Workplace-Based Entrustment Scales for the Core EPAs: A Multisite Comparison of Validity Evidence for Two Proposed Instruments Using Structured Vignettes and Trained Raters

Reimagining Undergraduate Critical Care Medical Education: A Path for the Next Decade

Foundational training in critical care medicine is an integral part of both undergraduate and graduate medical education. Yet, many medical school graduates enter residency underprepared to care for critically ill patients because of a lack of ubiquity of undergraduate critical care education and the heterogeneity of existing didactic and clinical experiences. This Perspective explores the importance of undergraduate critical care education, the current national and international landscape, innovative educational strategies and exemplar curricula, and recent advances in assessment that may better reflect learner-centered educational outcomes. As broad curricular reforms push medical education toward a more innovative, interactive, and collaborative future, now is the time to rethink and reimagine undergraduate critical care education.

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.

An Analysis of Workplace-Based Assessments for Core Entrustable Professional Activities for Entering Residency: Does Type of Clinical Assessor Influence Level of Supervision Ratings?

PURPOSE

The authors describe use of the workplace-based assessment (WBA) coactivity scale according to entrustable professional activities (EPAs) and assessor type to examine how diverse assessors rate medical students using WBAs.

METHOD

A WBA data collection system was launched at Oregon Health and Science University to visualize learner competency in various clinical settings to foster EPA assessment. WBA data from January 14 to June 18, 2021, for medical students (all years) were analyzed. The outcome variable was level of supervisor involvement in each EPA, and the independent variable was assessor type.

RESULTS

A total of 7,809 WBAs were included. Most fourth-, third-, and second-year students were assessed by residents or fellows (755 [49.5%], 1,686 [48.5%], and 918 [49.9%], respectively) and first-year students by attending physicians (803 [83.0%]; P < .001). Attendings were least likely to use the highest rating of 4 (1 was available just in case; 2,148 [56.7%] vs 2,368 [67.7%] for residents; P < .001). Learners more commonly sought WBAs from attendings for EPA 2 (prioritize differential diagnosis), EPA 5 (document clinical encounter), EPA 6 (provide oral presentation), EPA 7 (form clinical questions and retrieve evidence-based medicine), and EPA 12 (perform general procedures of a physician). Residents and fellows were more likely to assess students on EPA 3 (recommend and interpret diagnostic and screening tests), EPA 4 (enter and discuss orders and prescriptions), EPA 8 (give and receive patient handover for transitions in care), EPA 9 (collaborate as member of interprofessional team), EPA 10 (recognize and manage patient in need of urgent care), and EPA 11 (obtain informed consent).

CONCLUSIONS

Learners preferentially sought resident versus attending supervisors for different EPA assessments. Future research should investigate why learners seek different assessors more frequently for various EPAs and if assessor type variability in WBA levels holds true across institutions.

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.

Health Justice and Systems of Care: A Required Longitudinal Course for MD Students

Problem & Background

Medical education has acknowledged the impact of structural societal factors on health, prompting the need for curricula seeking to eliminate health inequities upstream while simultaneously caring for downstream effects of existing inequities. The Keck School of Medicine of USC (KSOM) implemented one such comprehensive curriculum, Health Justice and Systems of Care (HJSC), integrating health systems science, structural competency, and service-learning in a required course spanning the pre-clerkship and clerkship phases with an optional post clerkship elective.

Approach

The HJSC course addresses topics including racism in medicine, health inequities, and health systems science. Using transformative learning theory, it fosters critical consciousness and structural competency. Assessments include case analyses, reflections, team-based learning sessions, and group projects related to social justice in healthcare. The program aims to instill cultural humility and practical application, fostering a holistic approach to medical education that implores physicians to become advocates for health justice.

Outcomes of the Innovation

Feedback from students indicated generally positive perceptions of the curriculum. Students provided overall positive comments about discussions with guest speakers. However, students expressed a desire for more concrete examples of how health inequities can be remedied. Some found small-group activities less engaging. Other challenges included providing students of different readiness levels with tailored experiences and seamlessly integrating HJSC content within basic and clinical sciences courses.

Critical Reflection

Next steps include continuing to integrate content into the science curriculum and clerkships, improving opportunities for meaningful student interactions, and enhancing faculty development to address health justice concerns in clinical settings.

Development, Validation, and Reliability of a P1 Objective Structured Clinical Examination Assessing the National EPAs

OBJECTIVE

To document the performance of first-year pharmacy students on a revised objective structured clinical examination (OSCE) based on national entrustable professional activities, identify risk factors for poor performance, and assess its validity and reliability.

METHODS

A working group developed the OSCE to verify students' progress toward readiness for advanced pharmacy practice experiences at the L1 level of entrustment (ready for thoughtful observation) on the national entrustable professional activities, with stations cross-mapped to the Accreditation Council for Pharmacy Education educational outcomes. Baseline characteristics and academic performance were used to investigate risk factors for poor performance and validity, respectively, by comparing students who were successful on the first attempt with those who were not. Reliability was evaluated using re-grading by a blinded, independent grader, and analyzed using Cohen's kappa.

RESULTS

A total of 65 students completed the OSCE. Of these, 33 (50.8%) successfully completed all stations on first attempt, and 32 (49.2%) had to re-attempt at least 1 station. Successful students had higher Health Sciences Reasoning Test scores (mean difference 5, 95% CI 2-9). First professional year grade point average was higher for students who passed all stations on first attempt (mean difference 0.4 on a 4-point scale, 95% CI 0.1-0.7). When evaluated in a multiple logistic regression, no differences were statistically significant between groups. Most kappa values were above 0.4 (range 0.404-0.708), suggesting moderate to substantial reliability.

CONCLUSION

Though predictors of poor performance were not identified when accounting for covariates, the OSCE was found to have good validity and reliability.

EPMO: A novel medical student assessment tool that integrates entrustable professional activities, prime, and the modified Ottawa coactivity scale

PURPOSE

Alignment of workplace-based assessments (WPBA) with core entrustable professional activities (EPAs) for entering residency may provide opportunities to monitor student progress across the continuum of undergraduate medical education. Core EPAs, however, reflect tasks of varying degrees of difficulty and faculty assessors are not accustomed to rating students based on entrustability. Expectations of student progress should vary depending on the complexity of the tasks associated with the EPAs. An assessment tool that orients evaluators to the developmental progression of specific EPA tasks will be critical to fairly evaluate learners.

METHODS

The authors developed an EPA assessment tool combining the frameworks of Professionalism, Reporter, Interpreter, Manager, Educator (PRIME), and Modified Ottawa coactivity scales. Only those EPAs that could be repeatedly observed and assessed across clinical clerkships were included. From July 2019 to March 2020, third-year medical students across multiple clerkships were assessed using this tool. The authors hypothesized that if the tool was applied correctly, ratings of learner independence would be lower with higher complexity tasks and that such ratings would increase over the course of year with ongoing clinical learning.

RESULTS

Assessment data for 247 medical students were similar across clerkships suggesting that evaluators in diverse clinical contexts were able to use this tool to assign scores reflective of developing entrustability in the workplace. Faculty rated student entrustability highest in skills emphasized in the pre-clerkship curriculum (professionalism and reporter) and progressively lower in more advanced skills (interpreter and manager). Students' ratings increased over time with more clinical exposure.

CONCLUSIONS

The authors developed a composite WBPA tool that combines the frameworks of EPAs, PRIME, and Modified Ottawa Co- Activity and demonstrated the usability of applying it for learner assessments in clinical settings. Further multicenter studies with cohorts of pre- and post-clerkship students may provide additional validity evidence for the tool.

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.

A Question of Scale? Generalizability of the Ottawa and Chen Scales to Render Entrustment Decisions for the Core EPAs in the Workplace

PURPOSE

Assessments of the Core Entrustable Professional Activities (Core EPAs) are based on observations of supervisors throughout a medical student's progression toward entrustment. The purpose of this study was to compare generalizability of scores from 2 entrustment scales: the Ottawa Surgical Competency Operating Room Evaluation (Ottawa) scale and an undergraduate medical education supervisory scale proposed by Chen and colleagues (Chen). A secondary aim was to determine the impact of frequent assessors on generalizability of the data.

METHOD

For academic year 2019-2020, the Virginia Commonwealth University School of Medicine modified a previously described workplace-based assessment (WBA) system developed to provide feedback for the Core EPAs across clerkships. The WBA scored students' performance using both Ottawa and Chen scales. Generalizability (G) and decision (D) studies were performed using an unbalanced random-effects model to determine the reliability of each scale. Secondary G- and D-studies explored whether faculty who rated more than 5 students demonstrated better reliability. The Phi-coefficient was used to estimate reliability; a cutoff of at least 0.70 was used to conduct D-studies.

RESULTS

Using the Ottawa scale, variability attributable to the student ranged from 0.8% to 6.5%. For the Chen scale, student variability ranged from 1.8% to 7.1%. This indicates the majority of variation was due to the rater (42.8%-61.3%) and other unexplained factors. Between 28 and 127 assessments were required to obtain a Phi-coefficient of 0.70. For 2 EPAs, using faculty who frequently assessed the EPA improved generalizability, requiring only 5 and 13 assessments for the Chen scale.

CONCLUSIONS

Both scales performed poorly in terms of learner-attributed variance, with some improvement in 2 EPAs when considering only frequent assessors using the Chen scale. Based on these findings in conjunction with prior evidence, the authors provide a root cause analysis highlighting challenges with WBAs for Core EPAs.