenomenon: Many U.S. medical schools have responded to the adoption of competency-based medical education (CBME) frameworks by renewing their final-year curricula and including internship preparatory courses. The purpose of this scoping review was to map the published literature regarding the final year to discern how medical schools have responded to this paradigm change. Approach: A structured 5-step approach was used to conduct this scoping review. Electronic searches of PubMed, ERIC, Scopus, MedEdPortal, and 8 medical education journals were conducted to identify relevant articles published from 2006 to 2016. Four authors screened articles for inclusion using standardized eligibility criteria; interrater agreement was discussed and calculated. Authors extracted data elements, and a consensus-based approach was used to categorize, sort, and structure information gathered. Findings: Among 6,485 articles retrieved, 817 articles were included in the study. From 2007-2011 to 2012-2016, articles addressing the final year of medical school increased 93%, whereas articles describing internship preparatory courses increased 218%. The majority of articles did not reference a CBME framework (572/817; 70%), the frequency of mentions increased 268% from 2007-2011 to 2012-2016. Nearly three fourths of preparatory course-related papers reference a CBME framework (37/50; 74%). Insights: Our findings may reflect a movement in U.S. medical schools toward using shared assessment metrics to support 4th-year medical students' preparation for their postgraduate medical education. Despite an increased reference to CBME, there is relatively little use of competency-based assessment frameworks to evaluate learning outcomes. This review also found a substantial increase in the frequency of articles referencing senior-year preparatory courses in U.S. medical schools. Articles tended to describe institution-specific research or experiences. Opportunities likely exist for multi-institutional and organizational collaboration in determining the structure of the final year of medical school.

Entrustable professional activities in health care education: a scoping review

CONTEXT

The shift in medical education from time-based learning to outcome-based learning has drawn much attention to entrustable professional activities (EPAs) as an ideal assessment framework to translate competencies into clinical practice. Given the relative novelty of EPAs, this review aims to highlight research gaps and explore and consolidate available evidence pertaining to the development and implementation of EPAs in health care.

METHOD

Arksey and O'Malley's scoping review framework was used to present the findings. The authors performed a systematic search of PubMed, Embase, CINAHL, Scopus, MedNar, OpenGrey and ProQuest Dissertation and Theses for English articles published from the inception of each database to May 2018. A manual search of the reference lists of the included studies was conducted and an expert panel was consulted. Two reviewers screened the articles for eligibility using the inclusion criteria. All authors extracted key data and analysed the data descriptively. Thematic analysis was used to categorise the results into themes.

RESULTS

Eighty articles were included in the review. All articles were published between 2010 and 2018. Three major themes and eight sub-themes were generated: (i) development of EPAs (frameworks for EPA development and implementation, identifying core or specialty-specific EPAs, and EPAs for faculty development), (ii) evaluation of EPAs and EPA entrustment factors (revised curriculum, entrustment decisions for professional activities, and feedback on implemented EPAs and the development process), and (iii) future directions and recommendations for EPAs (implementation of EPAs in undergraduate medical education and specific disciplines, and other criticisms and recommendations for EPAs).

CONCLUSIONS

Entrustable professional activities are an essential means to translate competencies into observable and measurable clinical practice. However, high-level evidence-based research on the efficacy, development and implementation of EPAs for specific target groups (i.e. undergraduates and staff) and geographical regions (i.e. Asia and Africa) is still lacking, which suggests a direction for future research.

Beyond the United States Medical Licensing Examination Score: Assessing Competence for Entering Residency

Assessments of physician learners during the transition from undergraduate to graduate medical education generate information that may inform their learning and improvement needs, determine readiness to move along the medical education continuum, and predict success in their residency programs. To achieve a constructive transition for the learner, residency program, and patients, high-quality assessments should provide meaningful information regarding applicant characteristics, academic achievement, and competence that lead to a suitable match between the learner and the residency program's culture and focus.The authors discuss alternative assessment models that may correlate with resident physician clinical performance and patient care outcomes. Currently, passing the United States Medical Licensing Examination Step examinations provides one element of reliable assessment data that could inform judgments about a learner's likelihood for success in residency. Yet, learner capabilities in areas beyond those traditionally valued in future physicians, such as life experiences, community engagement, language skills, and leadership attributes, are not afforded the same level of influence when candidate selections are made.While promising new methods of screening and assessment-such as objective structured clinical examinations, holistic assessments, and competency-based assessments-have attracted increased attention in the medical education community, currently they may be expensive, be less psychometrically sound, lack a national comparison group, or be complicated to administer. Future research and experimentation are needed to establish measures that can best meet the needs of programs, faculty, staff, students, and, more importantly, patients.

The New Internal Medicine Subinternship Curriculum Guide: a Report from the Alliance for Academic Internal Medicine

The internal medicine (IM) subinternship has been a long-established clinical experience in the final phase of medical school deemed by key stakeholders as a crucial rotation to prepare senior medical students for internship. Medical education has changed greatly since the first national curriculum for this course was developed in 2002 by the Clerkship Directors in Internal Medicine (CDIM). Most notably, competency-based medical education (CBME) has become a fixture in graduate medical education and has gradually expanded into medical school curricula. Still, residency program directors and empirical studies have identified gaps and inconsistencies in knowledge and skills among new interns. Recognizing these gaps, the Association of Program Directors in Internal Medicine (APDIM) surveyed its members in 2010 and identified four core skills essential for intern readiness. The Association of American Medical Colleges (AAMC) also published 13 core entrustable professional activities (EPAs) for entering residency to be expected of all medical school graduates. Results from the APDIM survey along with the widespread adoption of CBME informed this redesign of the IM subinternship curriculum. The authors provide an overview of this new guide developed by the Alliance for Academic Internal Medicine (AAIM) Medical Student-to-Resident Interface Committee (MSRIC).

Assessing Entrustable Professional Activities Using an Orientation OSCE: Identifying the Gaps

BACKGROUND

A residency program's intern cohort is comprised of individuals from different medical schools that place varying levels of emphasis on Core Entrustable Professional Activities for Entering Residency (CEPAERs). Program directors have expressed concerns about the preparedness of medical school graduates. Though guiding principles for implementation of the CEPAERs have been published, studies using this framework to assess interns' baseline skills during orientation are limited.

OBJECTIVE

A CEPAER-based objective structured clinical examination (OSCE) was implemented with the aims to (1) assess each intern's baseline clinical skills and provide formative feedback; (2) determine an intern's readiness for resident responsibilities; (3) inform individualized education plans; and (4) address identified gaps through curricular change.

METHODS

During orientation, all 33 interns from internal medicine (categorical, preliminary, and medicine-psychiatry) participated in the OSCE. Six 20-minute stations evaluated 8 EPAs. Faculty completed a global assessment, and standardized patients completed a communications checklist and global assessment. All interns completed a self-assessment of baseline skills and a post-OSCE survey.

RESULTS

Stations assessing handoffs, informed consent, and subjective, objective, assessment, and plan (SOAP) note were the lowest-performing stations. Interns performed lower in skills for which they did not report previous training. Formal instruction was incorporated into didactic sessions for the lowest-performing stations. The majority of interns indicated that the assessment was useful, and immediate feedback was beneficial.

CONCLUSIONS

This OSCE during orientation offers just-in-time baseline information regarding interns' critical skills and may lead to individualized feedback as well as continuous curricular improvement.

Are medical students trained in cross-cover?

OBJECTIVES

To examine the current state of cross-cover education in undergraduate medical education and intern perceived readiness to provide cross-cover.

METHODS

An electronic survey was distributed to 126 incoming interns in surgery, internal medicine, family medicine and paediatrics residencies at a single academic centre. Information regarding prior cross-cover training, experience, confidence, and responses to a sample cross-cover case were obtained.

RESULTS

The survey response rate was 69.8% (88 of 126), which included both partial and complete responses. Fifty-seven interns out of 85 (67.1%) had no formal training and 51 (60.0%) had no experience performing cross-cover. They reported feeling unprepared to provide cross-cover, with an average score of 1.8 on a 5-point Likert scale (1, not at all confident; 5, extremely confident). Interns had more confidence in performing cross-cover tasks if they had prior direct cross-cover experience (p = 0.001), and were the least confident in performing the initial evaluation and management of urgent issues (Likert score = 1.6). Scores on the sample case were correlated with the amount of prior experience with patients (p = 0.06). Only 77.7% of interns indicated that they would notify their senior resident in two urgent scenarios. Those who reported higher confidence in knowing when to ask for help were more likely to appropriately notify their senior colleague (p = 0.005). We identified gaps in cross-cover training and in the preparedness of incoming interns CONCLUSIONS: We identified gaps in cross-cover training and in the preparedness of incoming interns. This has important implications for the first day of residency, when interns are often asked to perform cross-coverage, yet feel unprepared to do so and express the greatest concern in urgent cross-cover scenarios. Addressing this curricular gap is crucial in assuring safe cross-cover care.

An Entrustable Professional Activity (EPA)-Based Framework to Prepare Fourth-Year Medical Students for Internal Medicine Careers

The purpose of the fourth year of medical school remains controversial. Competing demands during this transitional phase cause confusion for students and educators. In 2014, the Association of American Medical Colleges (AAMC) released 13 Core Entrustable Professional Activities for Entering Residency (CEPAERs). A committee comprising members of the Clerkship Directors in Internal Medicine and the Association of Program Directors in Internal Medicine applied these principles to preparing students for internal medicine residencies. The authors propose a curricular framework based on five CEPAERs that were felt to be most relevant to residency preparation, informed by prior stakeholder surveys. The critical areas outlined include entering orders, forming and answering clinical questions, conducting patient care handovers, collaborating interprofessionally, and recognizing patients requiring urgent care and initiating that care. For each CEPAER, the authors offer suggestions about instruction and assessment of competency. The fourth year of medical school can be rewarding for students, while adequately preparing them to begin residency, by addressing important elements defined in the core entrustable activities. Thus prepared, new residents can function safely and competently in supervised postgraduate settings.

Assessing Entrustable Professional Activities During the Psychiatry Clerkship

OBJECTIVE

Within 10 years, the Association of American Medical Colleges envisions graduating medical students will be entrusted by their school to perform 13 core entrustable professional activities (EPAs) without direct supervision. The authors focused on eight EPAs that appear most relevant to clinical training during the psychiatry clerkship at their institution to evaluate whether students assess themselves as making progress in EPAs during this clerkship, to see how students' self-assessments compare with the clerkship director's assessments, and to see if weaknesses in the curriculum were found.

METHODS

An EPA-assessment scale was designed (ratings 1 to 5) to assess progress toward entrustment in each EPA. Medical students completed pre- and post-psychiatry clerkship self-assessments. The clerkship director independently assessed each student's progress in EPAs utilizing assessment methods already present in the curriculum.

RESULTS

Seventy of 116 students (60.3%) completed both pre- and post-clerkship self-assessments. These ratings increased significantly from pre- to post-clerkship, representing large effect sizes from 0.83 to 1.13. The largest mean rating increase was observed for EPA 2, Prioritize a differential diagnosis following a clinical encounter. Mean post-clerkship self-assessment ratings were significantly higher than mean post-clerkship instructor ratings for seven of the eight EPAs.

CONCLUSIONS

The results suggest training during the psychiatry clerkship can contribute to the professional development of medical students in the eight EPAs studied but that student self-assessments tend to be higher than those of the clerkship director. Further study is needed of the relative value and role of student self-assessments versus faculty assessments of progress in EPAs.