Would you like to have a starting medical trainee perform a laparoscopy on you?

O.M.W. I definitely wouldn’t!  
That’s why I am happy that these days medical trainees are guided through workplace curricula in which they learn step by step, with decreasing supervision, to master such procedures. The assessment of trainees is directed to the way they perform tasks. Because of this emphasis on workplace learning, today’s physicians are much better prepared for their job than they used to be. An Entrustable Professional Activity (EPA) is a rather new concept that provides a framework for such a workplace curriculum.

EPA?


EPA stands for Entrustable Professional Activity. An EPA is a complex activity that is typical for a specific professional practice. It needs to be mastered by every professional and is central in the training of trainees who are going to be physician or health care worker. ‘Entrustable‘ means that it can be entrusted to a sufficiently competent learner. Examples from health care are: providing end-of-life care for older adults; conducting a risk assessment; care of a young patient in the acute emergency care unit; conducting a laparoscopic cholecystectomy. EPAs are high-risk or error sensitive and involve different competences.
It takes time for a trainee to master such high risk activities. That’s why -in the workplace curriculum- trainees move from simple to more complex tasks and are only allowed to do more independently overtime. That is why learning is organized via 5 different levels of supervision:

  1. The trainee is present when a task is performed by another professional, (s)he just observes;
  2. The trainee can act with direct, pro-active supervision, the supervisor is physically present in room;
  3. The trainee acts with indirect, re-active supervision, meaning the supervisor is around when needed;
  4. The trainee can act rather independent with supervision not readily available;
  5. The trainee is close to a professional and can provide supervision to junior trainees.  

Where do EPAs come from?

In 2005 ten Cate et al. introduced this concept to get a better grip on learning in the workplace. Medical faculties in The Netherlands, United States, Germany started working with EPAs in their workplace curriculum. They are motivated by the idea that an EPA seems to be a more suitable focus for assessment than separate competences.

EPAs!? What happened with competences?

Competence-development is still important for medical trainees. Competencies describe the qualities of a person and are hard to assess, whereas EPAs describe the work that needs to be done.
In  practice it turned out to be quite difficult to assess competencies, not only because it is hard to define them in solid criteria but also to different levels.


Since EPAs are directly related to activities, they can be described in terms of required knowledge, skills and attitudes; the link with a competence-domain; the type of information needed to monitor progress; criteria that need to be fulfilled in order to achieve the EPA at a specific level.
An overview of the components that fully describe an EPA can be found here.
An example of an early EPA in undergraduate medical education can be found here.

What about the assessment of trainees?

Assessing the progress of a trainee is not a one-time event but an ongoing process based on different kinds of inputs like observations, quantitative and narrative feedback from different sources (e.g. patients, peers, specialists), knowledge and skills tests. All these formative assessments are used to ground a summative entrustment decision for an EPA at a specific level. Assessment is directly related to supervision and is meaningful.

Why digital?

Technology can support trainees and supervisors in generating overviews of the progress of a trainee. EPASS does just that. Feedback-overviews help trainees in deciding what actions and behaviour (rehearse knowledge and skill, actively select next experiences) are needed in order to move on to a next entrustment decision about an EPA. For supervisors, all the information about a trainee are collected and aggregated to support summative entrustment decisions and inform supervisors in the workplace.

Conclusion

EPASS supports entrustment decisions about an EPA, this helps to make sure that we as patients never run the risk that an uncappable trainee to be is going to do a laparoscopy on us.  

Source: Curriculum development for the workplace using Entrustable Professional Activities (EPAs):
​AMEE Guide No. 99
Olle ten Cate, Huiju Carrie Chen, Reinier G. Hoff, Harm Peters, Harold Bok & Marieke van der Schaaf
Medical Teacher Vol. 37 , Iss. 11,2015

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