A Patient-Centered Approach to Developing Entrustable Professional Activities

Active and direct patient participation in health professions education: A narrative overview of literature from the global south

OBJECTIVES

Patients traditionally played a passive role in health professions education (HPE). However, their active involvement is increasingly valued, particularly in higher-resourced regions of the world known as the Global North. This study explores active and direct patient involvement in HPE contexts in the Global South (GS) regions of the world.

METHODS

A narrative review of literature was conducted, utilising a systematic search of multiple electronic databases. 3966 abstracts were identified, and 80 full texts were reviewed. Ultimately, five papers were included in the final corpus.

RESULTS

The selected studies were set in five GS countries, involving undergraduate, postgraduate medical and pharmacy training. Real patients, their caregivers and standardized patients acted as teachers or assessors focusing on learners' history-taking, communication skills, and professionalism. Challenges included cultural sensitivity and safety concerns, e.g. during home visits. Educators faced difficulties in patient recruitment, training and compensation.

CONCLUSION & PRACTICE IMPLICATIONS

Active and direct patient involvement in HPE within GS contexts remains limited. Current efforts focus on patients as teachers or assessors, with little contribution to educational design, instruction and mentoring. Educators may be overlooking the potential of diverse cultural perspectives to enhance patient engagement in HPE, making this a valuable area for future research.

Could entrustable professional activities support assessment in optometric clinical education in Australia and New Zealand?

Entrustable professional activities (EPAs) are increasingly being adopted as an assessment tool by medicine and other health professions in a bid to enhance competency-based health professional education. EPAs are well-defined professional activities that can be entrusted to students to perform with varying levels of supervision. They were introduced to overcome some of the limitations of traditional assessment methods of competency such as individual skills assessment or Direct Observation of Procedures and Objective Structured Clinical Examinations. Could EPAs be beneficial in Australian and New Zealand optometric clinical education for advanced skills training and accreditation including the credentialing assessment of overseas educated practitioners? This paper discusses the historical context of how competencies were introduced and assessed in Australian optometry, the evolution of the concept of EPAs in medicine and other health professions, their design and implementation worldwide and whether EPAs could be adopted into optometric training and assessment in Australia and New Zealand.

Evaluating a medication history-taking entrustable professional activity and its assessment tool - Survey of a statewide public hospital pharmacy service

INTRODUCTION

Entrustable Professional Activities (EPAs) are tasks that professionals within a field perform autonomously. EPAs are incorporated in workplace-based assessment tools to assist training and professional development. Few studies have evaluated medication history-taking EPAs use in pharmacy practice and none have sought stakeholder feedback on their use. This study evaluates the quality of the medication history-taking EPA utilized in South Australian public hospitals and the usability of its assessment tool.

METHODS

A voluntary online questionnaire was conducted from July 15th to September 2nd 2021 to gather the opinions of stakeholders on the use of the medication history-taking EPA. The questionnaire was developed based on tools identified in the literature and utilized 14 open-text and five-point Likert scale questions. The questionnaire was distributed using Survey Monkey® to a purposive sample of staff and students.

RESULTS

82 responses were received from 218 surveys distributed, yielding a response rate of 38%. Respondents believed the EPA promotes learner development (90.6%) and the provision of useful feedback (83%). 94.3% considered the EPA to be easy to use but only 56.6% indicated that using it fits easily within their workday. Time constraints and the presence of context-specific descriptors were commonly perceived as limitations. Some stakeholders indicated a lack of understanding of entrustment decisions.

CONCLUSION

The EPA and its assessment tool were perceived to have good quality and usability. Reducing the length of the tool, broadening its applicability across contexts, and improving user understanding of entrustment decision-making may support better use of the tool.

Better together: A multistakeholder approach to developing specialty-wide entrustable professional activities in emergency medicine

Purpose

Entrustable professional activities (EPAs) are a widely used framework for curriculum and assessment, yet the variability in emergency medicine (EM) training programs mandates the development of EPAs that meet the needs of the specialty as a whole. This requires eliciting and incorporating the perspectives of multiple stakeholders (i.e., faculty, residents, and patients) in the development of EPAs. Without a shared understanding of what a resident must be able to do upon graduation, we run the risk of advancing ill-prepared residents that may provide inconsistent care.

Methods

In an effort to address these challenges, beginning in February 2020, the authors assembled an advisory board of 25 EM faculty to draft and reach consensus on a final list of EPAs that can be used across all training programs within the specialty of EM. Using modified Delphi methodology, the authors came to consensus on an initial list of 22 EPAs. The authors presented these EPAs to faculty supervisors, residents, and patients for refinement. The authors collated and analyzed feedback from focus groups of residents and patients using thematic analysis. The EPAs were subsequently refined based on this feedback.

Results

Stakeholders in EM residency training endorsed a final revised list of 22 EPAs. Stakeholder focus groups highlighted two main thematic considerations that helped shape the finalized list of EM EPAs: attention to the meaningful nuances of EPA language and contextualizing the EPAs and viewing them developmentally.

Conclusions

To foreground all key stakeholders within the EPA process for EM, the authors chose within the development process to draft; come to consensus; and refine EPAs for EM in collaboration with relevant faculty, patient, and resident stakeholders. Each stakeholder group contributed meaningfully to the content and intended implementation of the EPAs. This process may serve as a model for others in developing stakeholder-responsive EPAs.

Multi-stakeholder validation of entrustable professional activities for a family medicine care of the elderly residency program: A focus group study

Entrustable Professional Activities (EPAs) have become widely used within Competency-Based Medical Education (CBME) for the training and evaluation of residents. Little is known about the effectiveness of incorporating multiple stakeholder groups in the validation of EPAs. Here, we seek to validate an EPA framework developed for the University of Manitoba Care of the Elderly Enhanced Skills program using online focus groups consisting of five stakeholder groups. Participants were recruited to take part in one of five online focus groups, one for each stakeholder group (physician faculty, residents, non-physician healthcare professionals, administrators/managers, and patients). Each group met one time for 90 minutes over ZOOM®. The themes arising from stakeholder feedback suggest that successful EPAs must neither be too specific nor too expansive in scope, clearly delineate appropriate means of evaluation, and indicate specific clinical settings in which each EPA should be evaluated. Cross-cutting themes included requiring trainees to collaborate with other professionals when it would optimize patient care, and preparing trainees to advocate for their patients' health (Advocacy). The present study demonstrates that multi-stakeholder analysis yields diverse feedback that can help make EPAs more clear, easier to use in evaluation, and more socially accountable.

Family-Educator Partnership in the Development of Entrustable Professional Activities in Complex Care

PROBLEM

Incorporating patient and family voices in the development of entrustable professional activities (EPAs) is not standard practice. Care of children with medical complexity (CMC) is an area of pediatrics that relies on family partnership, and families of CMC are ideal partners in EPA development given their expertise in their child's care and experience interacting with the health care system. The authors describe their model for partnering with families to develop EPAs and reflect on the unique contributions of family leaders to the process.

APPROACH

After recruitment of family leaders from a national organization of families and friends of children with special health care needs, the authors used a multistage process for EPA development from June 2019 to February 2021. Family leaders were integrated throughout the process, including creating EPA descriptions, revising content across all EPAs, appraising EPAs through virtual focus groups with other key stakeholders, and finalizing and publishing EPAs. The authors used content analysis to identify recommendations for patient- and family-integrated EPA development.

OUTCOMES

Family leaders and educators partnered in every phase of developing EPAs for the care of CMC, including as content experts, editors, focus group facilitators, and coauthors. Family leaders recommended substantive changes to all EPAs, including revising language, augmenting content, and modifying scope of practice. In addition, content analysis of family leaders' revisions yielded 10 recommendations to ensure that written EPA descriptions are patient- and family-centered.

NEXT STEPS

The described process of EPA development for the care of CMC models how families can be integrated into competency framework development and highlights their contributions. Family leader recommendations for embedding patient and family voices in EPA descriptions can serve as a guide for EPA development in other specialties.

Entrustable professional activities in dental education: a scoping review

Background Competency-based education has led to the introduction of entrustable professional activities (EPAs) in health sciences education. EPAs are assessment tools that serve to certify a trainee's preparedness to conduct a given clinical activity. Objective Given its modest introduction into dental education, we sought to examine the current situation of EPAs in our field and identify possible barriers and facilitators. This review aimed to summarise evidence about EPA introduction in dental education programmes.Data sources A review of articles published between January 2005 and December 2021 was conducted using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews methodology in three databases (PubMed, Cochrane and Embase).Data selection Keywords were 'entrustable professional activity' OR 'entrustable professional activities' AND 'dentistry' OR 'dental education'.Data extraction Eligibility criteria targeted papers published in English describing dental education EPA.Data synthesis Ten publications were selected: six reported on new EPAs, three discussed their relevance for dental education and one article described a process for developing validated EPAs. EPAs focused on clinical examination, health promotion, treatment planning, pain and/or anxiety control and topics related to a specific discipline or care procedures.Conclusion Topics covered by EPAs described in our study adequately reflect the specificities of today's dental professional. The benefits of EPAs will ensure tomorrow's dentists consistently meet societal expectations.

Defining the observable processes of patient care related to social determinants of health

INTRODUCTION

An understanding of social determinants of health (SDH) and patients' social circumstances is recommended to deliver contextualised care. However, the processes of patient care related to SDH in clinical settings have not been described in detail. Observable practice activities (OPAs) are a collection of learning objectives and activities that must be observed in daily practice and can be used to describe the precise processes for professionals to follow in specific situations (process OPA.) METHODS: We used a modified Delphi technique to generate expert consensus about the process OPA for patient care related to SDH in primary care settings. To reflect the opinions of various stakeholders, the expert panel comprised clinical professionals (physicians, nurses, public health nurses, social workers, pharmacists and medical clerks), residents, medical students, researchers (medical education, health care, sociology of marginalised people), support members for marginalised people and patients. The Delphi rounds were conducted online. In Round 1, a list of potentially important steps in the processes of care was distributed to panellists. The list was modified, and one new step was added. In Round 2, all steps were acknowledged with few modifications.

RESULTS

Of 63 experts recruited, 61 participated, and all participants completed the Delphi rounds. A total of 14 observable steps were identified, which were divided into four components: communication, practice, maintenance and advocacy. The importance of ongoing patient-physician relationships and collaboration with professionals and stakeholders was emphasised for the whole process of care.

DISCUSSION

This study presents the consensus of a variety of experts on the process OPA for patient care related to SDHs. Further research is warranted to investigate how this Communication-Practice-Maintenance-Advocacy framework could affect medical education, quality of patient care, and patient outcomes.

"Listen to me, learn from me": a priority setting partnership for shaping interdisciplinary pain training to strengthen chronic pain care

ABSTRACT

What are the care-seeking priorities of people living with chronic pain and carers and how can these shape interdisciplinary workforce training to improve high-value pain care? Phase 1: Australian people living with chronic pain (n = 206; 90% female) and carers (n = 10; 40% female) described their pain care priorities (eDelphi, round 1). A coding framework was inductively derived from 842 pain care priorities (9 categories, 52 priorities), including validation; communication; multidisciplinary approaches; holistic care; partnerships; practitioner knowledge; self-management; medicines; and diagnosis. Phase 2: In eDelphi round 2, panellists (n = 170; valid responses) rated the importance (1 = less important; 9 = more important) of the represented framework. In parallel, cross-discipline health professionals (n = 267; 75% female) rated the importance of these same priorities. Applying the RAND-UCLA method (panel medians: 1-3: "not important," 4-6: "equivocal," or 7-9: "important"), "important" items were retained where the panel median score was >7 with panel agreement ≥70%, with 44 items (84.6%) retained. Specific workforce training targets included the following: empathic validation; effective, respectful, safe communication; and ensuring genuine partnerships in coplanning personalised care. Panellists and health professionals agreed or strongly agreed (95.7% and 95.2%, respectively) that this framework meaningfully reflected the importance in care seeking for pain. More than 74% of health professionals were fairly or extremely confident in their ability to support care priorities for 6 of 9 categories (66.7%). Phase 3: An interdisciplinary panel (n = 5) mapped an existing foundation-level workforce training program against the framework, identifying gaps and training targets. Recommendations were determined for framework adoption to genuinely shape, from a partnership perspective, Australian interdisciplinary pain training.

Does patient and public involvement influence the development of competency frameworks for the health professions? A systematic review

Competency frameworks typically describe the perceived knowledge, skills, attitudes and other characteristics required for a health professional to practice safely and effectively. Patient and public involvement in the development of competency frameworks is uncommon despite delivery of person-centered care being a defining feature of a competent health professional. This systematic review aimed to determine how patients and the public are involved in the development of competency frameworks for health professions, and whether their involvement influenced the outcome of the competency frameworks. Studies were identified from six electronic databases (MEDLINE, CINAHL, PsycINFO, EMBASE, Web of Science and ERIC). The database search yielded a total of 8,222 citations, and 43 articles were included for data extraction. Most studies were from the United Kingdom (27%) and developed through multidisciplinary collaborations involving two or more professions (40%). There was a large variation in the number of patients and members of the public recruited (range 1–1,398); recruitment sources included patients and carers with the clinical condition of interest (30%) or established consumer representative groups (22%). Common stages for involving patients and the public were in generation of competency statements (57%) or reviewing the draft competency framework (57%). Only ten studies (27%) took a collaborative approach to the engagement of patients and public in competency framework development. The main ways in which involvement influenced the competency framework were validation of health professional-derived competency statements, provision of desirable behaviors and attitudes and generation of additional competency statements. Overall, there was a lack of reporting regarding the details and outcome of patient and public involvement. Further research is required to optimize approaches to patient and public involvement in competency framework development including guidance regarding who, how, when and for what purposes they should be engaged and the requirements for reporting.

An Entrustable Professional Activity Addressing Racism and Pediatric Health Inequities

Racism and discrimination are the root of many pediatric health inequities and are well described in the literature. Despite the pervasiveness of pediatric health inequities, we have failed to adequately educate and prepare general pediatricians and pediatric subspecialists to address them. Deficiencies within education across the entire continuum and in our health care systems as a whole contribute to health inequities in unacceptable ways. To address these deficiencies, the field of pediatrics, along with other specialties, has been on a journey toward a more competency-based approach to education and assessment, and the framework created for the future is built on entrustable professional activities (EPAs). Competency-based medical education is one approach to addressing the deficiencies within graduate medical education and across the continuum by allowing educators to focus on the desired equitable patient outcomes and then develop an approach to teaching and assessing the tasks, knowledge, skills, and attitudes needed to achieve the goal of optimal, equitable patient care. To that end, we describe the development and content of a revised EPA entitled: Use of Population Health Strategies and Quality Improvement Methods to Promote Health and Address Racism, Discrimination, and Other Contributors to Inequities Among Pediatric Populations. We also highlight the ways in which this EPA can be used to inform curricula, assessments, professional development, organizational systems, and culture change.

Entrustable Professional Activities for Small-Group Facilitation: A Validation Study Using Modified Delphi Technique

:

Entrustable professional activities (EPAs) provide a novel approach to support teachers' structured professionalization and to assess improvement in teaching competence thereafter. Despite their novelty, it is important to assess EPAs as a construct to ensure that they accurately reflect the work of the targeted profession.

BACKGROUND:

The co-creation of an EPA framework for training and entrustment of small-group facilitators has been discussed in the literature. Although a rigorous design process was used to develop the framework, its content validity has not been established yet.Approach: A modified Delphi technique was used. Three survey rounds were conducted from December 2019 to April 2020. Expert health professions educationalists were recruited using purposive sampling and snowball techniques. In Round 1, a rubric consisting of seven items was used to assess the quality of nine pre-designed EPAs. In Round 2, competencies required to perform the agreed-upon EPAs were selected from 12 competencies provided. In Round 3, consensus was sought on sub-activities recommended for agreed-upon EPAs. Quantitative data were analyzed using multiple statistical analyses, including item-wise and rubric-wise content validity indices, asymmetric confidence interval, mean, standard deviation, and response frequencies. Qualitative data were thematically analyzed using content analysis.

FINDINGS:

Three of the nine proposed EPAs achieved statistical consensus for retention. These EPAs were: (1) preparing an activity, (2) facilitating a small-group session, and (3) reflecting upon self and the session. Nine of the 12 pre-determined competencies achieved consensus and were then mapped against each agreed-upon EPA based on their relevance. Finally, results indicated consensus on five, six, and four sub-activities for EPA 1, EPA 2, and EPA 3, respectively.

CONCLUSIONS:

The final framework delineates three EPAs for small-group facilitation and their associated sub-activities. The full description of each EPA provided in this article includes the title, context, task specification, required competencies, and entrustment resources. Program developers, administrative bodies, and teaching staff may find this EPA framework useful to structure faculty development, to entrust teachers, and to support personal development.

A patient expectations questionnaire for determining criteria for entrustment decisions

INTRODUCTION

To train health professionals for patient-centered care, patient engagement in medical curriculum development and assessment is widely recommended. But there are few published methods on how to consult with patients effectively, particularly when creating entrustable professional activities (EPAs). In this mixed-method study, we developed a questionnaire for facilitating patient input when developing EPA assessment criteria.

METHODS

We developed a questionnaire for documenting patient expectations of their doctors which included: patient interviews to identify questionnaire items, expert validation, cognitive interviews with respondents, and finally, pilot testing. For the pilot testing, 87 participants with a variety of health problems from medical/surgical wards and outpatient clinics at a tertiary hospital were recruited. The final questionnaire included open-ended and ranking-style questions.

RESULTS

Using the questionnaire, patients could identify their key expectations of their doctors when managing their current medical problem. Most patients wrote clear, brief free-text responses directly applicable to EPA descriptors that were time-efficient to analyze.

CONCLUSIONS

The questionnaire is a feasible method of recording patient expectations, enabling educators to consult with and include patient perspectives when developing criteria for entrustment decisions in a diverse range of clinical contexts.

Distant and Hidden Figures: Foregrounding Patients in the Development, Content, and Implementation of Entrustable Professional Activities

Entrustable professional activities (EPAs) describe activities that qualified professionals must be able to perform to deliver safe and effective care to patients. The entrustable aspect of EPAs can be used to assess learners through documentation of entrustment decisions, while the professional activity aspect can be used to map curricula. When used as an assessment framework, the entrustment decisions reflect supervisory judgments that combine trainees' relational autonomy and patient safety considerations. Thus, the design of EPAs incorporates the supervisor, trainee, and patient in a way that uniquely offers a link between educational outcomes and patient outcomes. However, achieving a patient-centered approach to education amidst both curricular and assessment obligations, educational and patient outcomes, and a supervisor-trainee-patient triad is not simple nor guaranteed. As medical educators continue to advance EPAs as part of their approach to competency-based medical education, the authors share a critical discussion of how patients are currently positioned in EPAs. In this article, the authors examine EPAs and discuss how their development, content, and implementation can result in emphasizing the trainee and/or supervisor while unintentionally distancing or hiding the patient. They consider creative possibilities for how EPAs might better integrate the patient as finding ways to better foreground the patient in EPAs holds promise for aligning educational outcomes and patient outcomes.

Entrustable Professional Activities and Entrustment Decision Making: A Development and Research Agenda for the Next Decade

To establish a research and development agenda for Entrustable Professional Activities (EPAs) for the coming decade, the authors, all active in this area of investigation, reviewed recent research papers, seeking recommendations for future research. They pooled their knowledge and experience to identify 3 levels of potential research and development: the micro level of learning and teaching; the meso level of institutions, programs, and specialty domains; and the macro level of regional, national, and international dynamics. Within these levels, the authors categorized their recommendations for research and development. The authors identified 14 discrete themes, each including multiple questions or issues for potential exploration, that range from foundational and conceptual to practical. Much research to date has focused on a variety of issues regarding development and early implementation of EPAs. Future research should focus on large-scale implementation of EPAs to support competency-based medical education (CBME) and on its consequences at the 3 levels. In addition, emerging from the implementation phase, the authors call for rigorous studies focusing on conceptual issues. These issues include the nature of entrustment decisions and their relationship with education and learner progress and the use of EPAs across boundaries of training phases, disciplines and professions, including continuing professional development. International studies evaluating the value of EPAs across countries are another important consideration. Future studies should also remain alert for unintended consequences of the use of EPAs. EPAs were conceptualized to support CBME in its endeavor to improve outcomes of education and patient care, prompting creation of this agenda.

Understanding Patient Expectations of Health Care: A Qualitative Study

Understanding and measuring patient expectations of health care is central to improving patient satisfaction and delivering patient-centered care. However, most empiric research in this field has focused on measuring patient expectations for specific diseases only. Patient expectations common to a variety of settings and clinical contexts need to be better understood to design measures with wider utility. We aimed to understand how patients express and conceptualize their expectations of health care across a range of clinical contexts and conditions. Semi-structured interviews were conducted with patients presenting to a major metropolitan hospital, informed by interpretive phenomenological analysis. Sampling continued until thematic saturation. Interview topics explored the illness experience, interactions with clinicians, how patients communicated and conceptualized their expectations of health care, and the nature of these expectations. The 26 participants conceptualized and described their expectations in 3 distinct domains: (1) health outcomes, (2) individual clinicians, and (3) the health-care system. Importantly, these domains were consistent across a variety of clinical contexts, participant demographics, and medical conditions. Despite variation in expectations due to individual patient circumstances, we identified 3 conceptual domains within which expectations consistently lie. When designing measurement tools for patient expectations, we suggest incorporating questions specifically addressing the 3 domains we have identified. With such measures, clinicians and health-care providers can be empowered to provide and monitor patient-centered care with outcomes tailored to what patients desire.

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.

Embracing Multiple Stakeholder Perspectives in Defining Trainee Competence

PURPOSE

To explore how multiple stakeholder groups contribute to the understanding of trainee competence.

METHOD

The authors conducted a constructivist qualitative study in 2015 using focus group discussions to explore the perceptions of different stakeholder groups (patients, nurses/nurse practitioners, supervisors/senior physicians, leaders/administrators, trainees) regarding trainee competence in the emergency department. The authors used a conventional content analysis, a comparative analysis of supervisors'/senior physicians' versus other stakeholders' perspectives, and a directed analysis informed by stakeholder theory to analyze the focus group transcripts.

RESULTS

Forty-six individuals participated in nine focus groups. Four categories of competence were identified: Core Clinical Activities, Patient Centeredness, Aligning Resources, and Code of Conduct. Stakeholders generally agreed in their overall expectations regarding trainee competence. Within individual categories, each stakeholder group identified new considerations, details, and conflicts, which were a replication, elaboration, or complication of a previously identified theme. All stakeholders stressed those aspects of trainee competence that were relevant to their work or values. Trainees were less aware of the patient perspective than that of the other stakeholder groups.

CONCLUSIONS

Considering multiple stakeholder perspectives enriched the description and conceptualization of trainee competence. It also can inform the development of curricula and assessment tools and guide learning about inter- and intradisciplinary conflicts. Further research should explore how trainees' perceptions of value are influenced by their organizational context and, in particular, how trainees adapt their learning goals in response to the divergent demands of key stakeholders.

A systematic review of 7 years of research on entrustable professional activities in graduate medical education, 2011-2018

PURPOSE

This review aimed to synthesise some of the extant work on the use of entrustable professional activities (EPAs) for postgraduate physicians, to assess the quality of the work and provide direction for future research and practice.

METHOD

Systematic searches were conducted within five electronic databases (Medline, Scopus, Web of Science, PsycINFO and CINAHL) in September 2018. Reference lists, Google Scholar and Google were also searched. Methodological quality was assessed using the Quality Assessment Tool for Studies with Diverse Designs (QATSDD).

RESULTS

In total, 49 studies were included, classified as Development of EPAs (n = 37; 76% of total included), Implementation and/or assessment of EPAs (n = 10; 20%), or both (n = 2; 4%). EPAs were described for numerous specialties, including internal medicine (n = 14; 36%), paediatrics (n = 8; 21%) and psychiatry (n = 4; 10%). Of the development studies, 92% utilised more than one method to generate EPAs. The two most commonly used methods were developing initial EPAs in a working group, (n = 27; 69%) and revising through deliberation (n = 21; 54%). Development papers were of variable quality (mean QATSDD score = 20, range 6-41). Implementation and assessment studies utilised methods that included observing trainee performance (n = 6; 50%) and enrolling trainees in competency-based curricula, which included EPAs (n = 4; 33%). The methodological quality of these implementation studies varied (mean QATSDD score = 19.5, range = 6-32).

CONCLUSIONS

This review highlighted a need for: (i) consideration of best practice guidelines for EPA development; (ii) focus on the methodological quality of research on EPA development and of EPAs, and (iii) further work investigating the implementation of EPAs in the curriculum.

An entrustable professional activity descriptor for medical aid in dying: a mixed-methods study

BACKGROUND

In jurisdictions where medical aid in dying (MAiD) is legal, there is an obligation to ensure the competence of those who assess eligibility and provide MAiD to patients. Entrustable professional activities (EPAs) are one framework for incorporating competency-based training and assessment into the workplace, so we convened a group of experienced MAiD providers to develop an EPA descriptor for MAiD.

METHODS

We performed a mixed-methods sequential qualitative (focus group via 2 teleconferences) and quantitative (survey) study to generate and refine a consensus descriptor using open coding followed by a modified Delphi approach. Participants were experienced MAiD assessors and providers identified purposively from a national community of practice in Canada.

RESULTS

Of the 22 MAiD assessors and providers invited to participate in the focus group, 13 (59%) agreed. The focus group divided MAiD into 3 components: assessment, preparation and provision of MAiD. Participants identified key knowledge, skills and attitudes for each component. They also suggested teaching approaches, potential sources of information to evaluate progress and a potential basis for evaluating progress and entrustment. Key points from this descriptor were sent via survey to 88 assessors and providers, of whom 64 (73%) responded. Respondents agreed on all key points except for the conditions of entrustment; these were modified based on feedback and sent back to the respondents for a second Delphi round, where agreement was achieved.

INTERPRETATION

We achieved a high degree of agreement on a competency-based descriptor of MAiD in the form of an EPA. This can be used to inform practice standards, curriculum development and/or assessment of competence among learners and practising providers alike.