The entrustable professional activities of laparoscopic surgery: moving toward an integrated training model

BACKGROUND

Entrustable Professional Activities (EPAs) provide the opportunity to integrate multiple competencies into meaningful units that facilitate curriculum development and assessment design. As part of the process of reviewing and enhancing the Fundamentals of Laparoscopic of Surgery (FLS) program, we used the concept of EPAs to create a framework of reference that articulates a contemporary definition of Laparoscopic Surgery (LS).

METHODS

The framework of reference of LS was created with data gathered from a literature review and during series of educational retreats with subject matter experts (SMEs). Various activities were implemented during these retreats to develop the LS EPAs, their constitutive competencies, and related observable behaviors.

RESULTS

Ten EPAs and associated competency descriptors (articulated as observable behaviors) specific to LS were identified. In addition, knowledge areas were associated to each EPA.

DISCUSSION

A comprehensive list of EPAs for LS were identified. These EPAs will be used in the development and update of the FLS program. Further, they can be used to guide the development of curriculum, clinical teaching, and assessment in any surgical program with a laparoscopic training component. They are applicable to any level of training by defining the expected observable behaviors associated with a given level of expertise. These fundamental aspects of LS provide a common framework of reference across different surgical specialties.

Firsthand Experience in Graduating Three Cohorts of Forensic Pathologists Trained With Competency by Design (CBD) Curriculum

Introduction

The University of Toronto experienced graduating three cohorts of forensic pathologists trained with Competency by Design (CBD) curriculum. We achieved this as a result of multiyear development of Entrustable Professional Activities (EPAs), Required Training Experience (RTEs), and Specialty Competency Requirements (SCRs) by the Royal College of Physicians and Surgeons of Canada's Forensic Pathology Speciality Committee, the Ontario Forensic Pathology Service, and the University of Toronto.

Method

Our academic year is comprised of 13 blocks. We divided the 13-block period into 4 stages to map all the EPAs and RTEs. The first stage, Transition to Discipline, is 1 block, the second stage, Foundation of Discipline, consists of 3 blocks; the third stage, Core of Discipline, consists of 6 blocks, and the final fourth stage, Transition to Practice, consists of 3 blocks. Board-certified faculty members in Forensic Pathology with more than five years of experience supervised the trainees. We graduated 5 Canadian and 4 international trainees at the end of the third cycle of CBD-based training program.

Conclusion

Using the Royal College Speciality Committee blueprint, the University of Toronto started in 2016 planning the CBD curriculum in the forensic pathology training program. By the end of June 2021, we graduated nine trainees from our CBD-based Forensic Pathology training program. We are training the fourth cohort, and they will be graduating at the end of June 2022. This article aims to share our firsthand experiencing in CBD training in forensic pathology.

Benefits of EPAs at risk? The influence of the workplace environment on the uptake of EPAs in EPA-based curricula

INTRODUCTION

Entrustable Professional Activities (EPAs) have been applied differently in many postgraduate medical education (PGME) programmes, but the reasons for and the consequences of this variation are not well known. Our objective was to investigate how the uptake of EPAs is influenced by the workplace environment and to what extent the benefits of working with EPAs are at risk when the uptake of EPAs is influenced. This knowledge can be used by curriculum developers who intend to apply EPAs in their curricula.

METHOD

For this qualitative study, we selected four PGME programmes: General Practice, Clinical Geriatrics, Obstetrics & Gynaecology, and Radiology & Nuclear Medicine. A document analysis was performed on the national training plans, supported by the AMEE Guide for developing EPA-based curricula and relevant EPA-based literature. Interviews were undertaken with medical specialists who had specific involvement in the development of the curricula. Content analysis was employed and illuminated the possible reasons for variation in the uptake of EPAs.

RESULTS

An important part of the variation in the uptake of EPAs can be explained by environmental factors, such as patient population, the role of the physician in the health-care system, and the setup of local medical care institutions where the training programme takes place. The variation in uptake of EPAs is specifically reflected in the number and breadth of the EPAs, and in the way the entrustment decision is executed within the PGME programme.

DISCUSSION

Due to variation in uptake of EPAs, the opportunities for trainees to work independently during the training programme might be challenging. EPAs can be implemented in the curriculum of PGME programmes in a meaningful way, but only if the quality of an EPA is assessed, future users are involved in the development, and the key feature of EPAs (the entrustment decision) is retained.

Moving beyond the technical skills and promoting professionalism-the experience of the College of Anaesthesiologists of Ireland with incorporating the Medical Council Eight Domains of Good Professional Practice into Entrustable Professional Activities

BACKGROUND

The goal of the College of Anaesthesiologists of Ireland (CAI) is to train qualified anaesthesiologists who embody all aspects of professionalism. The Medical Council of Ireland has identified Eight Domains of Good Professional Practice which guide the standards for postgraduate specialist training, including within the CAI.

AIMS

Entrustable Professional Activities (EPAs) were adopted as the organising framework for a competency-based programme within CAI. The aims were (i) to ensure that the EPA-integrated competencies from across the full range of domains and (ii) to design workplace-based assessment which fosters a culture and practice of feedback above and beyond technical skills.

METHODS

Four core EPAs were developed for trialling; competencies were tagged to the eight domains in an iterative development process. Feedback Reports were devised as tools for workplace-based assessment. Analysis of the Feedback Report data revealed how well the content reflected the full range of domains.

RESULTS

'Clinical Skills' is the domain to which most competencies within the EPAs were tagged. Analysis of the content of Feedback Reports also revealed an overrepresentation of that domain. This highlighted the apparent preference of consultants and trainees for selecting clinical aspects of an EPA to provide and receive feedback on, rather than professionalism or any of the other non-technical domains.

CONCLUSIONS

We advocate and make recommendations for more effective incorporation of the non-technical domains of professional practice in the processes of curriculum development, teaching, learning, feedback and assessment.

Developing an Entrustment Process: Insights from the AAMC CoreEPA Pilot

One of the main goals of the CoreEPA pilot has been to determine the feasibility of developing a process to make summative entrustment decisions regarding entrustable professional activities (EPAs). Five years into the pilot, we report results of a research study we conducted to explore approaches to the entrustment process undertaken by our ten participating schools. We sought to identify the choices that participating schools made regarding the entrustment process and why these decisions were made. We are sharing these results, highlighting ongoing challenges that were identified with the intent of helping other medical schools that are moving toward EPA-based assessment. We conducted semi-structured interviews with representatives of all 10 medical schools in the CoreEPA pilot to understand their choices in designing the entrustment process. Additional information was obtained through follow-up communication to ensure completeness and accuracy of the findings. Several common themes are described. Our results indicate that, while approaches to the entrustment process vary considerably, all schools demonstrated consistent adherence to the guiding principles of the pilot. Several common barriers to the entrustment process emerged, and there was a consensus that more experience is needed with the process before consequential entrustment decisions can be made. The CoreEPA pilot schools continue to address challenges identified in implementing entrustment processes and making entrustment decisions for our students graduating in the Class of 2020.

Development and inclusion of an entrustable professional activity (EPA) scale in a simulation-based medicine dispensing assessment

BACKGROUND AND PURPOSE

Effective, safe, and patient-centred dispensing is a core task of community pharmacists. Entrustable professional activities (EPAs) offer a way of defining and assessing these daily practice activities. Although EPAs have become popular within competency-based medical education programs, their use is new to pharmacy education and assessment.

EDUCATIONAL ACTIVITY AND SETTING

A simulation-based assessment framework containing a scale of entrustment was developed to evaluate the readiness of Year 4 undergraduate pharmacy students to safely manage the supply of prescribed medicine(s) in a community pharmacy. The assessment framework was piloted in a fourth year "Transition to Practice" course with 28 simulation-based assessments conducted.

FINDINGS

An entrustment framework was developed and implemented successfully with Year 4 undergraduate pharmacy students. The EPA for medicine dispensing integrates competency domains that include information gathering, providing patient-centred care, clinical reasoning, medicine dispensing, and professional communications. On a scale ranging from level 1 to level 5, the majority (73%) of entrustment ratings were level 2 or level 3; and of the students who achieved different ratings between clinical scenarios, 75% of students improved on their second simulation attempt. There was a strong correlation between the global EPA ratings with the total score achieved across the domains.

SUMMARY

Using simulation-based assessment, entrustment decision making can be incorporated in "entry to profession" undergraduate and postgraduate pharmacy courses to assess students' readiness to transition between learning and professional practice.

Entrustable professional activity 7: opportunities to collaborate on evidence-based medicine teaching and assessment of medical students

BACKGROUND

This study was conducted to examine gaps and opportunities for involvement of librarians in medical education and patient care as well as improve the teaching and assessment of Entrustable Professional Activity 7 (EPA 7) -- the ability to form clinical questions and retrieve evidence to advance patient care.

METHODS

The Association of Academic Health Sciences Libraries (AAHSL) Competency-Based Medical Education Task Force surveyed all AAHSL member libraries in October 2016 on health sciences librarian awareness and involvement in teaching and assessing EPA 7.

RESULTS

The survey response rate was 54% (88/164 member libraries). While 90% (n = 76) of respondents were regularly engaged in teaching or assessing aspects of EPA 7 only 34 (39%) were involved explicitly in a Core EPA 7 project, 44% (15/34) of these projects were librarian initiated.

CONCLUSIONS

Involvement in teaching and assessment of EPA 7 is an untapped opportunity for librarians to collaborate in medical education and patient care. Although librarians are already deeply involved in teaching and assessment of EPA 7 related knowledge, skills, and behaviors, further librarian collaboration can help bolster the planning or updating of existing curricula and assessments of this entrustable professional activity.

Entrustment of the on-call senior medical resident role: implications for patient safety and collective care

BACKGROUND

The on-call responsibilities of a senior medicine resident (SMR) may include the admission transition of patient care on medical teaching teams (MTT), supervision of junior trainees, and ensuring patient safety. In many institutions, there is no standardised assessment of SMR competency prior to granting these on-call responsibilities in internal medicine. In order to fulfill competency based medical education requirements, training programs need to develop assessment approaches to make and defend such entrustment decisions. The purpose of this study is to understand the clinical activities and outcomes of the on-call SMR role and provide training programs with a rigorous model for entrustment decisions for this role.

METHODS

This four phase study utilizes a constructivist grounded theory approach to collect and analyse the following data sets: case study, focus groups, literature synthesis of supervisory practices and return-of-findings focus groups. The study was conducted in two Academic Health Sciences Centres in Ontario, Canada. The case study included ten attending physicians, 13 SMRs, 19 first year residents and 14 medical students. The focus groups included 19 SMRs. The later, return-of-findings focus groups included ten SMRs.

RESULTS

Five core on-call supervisory tasks (overseeing ongoing patient care, briefing, case review, documentation and preparing for handover) were identified, as well as a range of practices associated with these tasks. We also identified challenges that influenced the extent to which SMRs were able to effectively perform the core tasks. At times, these challenges led to omissions of the core tasks and potentially compromised patient safety and the admission transition of care.

CONCLUSION

By identifying the core supervisory tasks and associated practices, we were able to identify the competencies for the on-call SMR role. Our findings can further be used by training programs for assessment and for making entrustment decisions.