Assessing Trainees and Making Entrustment Decisions: On the Nature and Use of Entrustment-Supervision Scales

Associations Between Residency Program Size and Readiness for Unsupervised Practice in Pediatrics

OBJECTIVE

This study sought to determine differences in program-reported entrustable professional activity (EPA) entrustment-supervision levels based on residency program size.

METHODS

At the end of the 2021 to 2022, 2022 to 2023, and 2023 to 2024 academic years, entrustment-supervision levels for the 17 General Pediatrics EPAs were determined by clinical competency committees for graduating pediatric residents at 48 pediatrics residency programs. Programs were categorized as small, medium, large, and very large. The authors fitted a main-effects mixed-effects logistic regression model to predict the likelihood that a graduating resident was deemed ready to execute each EPA without supervision, with program size and EPA as fixed effects and program as a random effect. A second model also included the interaction between program size and EPA as a predictor.

RESULTS

A total of 33,335 entrustment-supervision levels were reported for 2285 graduating pediatrics residents. Small programs were more likely to report residents as ready for unsupervised practice than multiple larger-sized program groups for 4 EPAs (health screening, well newborn, recognize/refer surgical problems, and manage information).

CONCLUSIONS

Characteristics of small programs may lead them to be more likely to entrust graduating residents with unsupervised practice in certain areas.

Fixing disconnects: Exploring the emergence of principled adaptations in a competency-based curriculum

PURPOSE

Competency-based medical education (CBME) promises to improve medical education through curricular reforms to support learner development. This intention may be at risk in the case of a Canadian approach to CBME called Competence by Design (CBD), since there have been negative impacts on residents. According to Joseph Schwab, teachers, learners and milieu must be included in the process of curriculum-making to prevent misalignments between intended values and practice. This study considered what can be learned from the process of designing, enacting and adapting CBD to better support learners.

METHODS

This qualitative study explored the making of CBD through the perspectives of implementation leads (N = 18) at national, institutional and programme levels. A sociomaterial orientation to agency in curriculum-making guided the inductive approach to interviewing and analysis in phase one. A deductive analysis in phase two applied Schwab's theory to further understand sources of misalignments and the purpose of adaptive responses.

RESULTS

Misalignments occurred when the needs of teachers, learners and milieu were initially underestimated in the process of curriculum-making, disconnecting assessment practices from experiences of teaching, learning and entrustment. While technical and structural issues posed significant constraints on agency, some implementation leads were able to make changes to the curriculum or context to fix the disconnects. We identified six purposes for principled adaptations to align with CBME values of responsive teaching, individualised learning and meaningful entrustment.

CONCLUSION

Collectively, the adaptations we characterise demonstrate constructive alignment, a foundational principle of CBME in which assessment and teaching work together to support learning. This study proposes a model for making context-shaped, values-based adaptations to CBME to achieve its promise.

Factors influencing the incorporation of Entrustable Professional Activities into assessment in nutrition and dietetics education: A systematic review

AIMS

This study aimed to identify and synthesise the evidence on factors influencing the incorporation of Entrustable Professional Activities into assessment in nutrition and dietetics education.

METHODS

A systematic review was conducted with a narrative synthesis and was undertaken and reported in accordance with the PRISMA guidelines. Six electronic databases were searched (MEDLINE, CINAHL, SCOPUS, PsycINFO, Web of Science, and EMBASE) on 9 September 2024. Methodological quality was assessed using the Critical Appraisal Skills Program checklists. Key patterns identified from the narrative synthesis of the included manuscripts were labelled as themes and represented in a figure.

RESULTS

Across the international literature, six articles were identified revealing six main and interconnected themes related to factors influencing the incorporation of Entrustable Professional Activities in nutrition and dietetics. In summary, development and review processes for Entrustable Professional Activities require key stakeholder engagement in addition to ensuring they are linked to assessment structures and existing frameworks. Furthermore, technology platforms and applications appeared to support Entrustable Professional Activity incorporation, and training is an important part of integration.

CONCLUSIONS

Further research on factors influencing incorporation is occurring and is suggested to continue, especially given Entrustable Professional Activities seemingly offer a tangible option to simplify the intricacy of competency-based assessment in work-based practice. However, further research to enhance understanding of whether Entrustable Professional Activities support nutrition and dietetics learners and assessors in undertaking high-quality assessment with utility is warranted.

Entrustment and EPAs for Artificial Intelligence (AI): A Framework to Safeguard the Use of AI in Health Professions Education

ABSTRACT

In this article, the authors propose a repurposing of the concept of entrustment to help guide the use of artificial intelligence (AI) in health professions education (HPE). Entrustment can help identify and mitigate the risks of incorporating generative AI tools with limited transparency about their accuracy, source material, and disclosure of bias into HPE practice. With AI's growing role in education-related activities, like automated medical school application screening and feedback quality and content appraisal, there is a critical need for a trust-based approach to ensure these technologies are beneficial and safe. Drawing parallels with HPE's entrustment concept, which assesses a trainee's readiness to perform clinical tasks-or entrustable professional activities-the authors propose assessing the trustworthiness of AI tools to perform an HPE-related task across 3 characteristics: ability (competence to perform tasks accurately), integrity (transparency and honesty), and benevolence (alignment with ethical principles). The authors draw on existing theories of entrustment decision-making to envision a structured way to decide on AI's role and level of engagement in HPE-related tasks, including proposing an AI-specific entrustment scale. Identifying tasks that AI could be entrusted with provides a focus around which considerations of trustworthiness and entrustment decision-making may be synthesized, making explicit the risks associated with AI use and identifying strategies to mitigate these risks. Responsible, trustworthy, and ethical use of AI requires health professions educators to develop safeguards for using it in teaching, learning, and practice-guardrails that can be operationalized via applying the entrustment concept to AI. Without such safeguards, HPE practice stands to be shaped by the oncoming wave of AI innovations tied to commercial motivations, rather than modeled after HPE principles-principles rooted in the trust and transparency that are built together with trainees and patients.

Senior Year Clinical Trainees' Perceptions of a Clinical Entrustment Scale in an Academic Veterinary Medical Center

Researchers explored senior/clinical year veterinary trainees' perceptions of the Goal Oriented Learner Driven-Entrustment (GOLD-E) scale. Researchers recruited trainees from on-campus clinical service rotations to explore the following questions: 1) How do trainees regard the feedback the GOLD-E tool provides? 2) How do trainees enter into the clinical feedback relationship? 3) How does the GOLD-E tool create opportunities for trainees to engage authentically with themselves and with clinical coaches (i.e., clinicians, technicians, interns, and house officers)? Clinical year trainees completed the GOLD-E form with clinical coaches during the 2018-2019 academic year. Data collection included both quantitative and qualitative methods using bi-weekly surveys and focus groups. Findings point to the need for: Thoughtful integration of feedback and coaching when assessing practice using EPAs; better understanding of the role coaches play in the everyday expectations and practices of learning to become a practicing veterinarian; and realization of trainees' uncertainty concerning their role in the coaching relationship, the learning process, and when asking for feedback. These findings connect with the first paper in this series and further emphasize that culture change requires significant time and effort. Moreover, there needs to be careful consideration of organizational structures to effectively implement change.

Competency-Based Cultural Safety Training in Medical Education at La Sabana University, Colombia: A Roadmap of Curricular Modernization

Issue: Cultural safety enhances equitable communication between health care providers and cultural groups. Most documented cultural safety training initiatives focus on Indigenous populations from high-income countries, and nursing students, with little research activity reported from low- and middle-income countries. Several cultural safety training initiatives have been described, but a modern competency-based cultural safety curriculum is needed. Evidence: In this article, we present the Competency-Based Education and Entrustable Professional Activities frameworks of the Faculty of Medicine at La Sabana University in Colombia, and illustrate how this informed modernization of medical education. We describe our co-designed cultural safety training learning objectives and summarize how we explored its impact on medical education through mixed-methods research. Finally, we propose five cultural safety intended learning outcomes adapted to the updated curriculum, which is based on the Competency-Based Education model. Implications: This article presents five cultural safety intended learning outcomes for undergraduate medical education. These learning outcomes are based on Competency-Based Education and the Entrustable Professional Activities framework and can be used by faculties of medicine interested in including the cultural safety approach in their curriculum.

Comparison of clinical independence level scores among predoctoral dental students between dental school clinic and community clinic rotation

OBJECTIVES

The aim of this study was to compare the difference in the level of clinical independence among predoctoral dental students during their community clinic rotation with their dental school clinic rotations.

METHODS

Descriptive statistics, assessment of sample normality, and T-tests were performed to present the difference in average independence scale scores for the participants in each of the clinical disciplines at dental school clinical rotations and community rotations. The relative impact of each community clinical site was assessed to compare scores assigned at varying locations by different faculty.

RESULTS

This study analyzed 222 dental students, including 29 from International Dental Program (IDP) and 193 traditional Doctor of Dental Surgery (DDS) students. Community clinic scores showed greater variability, with significantly higher scores in diagnostics and operative dentistry compared to school clinics, where higher scores were noted in endodontics and oral surgery. IDP students scored lower than traditional DDS students in school clinics but outperformed them in community settings. Community clinic scores showed greater variation between 2023 and 2024 compared to the smaller changes observed in dental school clinic scores.

CONCLUSIONS

This study highlights the impact of clinical setting, and duration on student procedural experience and performance, suggesting that varied clinical settings can enhance students' skills and readiness for practice. It reveals differences in DDS and IDP students' experiences due to prior training and potential evaluation biases. Study findings suggested lack of significant variance in the overall scores across different evaluators in community rotations. Future research should focus on refining evaluation metrics and better prepare students for practice.

Association Between Teaching Clinic Structure and the Readiness of Ophthalmology Residents to Enter Independent Practice

OBJECTIVE

Our objective is to determine if the structure of Graduate Medical Education teaching clinics is associated with how well ophthalmology residents are prepared to meet the workload demands of independent clinical practice.

DESIGN

Resident preparedness to enter independent practice was measured by the Readiness Index. Part of the Department of Veterans Affairs' new Workload-based Resident Academic Performance measures (WRAP), resident readiness is computed from electronic health records for residents by clinic and service-date. The index compares resident productivity net of supervision and adjusted for care quality to the average productivity of non-supervising ophthalmologists. Readiness comprises a Workload component (ratio of resident gross productivity to the average productivity of non-supervising ophthalmologists) and Supervision component (ratio of resident net of supervision to gross productivity). Teaching clinic factors include resident postgraduate-year level, resident-to-physician staff ratios, patient care complexity, and program size. Covariates include time into the academic year, facility quality ranking and complexity rating, and attending physician productivity rate.

SETTING

Study setting is 109 ophthalmology outpatient clinics from the United States Department of Veterans Affairs and its 1,300 annual ophthalmology resident positions rotating on 84,600 ophthalmology clinic-days during academic years from July 1, 2015, through June 30, 2019.

PARTICIPANTS

An average 2.6 residents at a second-year or higher saw 25.0 patients requiring 93.6 relative value units (RVUs) of workload.

RESULTS

Senior ophthalmology residents from clinics with higher resident-to-physician ratios had greater practice readiness than their counterparts primarily from having greater progressive autonomy from supervision. Residents from larger programs treating more complex patients had only slightly greater practice readiness than their counterparts primarily from having greater workload productivity.

CONCLUSIONS

The readiness of ophthalmology residents to enter independent practice is associated with their academic level and resident-to-physician staff ratios, and to a lesser extent care complexity and program size.

Exploring the Utility of a Novel Approach of Evaluating Application of a Validated Violence Risk Assessment Instrument

Mental health nurses are often responsible for assessment/management of inpatient aggression. Validated instruments such as the Dynamic Appraisal of Situational Aggression (DASA), can aid risk assessment. However, limited attention has been paid to evaluating nurses' ability to administer risk assessment instruments. An entrustable professional activity may offer way of evaluating risk assessment clinical activities. DASA trainers' perceptions of the value and utility of an EPA were explored via collection of data through focus groups, with 17 participants from six countries. Thematic analysis was conducted to analyze the data. Three themes were interpreted: (1) DASA trainers-a way of knowing and being (2) An EPA-something you did not know you need until you see it; (3) The DASA-EPA supports the need for training and importance of integrity in assessment. Trainers engaged in innovative ways to ensure training is suitable and responsive to needs of nurses and their setting. Participants understood how an EPA could be used to evaluate DASA administration, monitor DASA use, provide feedback, and highlight the importance of training to ensure best practice.

There is no "too small" for frequent workplace-based assessment: Differences between large and small residency programs in anesthesia when using a mobile application to assess EPAs

Background

A competency-based education approach calls for frequent workplace-based assessments (WBA) of Entrustable Professional Activities (EPAs). While mobile applications increase the efficiency, it is not known how many assessments are required for reliable ratings and whether the concept can be implemented in all sizes of residency programs.

Methods

Over 5 months, a mobile app was used to assess 10 different EPAs in daily clinical routine in Swiss anesthesia departments. The data from large residency programs was compared to those from smaller ones. We applied generalizability theory and decision studies to estimate the minimum number of assessments needed for reliable assessments.

Results

From 28 residency programs, we included 3936 assessments by 306 supervisors for 295 residents. The median number of assessments per trainee was 8, with a median of 4 different EPAs assessed by 3 different supervisors. We found no statistically significant differences between large and small programs in the number of assessments per trainee, per supervisor, per EPA, the agreement between supervisors and trainees, and the number of feedback processes stimulated. The average "level of supervision" (LoS, scale from 1 to 5) recorded in larger programs was 3.2 (SD 0.5) compared to 2.7 (SD 0.4) (p<0.05). To achieve a g-coefficient >0.7, at least a random set of 3 different EPAs needed to be assessed, with each EPA rated at least 4 times by 4 different supervisors, resulting in a total of 12 assessments.

Conclusion

Frequent WBAs of EPAs were feasible in large and small residency programs. We found no significant differences in the number of assessments performed. The minimum number of assessments required for a g-coefficient >0.7 was attainable in large and small residency programs.

Assessing supervisor versus trainee viewpoints of entrustment through cognitive and affective lenses: an artificial intelligence investigation of bias in feedback

The entrustment framework redirects assessment from considering only trainees' competence to decision-making about their readiness to perform clinical tasks independently. Since trainees and supervisors both contribute to entrustment decisions, we examined the cognitive and affective factors that underly their negotiation of trust, and whether trainee demographic characteristics may bias them. Using a document analysis approach, we adapted large language models (LLMs) to examine feedback dialogs (N = 24,187, each with an associated entrustment rating) between medical student trainees and their clinical supervisors. We compared how trainees and supervisors differentially documented feedback dialogs about similar tasks by identifying qualitative themes and quantitatively assessing their correlation with entrustment ratings. Supervisors' themes predominantly reflected skills related to patient presentations, while trainees' themes were broader-including clinical performance and personal qualities. To examine affect, we trained an LLM to measure feedback sentiment. On average, trainees used more negative language (5.3% lower probability of positive sentiment, p < 0.05) compared to supervisors, while documenting higher entrustment ratings (+ 0.08 on a 1-4 scale, p < 0.05). We also found biases tied to demographic characteristics: trainees' documentation reflected more positive sentiment in the case of male trainees (+ 1.3%, p < 0.05) and of trainees underrepresented in medicine (UIM) (+ 1.3%, p < 0.05). Entrustment ratings did not appear to reflect these biases, neither when documented by trainee nor supervisor. As such, bias appeared to influence the emotive language trainees used to document entrustment more than the degree of entrustment they experienced. Mitigating these biases is nonetheless important because they may affect trainees' assimilation into their roles and formation of trusting relationships.

For which entrustable professional activities must medical students be prepared if unsupervised patient care without further training is an expectation? An international Global South study

INTRODUCTION

Training medical students requires objectives that are often translated into frameworks of competencies. Since the introduction of entrustable professional activities (EPAs), these tasks or 'units of professional practice', originally conceived for postgraduate training, define what residents must be prepared to do unsupervised. Nowadays, EPAs are also applied to undergraduate training, with the prospect of entering residency. However, in many countries, especially in the Global South, a substantial number of medical graduates will be working in healthcare with little or no supervision and no further training soon or ever. EPAs for these conditions cannot be copied from undergraduate medical education EPA frameworks in Global North countries.

METHODS

We conducted a generative investigation to identify and elaborate EPAs for Global South countries who must train students for unsupervised general practice. We included 39 medical educators from 13 Global South countries and 17 specialties in either one of two online focus group sessions using a nominal group technique (NGT) or as Delphi panel member. Results from the two NGT sessions were merged and fed into the two-round Delphi investigation.

RESULTS

A framework of 11 EPAs resulted, each with an elaborate description (specification, setting and limitations).

CONCLUSION

This framework of undergraduate medical education Global South EPAs differs in its nature and specifications from existing Global North EPAs. The authors do not pretend universality for all Global South countries with graduates who face expectations of unsupervised practice but present it to support countries that consider introducing the model of entrustable professional activities.

Defining Nurse Practitioner Core Entrustable Professional Activities: Essential Step Toward Competency-Based Education

BACKGROUND

Gaps between educational preparation and clinical practice readiness have led to innovative approaches to competence assessment. Entrustable professional activities (EPAs) show promise as a competence assessment framework in graduate nursing education.

PURPOSE

This study sought to develop and validate a set of EPAs that reflect the core activities performed by all nurse practitioners (NPs).

METHODS

Eight EPAs were developed. A Delphi approach was used to validate the EPAs by NP practice experts located across the United States and representing most NP populations.

RESULTS

Consensus was reached after 2 Delphi rounds.

CONCLUSIONS

The EPAs developed and validated in this study map multiple advanced-level NP competencies to workplace expectations and provide a shared framework for competency-based workplace assessment among NP preceptors from varied health care professions.

Integration of Entrustable Professional Activities in a Competency-Based Clinical Assessment Tool in a Nurse Practitioner Program

BACKGROUND

Entrustable professional activities (EPAs) are used in competency-based clinical assessment.

PROBLEM

Faculty in a Family Nurse Practitioner program aimed to improve their clinical assessment tool to more effectively measure students' clinical performance, outline expectations, track progress, and document evidence related to clinical competence.

APPROACH

EPAs that aligned with the American Association of Colleges of Nursing Essentials and National Organization of Nurse Practitioner (NP) Faculties Core NP Competencies were integrated into a clinical assessment tool. Student performance expectations at different points in the program were outlined. Students documented each time they performed an EPA during clinical experiences.

OUTCOME

The EPA-based clinical assessment tool captured valuable information about student performance during clinical experiences and contributed to evidence related to competencies.

CONCLUSIONS

EPAs can be used to assess clinical performance and document evidence of competence and readiness for practice. Tracking the frequency of EPA performance was essential to ensure students had sufficient practice.

Implementation and faculty perception of outpatient medical student workplace-based assessments

BACKGROUND

There is growing interest in use of entrustable professional activity (EPA)-grounded workplace-based assessments (WBAs) to assess medical students through direct observation in the clinical setting. However, there has been very little reflection on how these tools are received by the faculty using them to deliver feedback. Faculty acceptance of WBAs is fundamentally important to sustained utilisation in the clinical setting, and understanding faculty perceptions of the WBA as an adjunct for giving targeted feedback is necessary to guide future faculty development in this area.

APPROACH

Use of a formative EPA-grounded WBA was implemented in the ambulatory setting during the paediatrics clerkship following performance-driven training and frame-of-reference training with faculty. Surveys and semi-structured interviews with faculty members explored how faculty perceived the tool and its impact on feedback delivery.

EVALUATION

Faculty reported providing more specific, task-oriented feedback following implementation of the WBA, as well as greater timeliness of feedback and greater satisfaction with opportunities to provide feedback, although these later two findings did not reach significance. Themes from the interviews reflected the benefits of WBAs, persistent barriers to the provision of feedback and suggestions for improvement of the WBA.

IMPLICATIONS

EPA-grounded WBAs are feasible to implement in the outpatient primary care setting and improve feedback delivery around core EPAs. The WBAs positively impacted the way faculty conceptualise feedback and provide learners with more actionable, behaviour-based feedback. Findings will inform modifications to the WBA and future faculty development and training to allow for sustainable WBA utilisation in the core clerkship.

How well do workplace-based assessments support summative entrustment decisions? A multi-institutional generalisability study

BACKGROUND

Assessment of the Core Entrustable Professional Activities for Entering Residency requires direct observation through workplace-based assessments (WBAs). Single-institution studies have demonstrated mixed findings regarding the reliability of WBAs developed to measure student progression towards entrustment. Factors such as faculty development, rater engagement and scale selection have been suggested to improve reliability. The purpose of this investigation was to conduct a multi-institutional generalisability study to determine the influence of specific factors on reliability of WBAs.

METHODS

The authors analysed WBA data obtained for clerkship-level students across seven institutions from 2018 to 2020. Institutions implemented a variety of strategies including selection of designated assessors, altered scales and different EPAs. Data were aggregated by these factors. Generalisability theory was then used to examine the internal structure validity evidence of the data. An unbalanced cross-classified random-effects model was used to decompose variance components. A phi coefficient of >0.7 was used as threshold for acceptable reliability.

RESULTS

Data from 53 565 WBAs were analysed, and a total of 77 generalisability studies were performed. Most data came from EPAs 1 (n = 17 118, 32%) 2 (n = 10 237, 19.1%), and 6 (n = 6000, 18.5%). Low variance attributed to the learner (<10%) was found for most (59/77, 76%) analyses, resulting in a relatively large number of observations required for reasonable reliability (range = 3 to >560, median = 60). Factors such as DA, scale or EPA were not consistently associated with improved reliability.

CONCLUSION

The results from this study describe relatively low reliability in the WBAs obtained across seven sites. Generalisability for these instruments may be less dependent on factors such as faculty development, rater engagement or scale selection. When used for formative feedback, data from these instruments may be useful. However, such instruments do not consistently provide reasonable reliability to justify their use in high-stakes summative entrustment decisions.

A realist synthesis of prospective entrustment decision making by entrustment or clinical competency committees

INTRODUCTION

The real-world mechanisms underlying prospective entrustment decision making (PEDM) by entrustment or clinical competency committees (E/CCCs) are poorly understood. To advance understanding in this area, the authors conducted a realist synthesis of the published literature to address the following research question: In E/CCC efforts to make defensible prospective entrustment decisions (PEDs), what works, for whom, under what circumstances and why?

METHODS

Realist work seeks to understand the contexts (C), mechanisms (M) and outcomes (O) that explain how and why things work (or do not). In the authors' study, contexts included individual E/CCC members, E/CCC structures and processes, and training programmes. The outcome (i.e. desired outcome) was a PED. Mechanisms were a substantial focus of the analysis and informed the core findings. To define a final corpus of 52 included papers, the authors searched four databases, screened all results from those searches and performed a full-text review of a subset of screened papers. Data extraction focused on developing context-mechanism-outcome configurations from the papers, which were used to create a theory for how PEDM leads to PEDs.

RESULTS

PEDM is often driven by default (non-deliberate) decision making rather than a deliberate process of deciding whether a trainee should be entrusted or not. When defaulting, some E/CCCs find red flags that sometimes lead to being more deliberate with decision making. E/CCCs that seek to be deliberate describe PEDM that can be effortful (when data are insufficient or incongruent) or effortless (when data are robust and tell a congruent story about a trainee). Both information about trainee trustworthiness and the sufficiency of data about trainee performance influence PEDM. Several moderators influence what is considered to be sufficient data, how trustworthiness data are viewed and how PEDM is carried out. These include perceived consequences and associated risks, E/CCC member trust propensity, E/CCC member personal knowledge of and experience with trainees and E/CCC structures and processes.

DISCUSSION

PEDM is rarely deliberate but should be. Data about trainee trustworthiness are foundational to making PEDs. Bias, equity and fairness are nearly absent from the papers in this synthesis, and future efforts must seek to advance understanding and practice regarding the roles of bias, equity and fairness in PEDM.

Trainee anaesthetist self-assessment using an entrustment scale in workplace-based assessment

The role of self-assessment in workplace-based assessment remains contested. However, anaesthesia trainees need to learn to judge the quality of their own work. Entrustment scales have facilitated a shared understanding of performance standards among supervisors by aligning assessment ratings with everyday clinical supervisory decisions. We hypothesised that if the entrustment scale similarly helped trainees in their self-assessment, there would be substantial agreement between supervisor and trainee ratings. We collected separate mini-clinical evaluation exercises forms from 113 anaesthesia trainee-supervisor pairs from three hospitals in Australia and New Zealand. We calculated the agreement between trainee and supervisor ratings using Pearson and intraclass correlation coefficients. We also tested for associations with demographic variables and examined narrative comments for factors influencing rating. We found ratings agreed in 32% of cases, with 66% of trainee ratings within one point of the supervisor rating on a nine-point scale. The correlation between trainee and supervisor ratings was 0.71, and the degree of agreement measured by the intraclass correlation coefficient was 0.67. With higher supervisor ratings, trainee ratings better correlated with supervisor ratings. We found no strong association with demographic variables. Possible explanations of divergent ratings included one party being unaware of a vital aspect of the performance and different interpretations of the prospective nature of the scale. The substantial concordance between trainee and supervisor ratings supports the contention that the entrustment scale helped produce a shared understanding of the desired performance standard. Discussion between trainees and supervisors on the reasoning underlying their respective judgements would provide further opportunities to enhance this shared understanding.

How Reliable are Single-Question Workplace-Based Assessments in Surgery?

OBJECTIVE

Workplace-based assessments (WBAs) play an important role in the assessment of surgical trainees. Because these assessment tools are utilized by a multitude of faculty, inter-rater reliability is important to consider when interpreting WBA data. Although there is evidence supporting the validity of many of these tools, inter-reliability evidence is lacking. This study aimed to evaluate the inter-rater reliability of multiple operative WBA tools utilized in general surgery residency.

DESIGN

General surgery residents and teaching faculty were recorded during 6 general surgery operations. Nine faculty raters each reviewed 6 videos and rated each resident on performance (using the Society for Improving Medical Professional Learning, or SIMPL, Performance Scale as well as the operative performance rating system (OPRS) Scale), entrustment (using the ten Cate Entrustment-Supervision Scale), and autonomy (using the Zwisch Scale). The ratings were reviewed for inter-rater reliability using percent agreement and intraclass correlations.

PARTICIPANTS

Nine faculty members viewed the videos and assigned ratings for multiple WBAs.

RESULTS

Absolute intraclass correlation coefficients for each scale ranged from 0.33 to 0.47.

CONCLUSIONS

All single-item WBA scales had low to moderate inter-rater reliability. While rater training may improve inter-rater reliability for single observations, many observations by many raters are needed to reliably assess trainee performance in the workplace.

Assessment of Entrustable Professional Activities Among Dutch Endocrine Supervisors

Entrustable Professional Activities (EPAs) are an important tool to support individualisation of medical training in a competency-based setting and are increasingly implemented in the clinical speciality training for endocrinologist. This study aims to assess interrater agreement and factors that potentially impact EPA scores. Five known factors that affect entrustment decisions in health profesions training (capability, integrity, reliability, humility, agency) were used in this study. A case-vignette study using standardised written cases. Case vignettes (n = 6) on the topics thyroid disease, pituitary disease, adrenal disease, calcium and bone disorders, diabetes mellitus, and gonadal disorders were written by two endocrinologists and a medical education expert and assessed by endocrinologists experienced in the supervision of residents in training. Primary outcome is the inter-rater agreement of entrustment decisions for endocrine EPAs among raters. Secondary outcomes included the dichotomous interrater agreement (entrusted vs. non-entrusted), and an exploration of factors that impact decision-making. The study protocol was registered and approved by the Ethical Review Board of the Netherlands Association for Medical Education (NVMO-ERB # 2020.2.5). Nine endocrinologists from six different academic regions participated. Overall, the Fleiss Kappa measure of agreement for the EPA level was 0.11 (95% CI: 0.03-0.22) and for the entrustment decision 0.24 (95% CI 0.11-0.37). Of the five features that impacted the entrustment decision, capability was ranked as the most important by a majority of raters (56%-67%) in every case. There is a considerable discrepancy between the EPA levels assigned by different raters. These findings emphasise the need to base entrustment decisions on multiple observations, made by a team of supervisors and enriched with factors other than direct medical competence.

Development and Use of the Competency-Based Veterinary Education (CBVE) Assessment Toolkit

The Competency-Based Veterinary Education (CBVE) Analyze Working Group of the American Association of Veterinary Medical Colleges (AAVMC) Council on Outcomes-based Veterinary Education (COVE) has developed a CBVE assessment toolkit. The toolkit is designed to provide curriculum committees and individual instructors with an opportune intersection of the CBVE domains of competence and various assessment techniques. College-wide curriculum committees can use the toolkit to guide programs of assessment in the larger unit, ensuring that assessment methods are aligned with intended learning outcomes throughout the curriculum. On a smaller unit basis, the toolkit allows a single instructor or team of instructors to identify domains of interest for evaluation and then to identify various assessment tools appropriate to those domains. For each of 21 different assessment tools, the toolkit provides information that includes: a description; appropriate CBVE domains and competencies; examples; documented uses; evidence of efficacy; references; and links to illustrations if available. Because the toolkit is published online, periodic updates can be made as more data become available on the efficacy of various assessment tools relative to the CBVE domains in veterinary education. From programmatic assessment to single course examinations, the toolkit is intended to assist both administrators and faculty alike in understanding how different assessment approaches can support a variety of competency domains.

Entrustment Decision Making in the Intensive Care Unit: It's About More Than the Learner

Background

The provision of graded supervision affording progressive autonomy is fundamental to the progression of a medical learner toward competency for independent practice; the decision of how much supervision versus autonomy to provide a trainee in the execution of clinical care constitutes an entrustment decision. Despite entrustment decision making occurring both daily in practice and summatively at points of matriculation through stages of medical training, the factors influencing entrustment decisions remain poorly understood across clinical contexts.

Objective

This study was designed to explore the central research question: How are entrustment decisions made in the medical intensive care unit (ICU)?

Methods

This qualitative case study used semistructured interviews with attending pulmonary and critical care physicians in the medical ICU at a major midwestern medical center to explore the entrustment decision-making process as it was enacted in the clinical environment.

Results

Five major themes emerged from the data: 1) task, circumstance, and trainee factors contribute to entrustment decision making; 2) ad hoc entrustment decisions are enacted by supervisors with a consideration of the care team as a unit, not only an individual; 3) autonomy does not only arise out of entrustment, but outcomes of prior autonomous actions by the trainee inform the intention to entrust; 4) entrustment decision making includes a social process of back-and-forth akin to negotiation; and 5) entrustment is a learned skill.

Conclusion

The process of entrustment decision making in the ICU is more complex than prior frameworks have captured; a model with more complete incorporation of the factors that influence entrustment in the ICU is presented. It is not clear how often ad hoc entrustment decisions in clinical practice are primarily driven by factors pertaining directly to trainee competence, which carries implications in the use of entrustment for assessment.

Design and Implementation of a National Program of Assessment Model - Integrating Entrustable Professional Activity Assessments in Canadian Specialist Postgraduate Medical Education

Traditional approaches to assessment in health professions education systems, which have generally focused on the summative function of assessment through the development and episodic use of individual high-stakes examinations, may no longer be appropriate in an era of competency based medical education. Contemporary assessment programs should not only ensure collection of high-quality performance data to support robust decision-making on learners' achievement and competence development but also facilitate the provision of meaningful feedback to learners to support reflective practice and performance improvement. Programmatic assessment is a specific approach to designing assessment systems through the intentional selection and combination of a variety of assessment methods and activities embedded within an educational framework to simultaneously optimize the decision-making and learning function of assessment. It is a core component of competency based medical education and is aligned with the goals of promoting assessment for learning and coaching learners to achieve predefined levels of competence. In Canada, postgraduate specialist medical education has undergone a transformative change to a competency based model centred around entrustable professional activities (EPAs). In this paper, we describe and reflect on the large scale, national implementation of a program of assessment model designed to guide learning and ensure that robust data is collected to support defensible decisions about EPA achievement and progress through training. Reflecting on the design and implications of this assessment system may help others who want to incorporate a competency based approach in their own country.

Exploration of validity evidence for core residency entrustable professional activities in Chinese pediatric residency

Introduction

This study seeks to explore validity and reliability evidence for core residency entrustable professional activities (CR-EPAs) that were developed by Peking University First Hospital (PKUFH) in 2020.

Methods

A prospective cohort study was conducted in PKUFH. Trainers (raters) assessed pediatric residents on CR-EPAs over 1 academic year, bi-annually. Critical components within a validity evidence framework were examined: response process (rater perceptions), the internal structure (reliability and contributions of different variance sources), and consequences (potential use of a cutoff score).

Results

In total, 37 residents were enrolled, and 111 and 99 trainers' ratings were collected in Fall 2020 and Spring 2021, respectively. For rater perceptions, all the raters considered CR-EPAs highly operational and convenient. In all ratings, individual EPAs correlate with total EPA moderately, with Spearman correlation coefficients spanning from 0.805 to 0.919. EPA 2 (select and interpret the auxiliary examinations), EPA 5 (prepare and complete medical documents), EPA 6 (provide an oral presentation of a case or a clinical encounter), and EPA 7 (identify and manage the general clinical conditions) were EPAs correlated with other EPAs significantly. The results of the generalizability theory indicated that the variability due to residents is the highest (nearly 78.5%), leading to a large size of the reliability estimates. The matching results indicate that the lowest error locates at 5.933.

Conclusion

The rating showed good validity and reliability. The ratings were reliable based on G-theory. CR-EPAs have a magnificent internal structure and have promising consequences. Our results indicate that CR-EPAs are a robust assessment tool in workplace-based training in a carefully designed setting.

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.

Perceptions and Guiding Strategies to Regulate Entrusted Autonomy of Residents in the Operating Room: A Systematic Literature Review

OBJECTIVE

To provide a systematic literature review of intraoperative entrusted autonomy for surgical residents. Specifically, perceptions from residents and supervising surgeons, supervising behavior and influencing factors on intraoperative teaching and learning are analyzed.

BACKGROUND

Increasing demands on surgical training and the need for effective development of technical skills, amplify the importance of making the most of intraoperative teaching and learning opportunities in the operating room. It is critical for residents to gain the greatest benefit from every surgical case and to achieve operative competence.

METHODS

A systematic literature search identified 921 articles from 2000 to 2022 that addressed surgical education/training, intraoperative supervision/teaching, autonomy and entrustment. 40 studies with heterogeneous designs and methodologies were included.

RESULTS

Four themes were established in the analysis: patient safety, learner, learning environment and supervising surgeon. The patient is identified as the primary responsibility during intraoperative teaching and learning. Supervisors continuously guard patient safety as well as the resident's learning process. Ideal intraoperative learning occurs when the resident has optimal entrusted autonomy during the procedure matching with the current surgical skills level. A safe learning environment with dedicated time for learning are prerequisites for both supervising surgeons and residents. Supervising surgeons' own preferences and confidence levels also play an important role.

CONCLUSIONS

This systematic literature review identifies patient safety as the overriding principle for supervising surgeons when regulating residents' entrusted autonomy. When the supervisor's responsibility toward the patient has been met, there is room for intraoperative teaching and learning. In this process the learner, the learning environment and the supervising surgeon's own preferences all intertwine, creating a triangular responsibility. This review outlines the challenge of establishing an equilibrium in this triangle and the broad arsenal of strategies supervising surgeons use to keep it in balance.

"Rater training" re-imagined for work-based assessment in medical education

In this perspective, the authors critically examine "rater training" as it has been conceptualized and used in medical education. By "rater training," they mean the educational events intended to improve rater performance and contributions during assessment events. Historically, rater training programs have focused on modifying faculty behaviours to achieve psychometric ideals (e.g., reliability, inter-rater reliability, accuracy). The authors argue these ideals may now be poorly aligned with contemporary research informing work-based assessment, introducing a compatibility threat, with no clear direction on how to proceed. To address this issue, the authors provide a brief historical review of "rater training" and provide an analysis of the literature examining the effectiveness of rater training programs. They focus mainly on what has served to define effectiveness or improvements. They then draw on philosophical and conceptual shifts in assessment to demonstrate why the function, effectiveness aims, and structure of rater training requires reimagining. These include shifting competencies for assessors, viewing assessment as a complex cognitive task enacted in a social context, evolving views on biases, and reprioritizing which validity evidence should be most sought in medical education. The authors aim to advance the discussion on rater training by challenging implicit incompatibility issues and stimulating ways to overcome them. They propose that "rater training" (a moniker they suggest be reserved for strong psychometric aims) be augmented with "assessor readiness" programs that link to contemporary assessment science and enact the principle of compatibility between that science and ways of engaging with advances in real-world faculty-learner contexts.

Mobile technologies to support workplace-based assessment for entrustment decisions: Guidelines for programs and educators: AMEE Guide No. 154

With the rise of competency-based medical education and workplace-based assessment (WBA) since the turn of the century, much has been written about methods of assessment. Direct observation and other sources of information have become standard in many clinical programs. Entrustable professional activities (EPAs) have also become a central focus of assessment in the clinical workplace. Paper and pencil (one of the earliest mobile technologies!) to document observations have become almost obsolete with the advent of digital technology. Typically, clinical supervisors are asked to document assessment ratings using forms on computers. However, accessing these forms can be cumbersome and is not easily integrated into existing clinical workflows. With a call for more frequent documentation, this practice is hardly sustainable, and mobile technology is quickly becoming indispensable. Documentation of learner performance at the point of care merges WBA with patient care and WBA increasingly uses smartphone applications for this purpose.This AMEE Guide was developed to support institutions and programs who wish to use mobile technology to implement EPA-based assessment and, more generally, any type of workplace-based assessment. It covers backgrounds of WBA, EPAs and entrustment decision-making, provides guidance for choosing or developing mobile technology, discusses challenges and describes best practices.

The Assessment Burden in Competency-Based Medical Education: How Programs Are Adapting

Residents and faculty have described a burden of assessment related to the implementation of competency-based medical education (CBME), which may undermine its benefits. Although this concerning signal has been identified, little has been done to identify adaptations to address this problem. Grounded in an analysis of an early Canadian pan-institutional CBME adopter's experience, this article describes postgraduate programs' adaptations related to the challenges of assessment in CBME. From June 2019-September 2022, 8 residency programs underwent a standardized Rapid Evaluation guided by the Core Components Framework (CCF). Sixty interviews and 18 focus groups were held with invested partners. Transcripts were analyzed abductively using CCF, and ideal implementation was compared with enacted implementation. These findings were then shared back with program leaders, adaptations were subsequently developed, and technical reports were generated for each program. Researchers reviewed the technical reports to identify themes related to the burden of assessment with a subsequent focus on identifying adaptations across programs. Three themes were identified: (1) disparate mental models of assessment processes in CBME, (2) challenges in workplace-based assessment processes, and (3) challenges in performance review and decision making. Theme 1 included entrustment interpretation and lack of shared mindset for performance standards. Adaptations included revising entrustment scales, faculty development, and formalizing resident membership. Theme 2 involved direct observation, timeliness of assessment completion, and feedback quality. Adaptations included alternative assessment strategies beyond entrustable professional activity forms and proactive assessment planning. Theme 3 related to resident data monitoring and competence committee decision making. Adaptations included adding resident representatives to the competence committee and assessment platform enhancements. These adaptations represent responses to the concerning signal of significant burden of assessment within CBME being experienced broadly. The authors hope other programs may learn from their institution's experience and navigate the CBME-related assessment burden their invested partners may be facing.

A Call to Shift to Competency-Based Education

This column explores the concept of competency-based education (CBE). A shift to CBE is a key trend for the future of health care education. Health care professions that have adopted, or started to adopt, a CBE framework include physical therapy, speech-language pathology, social work, medicine, nursing, pharmacology, and dentistry. Internationally, many occupational therapy programs are in the process of shifting to, or have shifted to, a CBE model. This column discusses how although select occupational therapy programs in the United States may individually be considering shifting to, or have shifted to, a CBE framework, there is no national movement to explore adopting the model for occupational therapy or a consensus on defined outcomes for the profession.

Relationship between epa level of supervision with their associated subcompetency milestone levels in pediatric fellow assessment

BACKGROUND

Entrustable Professional Activities (EPA) and competencies represent components of a competency-based education framework. EPAs are assessed based on the level of supervision (LOS) necessary to perform the activity safely and effectively. The broad competencies, broken down into narrower subcompetencies, are assessed using milestones, observable behaviors of one's abilities along a developmental spectrum. Integration of the two methods, accomplished by mapping the most relevant subcompetencies to each EPA, may provide a cross check between the two forms of assessment and uncover those subcompetencies that have the greatest influence on the EPA assessment.

OBJECTIVES

We hypothesized that 1) there would be a strong correlation between EPA LOS ratings with the milestone levels for the subcompetencies mapped to the EPA; 2) some subcompetencies would be more critical in determining entrustment decisions than others, and 3) the correlation would be weaker if the analysis included only milestones reported to the Accreditation Council for Graduate Medical Education (ACGME).

METHODS

In fall 2014 and spring 2015, the Subspecialty Pediatrics Investigator Network asked Clinical Competency Committees to assign milestone levels to each trainee enrolled in a pediatric fellowship for all subcompetencies mapped to 6 Common Pediatric Subspecialty EPAs as well as provide a rating for each EPA based upon a 5-point LOS scale.

RESULTS

One-thousand forty fellows were assessed in fall and 1048 in spring, representing about 27% of all fellows. For each EPA and in both periods, the average milestone level was highly correlated with LOS (rho range 0.59-0.74; p < 0.001). Correlations were similar when using a weighted versus unweighted milestone score or using only the ACGME reported milestones (p > 0.05).

CONCLUSIONS

We found a strong relationship between milestone level and EPA LOS rating but no difference if the subcompetencies were weighted, or if only milestones reported to the ACGME were used. Our results suggest that representative behaviors needed to effectively perform the EPA, such as key subcompetencies and milestones, allow for future language adaptations while still supporting the current model of assessment. In addition, these data provide additional validity evidence for using these complementary tools in building a program of assessment.

Assessing the utility of a novel entrustment-supervision assessment tool

BACKGROUND

Work-based assessments (WBAs) are increasingly used to inform decisions about trainee progression. Unfortunately, WBAs often fail to discriminate between trainees of differing abilities and have poor reliability. Entrustment-supervision scales may improve WBA performance, but there is a paucity of literature directly comparing them to traditional WBA tools.

METHODS

The Ottawa Emergency Department Shift Observation Tool (O-EDShOT) is a previously published WBA tool employing an entrustment-supervision scale with strong validity evidence. This pre-/post-implementation study compares the performance of the O-EDShOT with that of a traditional WBA tool using norm-based anchors. All assessments completed in 12-month periods before and after implementing the O-EDShOT were collected, and generalisability analysis was conducted with year of training, trainees within year and forms within trainee as nested factors. Secondary analysis included assessor as a factor.

RESULTS

A total of 3908 and 3679 assessments were completed by 99 and 116 assessors, for 152 and 138 trainees in the pre- and post-implementation phases respectively. The O-EDShOT generated a wider range of awarded scores than the traditional WBA, and mean scores increased more with increasing level of training (0.32 vs. 0.14 points per year, p = 0.01). A significantly greater proportion of overall score variability was attributable to trainees using the O-EDShOT (59%) compared with the traditional tool (21%, p < 0.001). Assessors contributed less to overall score variability for the O-EDShOT than for the traditional WBA (16% vs. 37%). Moreover, the O-EDShOT required fewer completed assessments than the traditional tool (27 vs. 51) for a reliability of 0.8.

CONCLUSION

The O-EDShOT outperformed a traditional norm-referenced WBA in discriminating between trainees and required fewer assessments to generate a reliable estimate of trainee performance. More broadly, this study adds to the body of literature suggesting that entrustment-supervision scales generate more useful and reliable assessments in a variety of clinical settings.

Unintended consequences of technology in competency-based education: a qualitative study of lessons learned in an OtoHNS program

BACKGROUND

Formative feedback and entrustment ratings on assessments of entrustable professional activities (EPAs) are intended to support learner self-regulation and inform entrustment decisions in competency-based medical education. Technology platforms have been developed to facilitate these goals, but little is known about their effects on these new assessment practices. This study investigates how users interacted with an e-portfolio in an OtoHNS surgery program transitioning to a Canadian approach to competency-based assessment, Competence by Design.

METHODS

We employed a sociomaterial perspective on technology and grounded theory methods of iterative data collection and analysis to study this OtoHNS program's use of an e-portfolio for assessment purposes. All residents (n = 14) and competency committee members (n = 7) participated in the study; data included feedback in resident portfolios, observation of use of the e-portfolio in a competency committee meeting, and a focus group with residents to explore how they used the e-portfolio and visualize interfaces that would better meet their needs.

RESULTS

Use of the e-portfolio to document, access, and interpret assessment data was problematic for both residents and faculty, but the residents faced more challenges. While faculty were slowed in making entrustment decisions, formative assessments were not actionable for residents. Workarounds to these barriers resulted in a "numbers game" residents played to acquire EPAs. Themes prioritized needs for searchable, contextual, visual, and mobile aspects of technology design to support use of assessment data for resident learning.

CONCLUSION

Best practices of technology design begin by understanding user needs. Insights from this study support recommendations for improved technology design centred on learner needs to provide OtoHNS residents a more formative experience of competency-based training.

The AACP Academic Affairs Committee's Guidance for Use of the Curricular Outcomes and Entrustable Professional Activities (COEPA) for Pharmacy Graduates

The 2021-2023 American Association of Colleges of Pharmacy Academic Affairs Committee (AAC) was charged with and completed the revision of the 2013 Center for the Advancement of Pharmacy Education Outcomes and the 2016 Entrustable Professional Activity (EPA) statements for new pharmacy graduates. This work resulted in a new combined document, the Curricular Outcomes and Entrustable Professional Activities (COEPA) that was unanimously approved by the American Association of Colleges of Pharmacy Board of Directors and was published in the Journal. The AAC was also charged with providing stakeholders with guidance about how to use the new COEPA document. To achieve this charge, the AAC created example objectives for all 12 Educational Outcomes (EOs) and example tasks for all 13 EPAs. Although programs are asked to retain the EO domains, subdomains, one-word descriptors, and descriptions, unless they are adding more EOs or increasing the taxonomy level of a description, colleges and schools of pharmacy can expand or edit the example objectives and example tasks to meet local needs, as these are not designed to be prescriptive. This guidance document is published separately from the COEPA EOs and EPAs to reinforce the message that the example objectives and tasks are modifiable.

Entrustment versus performance scale in high-stakes OSCEs: Rater insights and psychometric properties

BACKGROUND

Although entrustment scales are increasingly applied in workplace-based assessments, their role in OSCEs remains unclear. We investigated raters' perceptions using an entrustment scale and psychometric analyses.

METHOD

A mixed-methods design was used. OSCE raters' (n = 162) perceptions were explored via questionnaire and four focus groups (n = 14). Psychometric OSCE properties were analyzed statistically.

RESULTS

Raters (n = 53, response rate = 41%) considered the entrustment scale comprehensible (89%) and applicable (60%). A total of 43% preferred the entrustment scale, 21% preferred the global performance scale, and 36% were undecided. Raters' written comments indicated that while they appreciated the authenticity of entrustment levels, they considered them subjective. The focus groups highlighted three main themes: (1) recollections of the clinical workplace as a cognitive reference triggered by entrustment scales; (2) factors influencing entrustment decisions; and (3) cognitive load is reduced at the perceived cost of objectivity. Psychometric analyses (n = 480 students) revealed improvements in some OSCE metrics when entrustment and global performance scales were combined.

CONCLUSION

Entrustment scales are beneficial for high-stakes OSCEs and have greater clinical relevance from the raters' perspective. Our findings support the use of entrustment and global performance scales in combination.

Medical students remote consulting from home and from the health centre: A survey of prevalence and supervisor perspectives

PURPOSE

A shift to remote consulting characterised the early stages of the COVID-19 pandemic in general practice which resulted in significant changes in the delivery of medical education. It is unclear whether these changes have been sustained and how they are perceived by faculty.

METHODS

We surveyed a defined population of GP practices during April 2022 with questions to elicit estimates of medical student involvement in different types of remote consultation and supervisor ratings of their confidence in supervising different modalities of remote consultation. We performed thematic analysis on free text responses from a 'resistance to change' perspective.

RESULTS

A response rate of 96% (n = 115) was achieved. Analysis of quantitative data identified that a significant proportion of student consultations were remote, however there was a large variation between practices. Supervisor confidence was lowest for students consulting from home. Thematic analysis identified ways in which clinical supervisors may perceive the innovation to be at odds with their overriding commitments to safety, simplicity and quality.

CONCLUSIONS

Remote consultations form a significant proportion of medical student activity in many practices. Some supervisors are reluctant to supervise medical students consulting from home and our findings suggest ways of addressing this so that the benefits of the innovation can be harnessed.

Twelve tips to develop entrustable professional activities

Entrustable professional activities (EPAs), units of professional practice that require proficient integration of multiple competencies and can be entrusted to a sufficiently competent learner, are increasingly being used to define and inform curricula of health care professionals. The process of developing EPAs can be challenging and requires a deep yet pragmatic understanding of the concepts underlying EPA construction. Based on recent literature and the authors' lessons learned, this article provides the following practical and more or less sequential recommendations for developing EPAs: [1] Assemble a core team; [2] Build up expertise; [3] Establish a shared understanding of the purpose of EPAs; [4] Draft preliminary EPAs; [5] Elaborate EPAs; [6] Adopt a framework of supervision; [7] Perform a structured quality check; [8] Use a Delphi approach for refinement and/or consensus; [9] Pilot test EPAs; [10] Attune EPAs to their feasibility in assessment; [11] Map EPAs to existing curriculum; [12] Build a revision plan.

Would I Trust or Will I Trust? The Gap between Entrustment Determinations and Entrustment Decisions for Trainees in Pharmacy and Other Health Professions

Entrustable Professional Activities (EPAs) and entrustment decision making are rapidly becoming mainstream in competency-based education in the health professions. EPAs are the units of professional practice to entrust graduates with once they have developed the required competencies. They were conceived to enable a gradual increase in professional autonomy during training, by allowing trainees to practice activities in which they have demonstrated they have mastered well, with decreasing supervision. However, practicing health care unsupervised generally requires licensure. The question for pharmacy education, as well as for undergraduate medical education, is can students be given any autonomy in practice, even when they have fully mastered an EPA yet remain unlicensed? While entrustment decisions for licensed practitioners have autonomy consequences, some educators in undergraduate programs speak of 'entrustment determinations', to avoid decisions about students that affect patient care, in other words saying, we would trust you, rather than we will trust you. However, graduating learners without the experience of responsibility and reasonable autonomy creates a gap with full practice responsibilities, which may jeopardize patient safety after training. What can programs do to retain the power of using EPAs while at the same time guarding patient safety?

"A whole other competence story": exploring faculty perspectives on the process of workplace-based assessment of entrustable professional activities

The centrality of entrustable professional activities (EPAs) in competency-based medical education (CBME) is predicated on the assumption that low-stakes, high-frequency workplace-based assessments used in a programmatic approach will result in accurate and defensible judgments of competence. While there have been conversations in the literature regarding the potential of this approach, only recently has the conversation begun to explore the actual experiences of clinical faculty in this process. The purpose of this qualitative study was to explore the process of EPA assessment for faculty in everyday practice. We conducted 18 semi-structured interviews with Anesthesia faculty at a Canadian academic center. Participants were asked to describe how they engage in EPA assessment in daily practice and the factors they considered. Interviews were audio-recorded, transcribed, and analysed using the constant comparative method of grounded theory. Participants in this study perceived two sources of tension in the EPA assessment process that influenced their scoring on official forms: the potential constraints of the assessment forms and the potential consequences of their assessment outcome. This was particularly salient in circumstances of uncertainty regarding the learner's level of competence. Ultimately, EPA assessment in CBME may be experienced as higher-stakes by faculty than officially recognized due to these tensions, suggesting a layer of discomfort and burden in the process that may potentially interfere with the goal of assessment for learning. Acknowledging and understanding the nature of this burden and identifying strategies to mitigate it are critical to achieving the assessment goals of CBME.

Which Entrustment-Supervision Scale is Right for Pharmacy Education?

Entrustable professional activities (EPAs) are an outgrowth of the competency-based educational model to support workplace-based learner assessments and evaluation. A learner's performance of EPAs is assessed by the degree of provided entrustment and required supervision rather than by a score, percentage, or letter grade typically assigned in traditional academic coursework. Entrustment-supervision (ES) scales are used to document learner progression and steer learner development over time. The purpose of this article is to critique various ES tools in health professions education for utilization within an EPA framework for learner assessment in workplace-based settings and to determine which will best suit pharmacy education. Exploring the advantages and disadvantages across all types of ES scales is a critical step in determining the most useful ES tool for use within a specific pharmacy institution and across the Academy. An ES scale with the traditional 5 levels, a prospective assessment frame, and increased stratification at lower levels should be recommended by the Academy and utilized in workplace-based settings for formative and summative assessment to provide more valid assessment of learners, support the ideal of life-long learning, and give more meaning for pharmacy faculty and learners within assessment.

Differences in perceptions of capability, autonomy, and expectations between residents and surgical team members in executing EPAs in Ethiopian medical education

Background

Entrustable Professional Activities (EPAs) are units of professional practice that are defined as tasks or responsibilities that are entrusted to an unsupervised execution by a trainee. In 2021, a framework of 29 EPAs was developed for surgical residency training programs in Ethiopia, with the goal of residents being able to perform independently by the time they graduate. However, studies show that surgical residents lack confidence and are unable to execute EPAs autonomously upon graduation, and concerns have been raised about graduate competencies in EPA execution. The goal of this research is to assess how surgical team members judge/perceive residents' performance in executing these EPAs autonomously at the time of graduation and how residents rate their own capability and autonomy in executing EPAs in order to systematically introduce and implement EPAs in Ethiopian medical education.

Methods

A survey was conducted in the Departments of Surgery at four residency training institutions in Ethiopia. All eligible surgical team members and final-year general surgery residents were invited to participate. Surgical team members were asked to rate the observed performance of a group of graduating surgical residents in each of the 29 EPAs, and residents were asked to rate their own capability in executing EPAs. The analysis focused on variations in performance ratings between surgical team members and residents, as well as across surgical team members.

Results

A total of 125 surgical team members and 49 residents participated in this study. Residents rate their competence in performing these EPAs higher than surgical team members, mean 4.2 (SD = 0.63) vs. 3.7 (SD = 0.9). A statistically significant difference in perceptions of capability, autonomy, and expectations in executing EPAs was observed between the two groups of study (p = 0.03, CI: 0.51-0.95), as well as within surgical team members (p < 0.001).

Conclusions

Differences in perceptions of capability, autonomy, and expectations between residents and surgical team members, as well as within faculty members, were seen in executing EPAs. There were concerns about graduate surgical residents' competence to execute EPAs autonomously at the time of graduation. Surgical team members perceived that a set of graduating surgical residents are not yet safe to perform these EPAs independently (without supervision) and still requires distant supervision.

Can Rater Training Improve the Quality and Accuracy of Workplace-Based Assessment Narrative Comments and Entrustment Ratings? A Randomized Controlled Trial

PURPOSE

Prior research evaluating workplace-based assessment (WBA) rater training effectiveness has not measured improvement in narrative comment quality and accuracy, nor accuracy of prospective entrustment-supervision ratings. The purpose of this study was to determine whether rater training, using performance dimension and frame of reference training, could improve WBA narrative comment quality and accuracy. A secondary aim was to assess impact on entrustment rating accuracy.

METHOD

This single-blind, multi-institution, randomized controlled trial of a multifaceted, longitudinal rater training intervention consisted of in-person training followed by asynchronous online spaced learning. In 2018, investigators randomized 94 internal medicine and family medicine physicians involved with resident education. Participants assessed 10 scripted standardized resident-patient videos at baseline and follow-up. Differences in holistic assessment of narrative comment accuracy and specificity, accuracy of individual scenario observations, and entrustment rating accuracy were evaluated with t tests. Linear regression assessed impact of participant demographics and baseline performance.

RESULTS

Seventy-seven participants completed the study. At follow-up, the intervention group (n = 41), compared with the control group (n = 36), had higher scores for narrative holistic specificity (2.76 vs 2.31, P < .001, Cohen V = .25), accuracy (2.37 vs 2.06, P < .001, Cohen V = .20) and mean quantity of accurate (6.14 vs 4.33, P < .001), inaccurate (3.53 vs 2.41, P < .001), and overall observations (2.61 vs 1.92, P = .002, Cohen V = .47). In aggregate, the intervention group had more accurate entrustment ratings (58.1% vs 49.7%, P = .006, Phi = .30). Baseline performance was significantly associated with performance on final assessments.

CONCLUSIONS

Quality and specificity of narrative comments improved with rater training; the effect was mitigated by inappropriate stringency. Training improved accuracy of prospective entrustment-supervision ratings, but the effect was more limited. Participants with lower baseline rating skill may benefit most from training.

A Tool to Assess Competence in Critical Care Ultrasound Based on Entrustable Professional Activities

Background

Existing assessment tools for competence in critical care ultrasound (CCUS) have limited scope and interrupt clinical workflow. The framework of entrustable professional activities (EPAs) is well suited to developing an assessment tool that is comprehensive and readily integrated into the intensive care unit (ICU) training environment.

Objective

This study sought to design an EPA-based tool to assess competence in CCUS for pulmonary and critical care fellows and to assess the validity and reliability of the tool.

Methods

Eight experts in CCUS met to define the core EPAs for CCUS. A nominal group technique was used to reach consensus. An assessment tool was created based on the EPAs with a modified Ottawa entrustability scale. Trained faculty evaluated pulmonary and critical care fellows using this tool in the ICU over a 6-month study period at a single institution. An assessment of validity of the EPA-based tool is made with four sources of validity evidence: content, response process, reliability, and relation to other variables. Reliability and response process data were generated using generalizability theory analysis to estimate sources of variance in entrustment scores. Analysis of response process validity and validity by relation to other variables was performed using regression models.

Results

Fifty-four assessments were recorded during the study period, conducted on 23 trainees by 13 faculty. Content validity of the tool was demonstrated using expert consensus and published guidelines from critical care societies to define the EPAs. Response process validity was demonstrated by the low variance in entrustment scores due to evaluators (0.086 or 6%) and high agreement between score and trainee self-assessment (regression coefficient, 0.82; P < 0.0001). Reliability was demonstrated by the high "true" variance in entrustment score attributable to the trainee: 0.674 or 45%. Validity by relation to other variables was demonstrated using regression analysis to show correlation between entrustment score and the number of times a fellow has performed an EPA (regression coefficient, 0.023; P < 0.0001).

Conclusion

An EPA-based assessment tool for competence in CCUS was created. We obtained sufficient validity evidence on three of the diagnostic EPAs. Procedural EPAs were infrequently assessed, limiting generalizability in this subgroup.

Impact of number of critical care procedural skill repetitions on supervision level and teaching style

BACKGROUND

During critical care procedural skills training (e.g., in intubation and pericardiocentesis) the appropriate supervision level is important to ensure correct use of techniques and guarantee patient safety. The appropriate teaching style should be selected to address residents' learning behavior and foster their competence. The aim of this study was to explore the number of repetitions for given skills needed to achieve a specified supervision level and a specific teaching style.

METHODS

This cross-sectional multicenter survey obtained data from residents and faculty of three multidisciplinary intensive care units (ICU) in Switzerland. Using a 4-point Likert scale, participants were asked to indicate the number of repetitions required to achieve the specified supervision level and teaching style.

RESULTS

Among 91 physicians, the response rate was 64% (n = 59). Their median estimations of the numbers of skill repetitions needed to achieve the final fourth level of supervision and final fourth stage of teaching style were as follows: arterial catheter insertion: supervision level 32, teaching style 17.5; peritoneal paracentesis: supervision level 27, teaching style 17; central venous catheter insertion: supervision level 38, teaching style 28; lumbar puncture: supervision level 38, teaching style 21; endotracheal intubation: supervision level 100, teaching style 45; chest drain insertion: supervision level 27, teaching style 21.5; temporary pacemaker placement: supervision level 50, teaching style 19.5; percutaneous tracheostomy: supervision level 50, teaching style 29; pericardiocentesis: supervision level 50, teaching style 35. Comparison of repetitions between supervision level and teaching style revealed no difference at the first and second levels, except for endotracheal intubation at level 2 (p = 0.03). Differences were observed at the third and fourth levels of supervision level and teaching style (p≤0.04).

CONCLUSIONS

It appears that the supervision level and teaching style applied by faculty should change according to both the number of repetitions and the difficulty of critical care procedural skills.

Supervising the senior medical resident: Entrusting the role, supporting the tasks

INTRODUCTION

Postgraduate competency-based medical education has been implemented with programmatic assessment that relies on entrustment-based ratings. Yet, in less procedurally oriented specialties such as internal medicine, the relationship between entrustment and supervision remains unclear. We undertook the current study to address how internal medicine supervisors conceptualise entrusting senior medical residents while supervising them on the acute care wards.

METHODS

Guided by constructivist grounded theory, we interviewed 19 physicians who regularly supervised senior internal medicine residents on inpatient wards at three Canadian universities. We developed a theoretical model through iterative cycles of data collection and analysis using a constant comparative process.

RESULTS

On the internal medicine ward, the senior resident role is viewed as a fundamentally managerial and rudimentary version of the supervisor's role. Supervisors come to trust their residents in the senior role through an early 'hands-on' period of assessment followed by a gradual withdrawal of support to promote independence. When considering entrustment, supervisors focused on entrusting a particular scope of the senior resident role as opposed to entrustment of individual tasks. Irrespective of the scope of the role that was entrusted, supervisors at times stepped in and stepped back to support specific tasks.

CONCLUSION

Supervisors' stepping in and stepping back to support individual tasks on the acute care ward has an inconsistent relationship to their entrustment of the resident with a particular scope of the senior resident role. In this context, entrustment-based assessment would need to capture more of the holistic perspective of the supervisor's entrustment of the senior resident role. Understanding the dance of supervision, from relatively static overall support of the resident in their role, to fluidly stepping in and out for specific patient care tasks, allows us insight into the affordances of the supervisory relationship and how it may be leveraged for assessment.

Fidelity to Best Practices in EPA Implementation: Outcomes Supporting Use of the Core Components Framework From the University of Virginia Entrustable Professional Activity Program

PROBLEM

The rapid expansion of entrustable professional activity (EPA) assessment programs has led to calls to ensure fidelity in implementation and integrity in meeting the goals of competency-based medical education. Initiated in July 2017, in advance of the articulated core components of EPA implementation, this article describes the structure and outcomes of the University of Virginia (UVA) EPA Program and provides support for the identified essential components.

APPROACH

The UVA EPA Program includes workplace assessments by residents/fellows, attending faculty, and master assessors (MAs), experienced clinicians who assess students across disciplines and clinical settings. All assessors participate in formal professional development and provide verbal and written comments to support their supervision ratings. The Entrustment Committee, composed of 12 MAs, uses a shared mental model and aggregates all assessor data to make a high-stakes summative entrustment decision about students' readiness to assume the role of an acting intern.

OUTCOMES

Since 2017, over 2,000 assessors have completed 56,969 EPA assessments for 1,479 students. Ninety-four percent of assessments have been done during the clerkship phase. Residents/fellows have completed a mean of 18 assessments, attending faculty a mean of 27, and MAs a mean of 882. Seventy-four percent of observed encounters involved patients with acute concerns with or without a co-morbid condition. Fifty percent of assessments occurred in inpatient and 32% in ambulatory settings. Eighty-seven percent of assessments contained narrative comments with more than 100 characters.

NEXT STEPS

Planned next steps will include earlier identification of students who require individualized learning to promote the development of skills related to EPAs, expansion of the remediation program to enable more students to engage in a clinical performance mastery elective, and creation of targeted professional development for assessors to reinforce the tenets of the EPA program.

Developing the Expected Entrustment Score: Accounting for Variation in Resident Assessment

BACKGROUND

Clinical competency committees (CCCs) and residency program leaders may find it difficult to interpret workplace-based assessment (WBA) ratings knowing that contextual factors and bias play a large role.

OBJECTIVE

We describe the development of an expected entrustment score for resident performance within the context of our well-developed Observable Practice Activity (OPA) WBA system.

DESIGN

Observational study PARTICIPANTS: Internal medicine residents MAIN MEASURE: Entrustment KEY RESULTS: Each individual resident had observed entrustment scores with a unique relationship to the expected entrustment scores. Many residents' observed scores oscillated closely around the expected scores. However, distinct performance patterns did emerge.

CONCLUSIONS

We used regression modeling and leveraged large numbers of historical WBA data points to produce an expected entrustment score that served as a guidepost for performance interpretation.

"The Most Crushing Thing": Understanding Resident Assessment Burden in a Competency-Based Curriculum

BACKGROUND

Competency-based medical education (CBME) was expected to increase the workload of assessment for graduate training programs to support the development of competence. Learning conditions were anticipated to improve through the provision of tailored learning experiences and more frequent, low-stakes assessments. Canada has adopted an approach to CBME called Competence by Design (CBD). However, in the process of implementation, learner anxiety and assessment burden have increased unexpectedly. To mitigate this unintended consequence, we need a stronger understanding of how resident assessment burdens emerge and function.

OBJECTIVE

This study investigates contextual factors leading to assessment burden on residents within the framework of CBD.

METHODS

Residents were interviewed about their experiences of assessment using constructivist grounded theory. Participants (n=21) were a purposive sample from operative and perioperative training programs, recruited from 6 Canadian medical schools between 2019 and 2020. Self-determination theory was used as a sensitizing concept to categorize findings on types of assessment burden.

RESULTS

Nine assessment burdens were identified and organized by threats to psychological needs for autonomy, relatedness, and competence. Burdens included: missed opportunities for self-regulated learning, lack of situational control, comparative assessment, lack of trust, constraints on time and resources, disconnects between teachers and learners, lack of clarity, unrealistic expectations, and limitations of assessment forms for providing meaningful feedback.

CONCLUSIONS

This study contributes a contextual understanding of how assessment burdens emerged as unmet psychological needs for autonomy, relatedness, and competence, with unintended consequences for learner well-being and intrinsic motivation.

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.