Bringing competencies closer to day-to-day clinical work through entrustable professional activities

Over the past 20 years, medical training institutions, medical regulatory authorities and the public have sought to redefine the competent medical doctor. This has reshaped the training and assessment of students, interns and registrars across the continuum. Canada, the United Kingdom, the United States, the Netherlands and Australia have contributed to this global movement.1,2

Why were these changes necessary? For centuries, medical education was a matter of education on the job in apprenticeships.3 With the establishment of universities, medical faculties provided systematic knowledge about human anatomy, botany and medicine. Much of the practical teaching of medicine, however, remained with non-university professionals. By the mid-19th century, most Western countries combined university education with a requisite practice period.

Throughout the 20th century, medical education was propelled by the influential Flexner report (1910),4 and scientific advances and increased diagnostic and therapeutic possibilities further transformed medicine and surgery from a “practice-based knowledge” profession to a “knowledge-based practice” profession grounded in sound knowledge of the foundational sciences. By the late 20th century, a huge growth in biomedical knowledge dominated medical school curricula, disconnecting learning from the practice of health care. The length of training had significantly increased, as all practitioners needed to be licensed in a specialty as a condition for practice, and educational approaches favoured structured and integrated curricula with defined learning objectives, student-centred and problem-based learning, facilities for simulation and use of objective skills tests.5

Meanwhile, specialty training remained relatively unstructured and time based, with implicit objectives and inconsistent assessment.6,7 Provoked by patient safety concerns and demands for greater accountability,6,8 medical professional organisations, including colleges, realised that training and assessment needed to be more explicit and structured to ensure consistent quality in graduate outcomes.8 New objectives included not only technical expertise, but the intrinsic professional skills required to work effectively in teams and manage in complex health care systems. Comprehensive frameworks, such as the Canadian Medical Education Directive for Specialists, with detailed descriptions of roles, general domains of competence, specific competencies and behavioural milestones of development of competence were established.9,10 This move to competency-based postgraduate medical education was seen as a paradigm shift,11 and was embraced in many countries.

The Australian Medical Council (AMC), established in 1985 to assess medical schools,12 had its scope extended in 2001 to include accreditation of specialist medical education,13 and, in 2014, it developed the National Intern Accreditation Framework. The AMC standards for specialist medical education led to the development of curricula with detailed learning outcomes, as well as documented work-based assessment and feedback.

Entrustable professional activities

Despite these advances, teaching and assessing long lists of competencies evoked criticism as being cumbersome and inadequate.14-16 There appeared to be a conceptual “gap” that needed to be “bridged” between the competencies to be assessed and the daily clinical tasks of physicians.17 This is where the concept of entrustable professional activities (EPAs) emerged. EPAs are a reflection of actual practice described as units or tasks that may be entrusted to learners who have demonstrated that they are ready to perform them unsupervised or with distant supervision only.17,18

The essential difference between competencies and EPAs is that competencies are characteristics of individuals (ie, knowledge, skills and attitudes), while EPAs describe the work that must be done. In order to do the work to acceptable standards, individuals must have the requisite specific competencies. As EPAs require the integration of various competencies, they constitute a valid focus for assessment. Many busy clinicians find assessment of isolated competencies or competency domains challenging. In contrast, when asked “can this trainee be trusted to carry out this activity without your direct supervision?” clinicians usually have an adequate intuitive estimation they rely on. An “entrustment” question may elicit a more reliable answer than asking for a score on a scale.19 Moreover, EPAs serve more tangible outcomes than competencies because they relate directly to clinical practice and patient care.

EPAs can serve as the building blocks of a clinical workplace curriculum, form the primary focus of assessment of learners, and provide clear objectives for learning and practice. Instead of attempting to evaluate separate competencies of trainees, such as medical knowledge, communication and collaboration skills and professionalism, EPAs integrate these and focus on the task as a whole (Box 1).20

An EPA is like driving a car — as soon as learners have demonstrated sufficient competence, they may be licensed to practise without supervision. Learners not ready for unsupervised practice may have a lack of knowledge, skill, responsiveness to critical situations or other features of unpreparedness. Only an integrated application of these features makes the assessor confident that the learner is ready for a licence.

As an example, EPAs in obstetrics require multiple competencies to be enacted in an integrated fashion (Box 2). Almost all EPAs integrate multiple competencies; the assessment of trainees in an EPA-based program focuses on EPAs (the horizontal dimension), not primarily on separate competencies (the vertical dimension). When evaluating learners, specifically those with marginal performance, a well described EPA, mapped to competencies, will enable a more detailed judgment as well as tailored feedback to learners. One or more competencies may prove to be the reason why a trainee is not ready for the unsupervised practice of a certain EPA. So the primary assessment question is “can the trainee do this in all respects?” and then “if not, why not?” A review of the embedded competencies will help structure the feedback to the trainee (Box 2).

For example, a supervisor observing a trainee managing uncomplicated pregnancies may first focus particularly on the trainee’s medical expertise to make sure that they have the ability to identify when complications arise and help is needed. Next, health advocacy is important and, in this case, it particularly refers to knowledge and skills in the realm of prevention and advice. Professionalism is also essential to build a longitudinal relationship across the period of pregnancy. Other domains of competence may at times weigh in, but medical expertise, communication and collaboration are crucial.

Entrustment as an assessment tool

Assessing learners based on EPAs differs from traditional assessment in the clinical workplace. EPAs are geared to entrustment decisions. These include not only the evaluation of ability or competence, but they also grant the permission to act under a designated level of supervision (eg, direct supervision, indirect supervision and distant supervision) in providing clinical service.21,22 This essentially changes the nature of assessment of learners in the workplace by acknowledging their readiness for the unsupervised practice of specified units of professional work, and thus gradually allows them to develop as expert practitioners. If specialties have been well described in these units of professional practice (ie, EPAs), professional competence of individual practitioners may be identified as their portfolio of certified EPAs, a concept that may hold from medical school through professional practice until retirement.

When a particular EPA is fully mastered, the trainee may be granted permission to act unsupervised, while the same trainee may require more time and practice for a different EPA. Likewise, within a cohort of trainees, the time required to achieve entrustment of a particular EPA may differ. In this way, competency-based training using an EPA framework is more flexible and tailored to individual trainees because it is based on their observed competence and not on a predetermined time in training.

A pure competency-based approach to specialist training would enable learners to complete training at their own pace with variable times. This is impractical given that specialist training is integrated with clinical work and service rosters. A minimum training period will always be required.

What if trainees meet all requirements of core EPAs months before the minimum training period? In this case, they may choose to add elective EPAs to their portfolio. The key point is that only trainees who demonstrate achievement of all core EPAs, in addition to other training requirements (ie, research projects, examinations), should progress to the next stage of training or practice. While time and clinical experience will always be essential to the development of the high levels of tacit knowledge and expertise required of specialists, EPAs help make explicit the expected standards required at different stages of training. They can be used as the basis for learning, reflection, assessment and feedback in a way that is beneficial for trainees, helpful for supervisors and ultimately, more accountable to the community.

Application of EPAs

EPAs have become popular, and many undergraduate and postgraduate medical programs in the US and other countries are currently describing their programs using EPAs. A recent Association for Medical Education in Europe guide provides more details of this process.23 In many cases, EPAs are identified in consensus procedures, such as Delphi studies, workshops and focus groups among members of specialty associations. Within Australasia, EPAs now form an important component of the Competency Based Fellowship Program of the Royal Australian and New Zealand College of Psychiatrists.24 The Royal Australasian College of Physicians has recently successfully piloted EPAs in the Community Child Health Advanced Training Program,25 and the Royal Australasian College of Surgeons has incorporated EPAs (referred to as key clinical tasks) in its JDocs Framework.26 EPAs were extensively discussed at the 2016 International Medical Symposium in Sydney.27 The impact of EPAs, including their acceptability to trainees and supervisors and the benefits in terms of patient care, will need to be monitored and assessed over time.