Entrustable Professional Activities: Reflecting on Where We Are to Define a Path for the Next Decade

[Graduate medical education in old age psychiatry: a scoping literature review]

BACKGROUND

Gerontopsychiatry will become increasingly relevant as a discipline for primary care based on current demographic forecasts, destigmatization of mental illness and specific diagnostic and therapeutic developments. Hence, high quality graduate medical training in old age psychiatry is needed. Objectives The goal of this review was to summarize the literature on medical education relevant to residency training in old age psychiatry and to contrast the findings with international developments in competency-based medical education.

MATERIALS AND METHODS

The authors used the scoping review method of Arksey and O'Malley.

RESULTS

The initial search yielded 913 hits. After full text screening, 20 original articles were used for data extraction. The study content was summarized under three categories: trainee recruitment, length and structure of graduate training curricula in old age psychiatry, and learning goals and competencies in old age psychiatry training. Surveys and expert consensus were mostly used as study methods. High-quality clinical training experience with gerontopsychiatric patients and supervision of residents was an important factor for stimulating interest in old age psychiatry. Few studies provided evidence for educational benefit of digital learning and teaching formats and simulation training in old age psychiatry. Overall, there were no studies in old age psychiatry with explicit reference to concepts of competency-based graduate medical education.

CONCLUSIONS

Clinical rotations and mentoring foster interest of clinical residents in the discipline of old age psychiatry. Systematically introducing clinical rotations in old age psychiatry in general psychiatry residency programs seems necessary to enable residents to gain relevant knowledge and skills. Educational research in old age psychiatry considering patient outcomes seems to be a meaningful next step.

Facilitating flexibility in postgraduate nursing education through entrustable professional activities to address nursing shortages and career prospects

AIM

To communicate how the Dutch postgraduate nursing education landscape was redesigned using entrustable professional activities (EPAs). The goal of this initiative was to reduce training time, enhance transfer across nursing specialities and contribute to a better-aligned continuum of initial education, postgraduate education and continuing professional development.

BACKGROUND

Nursing shortages continue to worsen worldwide. An approach to address this growing shortage is to create a more flexible postgraduate training structure, offering training in the just-in-time and just-as-needed models. EPAs can be used as building blocks for training and assessment. Experience with EPAs (i.e. units of professional practice that can be entrusted once a trainee has demonstrated the required competencies) in health professions education, including nursing, is rising rapidly. While EPAs are largely used to create training flexibility within a programme, they can also be used to create flexibility across programmes. In 2018-2022, training hospitals and education institutions in the Netherlands collaborated in the CZO Flex Level Project to redesign the postgraduate nursing education landscape using EPAs.

DISCUSSION

The implementation of a flexible postgraduate nursing education model nationwide will face several challenges. An overview of these challenges and suggestions for future research on the effects of the new structure on nursing competence, satisfaction and career development are provided.

CONCLUSION

EPAs can imbue flexibility within and across training programmes. Designing an EPA-based educational landscape requires nationally coordinated efforts.

IMPLICATIONS FOR NURSING POLICY

Redesigning educational structures to allow for more flexibility is critical to address major societal challenges in healthcare.

Analysis of fellowship program director opinions of entrustable professional activities in adolescent medicine fellowship

OBJECTIVES

This study aimed to explore the minimum entrustable professional activity (EPA) supervision levels at which pediatric fellowship program directors (FPDs) would be willing to graduate fellows and the levels deemed necessary for safe and effective practice for each of the common pediatric subspecialty and the four adolescent medicine-specific EPAs.

METHODS

This cross-sectional study utilized survey data from pediatric FPDs in 2017. FPDs indicated the minimum level of supervision (LOS) for fellows at graduation and for safe and effective practice.

RESULTS

82 percent (23/28) of adolescent medicine FPDs completed the survey. For each EPA, there were differences (p<0.05) between LOS expected for graduation and for safe and effective practice. There was also variability in the level at which FPDs would graduate fellows.

CONCLUSIONS

This study summarizes pediatric FPD opinions regarding the minimum levels of supervision required for fellows at the time of graduation as well as the levels deemed necessary for safe and effective practice. The difference between the minimum LOS at which FPDs would graduate a fellow and that deemed appropriate for safe and effective practice, along with variability in minimum LOS for graduation, highlight the need for clearer standards for fellowship graduation as well as more structured early career support for ongoing learning. These data highlight variability in FPD opinion regarding such expectations and both the need to better define desired training outcomes and potential need for post-graduation supervision in clinical practice.

A multi-method approach to drafting candidate entrustable professional activities for a general internal medicine residency programme

INTRODUCTION

Entrustable professional activities (EPAs) are units of concrete daily clinical tasks that trainee physicians should be able to handle with increasing autonomy during their postgraduate training. EPAs are gaining international recognition as an essential component of competency-based medical training programmes. The process of developing EPAs for a nationwide training programme is complex and requires an in-depth understanding of EPAs as a concept and good knowledge of appropriate development processes. This article provides a detailed description of the methodology and results of a multi-step approach for developing a list of candidate EPAs for Switzerland's postgraduate training programme in general internal medicine (GIM).

METHODS

We took a multi-step approach including a systematic review of international literature, four national focus groups, a national consensus process using a RAND appropriateness method, and a quality check of the selected candidate EPAs using EQual criteria.

RESULTS

These steps generated a final list of 247 candidate EPAs in general internal medicine that were submitted for the national consensus process. After two rounds of rating, experts agreed on the appropriateness for general internal medicine postgraduate training of 225 candidate EPAs. Twenty-two were deemed inappropriate, and disagreement persisted only for two EPAs.

DISCUSSION

This multi-step programme is one of the few describing in detail the process of developing a list of EPAs and providing evidence of validity at each step. The clinical breadth of our candidate EPAs, together with the detailed description of our methodology, could serve as a useful starting point from which medical education specialists or clinicians could develop or revise applicable lists of EPAs, particularly for postgraduate training programmes in either general internal medicine or family medicine.

Pediatric Anesthesiology Milestones 2.0: An Update, Rationale, and Plan Forward

Formal training in the subspecialty of pediatric anesthesiology began >60 years ago. Over the years, the duration and clinical work has varied, but what has stayed constant is a mission to develop clinically competent and professionally responsible pediatric anesthesiologists. Since accreditation in 1997, there has been additional guidance by the Accreditation Council on Graduate Medical Education (ACGME) and greater accountability to the public that we, indeed, are producing competent and professional pediatric anesthesiologists. This has been influenced by the slow evolution from time-based educational curriculum to a competency-based paradigm. As with all ACGME-accredited specialties, education leaders in pediatric anesthesiology first convened in 2014 to design specialty-specific developmental trajectories within the framework of the 6 core competencies, known as milestones, on which fellows were to be tracked during the 1-year fellowship. With 5 years of implementation, and substantial data and feedback, it has become clear that an iterative improvement was necessary to mirror the evolution of the profession. It was evident that the community required brevity and clarity in the next version of the milestones and required additional resources for assessment and faculty development. We describe here the methodology and considerations of our working group, guided by ACGME, in the rewriting of the milestones. We also provide suggestions for implementation and collaboration to support the education and assessment of pediatric anesthesiology fellows across the 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.

Entrustable Professional Activities for the Training of Postgraduate Primary Care Pediatricians

PROBLEM

Competency-based training is a model of medical education program that uses an organized framework of competencies to develop entrustable professional activities (EPAs) for each specialty. Implementation of EPAs varies by medical specialty and country. Although national models for primary care pediatrics have been suggested in the past, standardized EPAs have not been established.

APPROACH

The authors, all members of the curriculum working group of the European Confederation of Primary Care Paediatricians, describe the development and design of a training model based on EPAs specifically for pediatricians in primary care. The objective was to facilitate and disseminate a training model that standardizes and improves training in primary care pediatrics. They aimed to make the model flexible enough so that it can be adapted to different training models and different European health systems.

OUTCOMES

Between May 2017 and December 2019, the authors developed a framework that includes 7 domains of competencies for the training in pediatric primary care and a set of 11 core EPAs to guide the learning process. They structured each EPA as follows: title, activity profile, domains of competence, competencies within each domain, required knowledge and skills, learning objectives described in terms of outcomes, and a 3-stage rating supervision scale to evaluate the level of performance.

NEXT STEPS

The next step is the progressive implementation of these EPAs into the postgraduate primary care pediatrics training programs of European health systems. To support this implementation, the authors intend to develop training videos to assist in daily teaching of the EPAs. The authors will also develop a pan-European online resident forum designed specifically to facilitate EPA learning by sharing and discussing clinical cases. They plan to launch a pilot study on the use of the EPAs in primary care health centers in 6 European countries.

Entrustable professional activities for residency in general internal medicine: a systematic review

CONTEXT

Entrustable Professional Activities (EPAs) are observable tasks that are regular parts of a physician's daily clinical work. Before being permitted to accomplish these tasks independently, trainees must gain their supervisors' trust. Defining the list of EPAs that should be mastered by the end of a residency is critical to setting clear expectations about autonomous practice.

OBJECTIVE

To collect all the lists of EPAs defined for residencies in general internal medicine and synthesise them into a reference work useful for developing new lists of EPAs or improving existing ones.

METHOD

This systematic review searched five databases and relevant grey literature using keywords related to EPAs and postgraduate education, from 2005, when the first article on EPAs was published, to April 2022. Inclusion criteria were the availability of an EPAs list and a focus on general internal medicine. Two reviewers independently selected the studies, extracted data and performed a quality assessment using QATSDD and AACODS tools. Mean values and inter-rater reliability were calculated.

RESULTS

The review yielded 3292 records, with 16 articles meeting the inclusion criteria, mostly from North America. Synthesising their 16 lists generated 395 EPAs. The reviewers then inductively categoried those EPAs, 308 of which fell into 6 domains, 14 themes and 24 subthemes. The domains were: (1) care and management of the general adult population (n = 103 EPAs); (2) care and management of patients with specific needs (n = 67); (3) care coordination and communication (n = 52); (4) management and leadership (N = 21); (5) healthcare quality, education, and research (n = 41); and (6) miscellaneous (n = 24). The remaining 87 EPAs were disease-specific and did not fit into this categorisation.

CONCLUSIONS

Categorising EPAs created a unique synthesis of the existing lists of EPAs for educating residents in general internal medicine. This synthesis could be used as a reference for anyone tasked with developing new lists of EPAs or improving existing ones.

Competency-Based Education and Practice in Physical Therapy: It's Time to Act!

Competency-based education (CBE) is a concept, a philosophy, and an approach to educational design where learner progression occurs when competency is demonstrated. It assumes a set of standard defined performance outcomes for any level of professional practice-students, residents, or practicing physical therapists. Those outcomes are based on the health needs of society and guide the curricular design, implementation, and evaluation of health professions education programs. Lack of a CBE framework-with no required demonstration of competence throughout one's career-has the potential to lead to variation in physical therapists' skills and to unwarranted variation in practice, potentially hindering delivery of the highest quality of patient care. CBE requires a framework that includes a commonly understood language; standardized, defined performance outcomes at various stages of learner development; and a process to assess whether competence has been demonstrated. The purpose of this perspective article is to (1) highlight the need for a shared language, (2) provide an overview of CBE and the impetus for the change, (3) propose a shift toward CBE in physical therapy, and (4) discuss the need for the profession to adopt a mindset requiring purposeful practice across one's career to safely and most efficiently practice in a given area. Utilizing a CBE philosophy throughout one's career should ensure high-quality and safe patient care to all-patient care that can adapt to the changing scope of physical therapist practice as well as the health care needs of society. The physical therapy profession is at a point at which we must step up the transition to a competency-based system of physical therapist education.