What is Entrustable Professional Activities? | Medical Education 101 #2
What is Entrustable Professional Activities? What are CanMEDs and ACGME competency frameworks? How is Entrustable Professional Activities examples? Flamingo explained them in five minutes: https://youtu.be/rDQOJNY19iQ
Analytic frameworks describe the abilities that the students should have. For instance, CanMEDs is an analytic framework and it describes the characteristics as discrete domains: Medical Expert, Communicator, Collaborator, Manager, Scholar, Health Advocate, Professional. It also describes subdomains and sub-subdomains.
As you see, CanMEDs divide the competence into domains. However, physicians use some of or all of these competencies at different rates at the same time in the clinics. In fact, competency is not divided, it’s a whole in the real clinical environment. Any physician could not say “when I manage this patient, I firstly use a big chunk of medical expert domain, and then little communicator, and then a little professional, and finally some health advocate”. It’s away from reality. Being competent is a whole, not discrete. If so, why do we still use these analytic frameworks? Isn’t there any alternative? There is! Synthetic frameworks like EPAs.
Flamingo is excited to reveal Entrustable Professional Activities.
CanMEDs and ACGME are analytic frameworks. In total, CanMEDS framework describes 7 roles, 134 elements, 28 key-competencies, and 125 enabling competencies. The assumptions of analytic frameworks are together the discrete elements equal competence, and they can be measured discretely. On the other hand, when physicians talk to a patient, they give information using their expertness, they respect the patients’ values using professionalism, they establish a strong communication using their communication skills. These are used at the same time and they are indistinguishable. So, there is a discrepancy between professional life and analytic frameworks.
To overcome this problem, EPAs, Entrustable Professional Activities could be used. While analytic frameworks describe the abilities of a competent medical student in detail, EPAs describe what the competent student is able to do. EPAs are units of professional practice.
For instance, measuring and reporting blood pressure could be an EPA for medical students, complete physical examination and history could be an EPA for interns, management of uncomplicated ambulant patient could be for junior resident, running a regular outpatient clinic could be for senior resident.
As you see, smaller EPAs are nested in larger ones. You may not be able to fully understand if a resident has become medical expert, professional, and communicator. But you can be witness that the resident is able to cope with the EPAs such as running a regular outpatient clinic, performing a routine check-up of the stable adult patient, conducting a laparoscopic cholecystectomy, breaking bad news to a patient’s family. If the student is able to do all required EPAs without any help, she is competent. You can entrust her for every EPA, it could be assumed that she can start to see patients anywhere without any concern.
Until reaching entrustment, the student goes through some levels for every EPA:
Level 1 — Be present and observe
Level 2 — Act with direct, pro-active supervision, i.e. with a supervisor physically present in the room
Level 3 — Act with indirect, re-active supervision, i.e. readily available on request
Level 4 — Act with supervision not readily available, but with distant supervision and oversight
Level 5 — Provide supervision to junior trainees
In short, EPAs are performable within a given time, observable, measurable, and suitable for focused entrustment decisions. It enables us to evaluate the students more integrated and holistic way. It provides high levels of authenticity.
If EPAs are great, why do we still use analytic frameworks such as CanMEDs? Don’t think like black or white. Nothing can be totally good or totally bad. EPAs have some disadvantages, and analytic frameworks have some advantages over EPAs.
Analytic frameworks theoretically cover all aspects, and allows discrete assessments and feedback on specific facets and domains individually. But EPAs’ holistic assessment may not identify specific reasons for failure to progress.
All in all, even if a framework is accepted by a regulatory institution, none of them is 100% correct or best framework to apply it every time and in every context. Using them with an awareness of strengths and weaknesses is the wise choice.
You can find the sources that I used in this article in the description: https://youtu.be/rDQOJNY19iQ
See you and adios para amigos.
And also, don’t forget the flamingo.
