Building Trust in Entrustment: Pursuing Evidence-Based Progress in the Core Entrustable Professional Activities for Entering Residency

Entrustable Professional Activity-Based Summative Performance Assessment in the Surgery Clerkship

OBJECTIVE

The objectives of this study were to 1) assess the performance Entrustable Professional Activities (EPAs) when integrated into the summative assessment of third-year medical students on the surgery clerkship and 2) to compare EPAs to traditional clinical performance assessment tools.

DESIGN

EPA assessments were collected prospectively from a minimum of 4 evaluators at the completion of each surgical clerkship rotation from November 2019 to June 2019. Overall EPA-based clinical performance scores were calculated as the sum of the mean EPA score from each evaluator. A rating of overall clinical performance called the clinical performance appraisal (CPA) was also collected. EPA ratings were compared to the CPA score, National Board of Medical Examiners exam score, objective structured clinical exam scores, and final clerkship grade.

SETTING

Northwestern Memorial Hospital, a tertiary care teaching institution in Chicago, IL.

RESULTS

Overall, 446 evaluations (111 students) were included in the analysis. The aggregate EPA scores ranged from 11.6-24.0 (mean 19.9 ± 2.0), and the CPA scores ranged from 4.4-9.0 (mean 7.6 ± 0.7). The variance among learners in EPA scores was significantly higher than CPA scores (p < 0.001). The aggregate EPA scores correlated well with CPA scores (Spearman's rho 0.803) but had lesser, positive correlations with the objective structured clinical exam (rho 0.153) and National Board of Medical Examiners (rho 0.265) scores. When all EPA scores were included in ordinal logistic regression, only EPA 6, oral presentation of patients, was independently associated with students' final grades (OR: 10.05, 95%CI 1.41-71.80; p = 0.02).

CONCLUSION

Integration of EPAs for use in clinical performance assessment of medical students is feasible within a surgery clerkship. Compared to a global clinical performance assessment, EPA-based assessment provided better discrimination of clinical performance among learners. Use of EPAs may better identify advanced learners and those that need additional time.

EQual Rubric Evaluation of the Association of American Medical Colleges' Core Entrustable Professional Activities for Entering Residency

PURPOSE

To have subject matter experts evaluate the Core Entrustable Professional Activities for Entering Residency (Core EPAs) with the EQual rubric to determine if revisions were required and, if applicable, how to focus revision efforts.

METHOD

Ten entrustable professional activity (EPA) experts were invited to evaluate the 13 Core EPAs. Experts had a 6-month window (December 2018-May 2019) to complete the evaluation, which contained the complete EQual rubric and 3 additional prompts, one of which-"Do you think this EPA requires revision?"-was limited to a "yes/no" response. Descriptive statistics for overall and domain-specific EQual rubric scores for each of the 13 Core EPAs were calculated. Free-text responses to why and/or how a Core EPA should be revised were summarized for any Core EPA that scored below a cutoff or for which the majority of experts recommended revision.

RESULTS

Six experts completed the evaluation. Most Core EPAs' (9/13) overall score was above the cutoff, indicating that they align with the key domains of the EPA construct. The remaining 4 Core EPAs (2, 7, 9, and 13) scored below the overall cutoff, suggesting that they may require revision. A majority of experts felt that Core EPAs 6, 7, 9, and 13 required revision. With regard to domain-specific scores, Core EPAs 2, 3, 7, 9, and 13 were below the discrete units of work cutoff; Core EPAs 7, 9, and 13 were below the entrustable, essential, and important tasks of the profession of medicine cutoff; and Core EPA 9 was below the curricular role cutoff.

CONCLUSIONS

The Core EPAs represent a promising initial framework of EPAs for undergraduate medical education. Some Core EPAs might benefit from revision. The process of improving the Core EPAs must continue if they are to standardize outcomes for medical school graduates.

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.