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

The story of EPASS and Family Medicine at Stellenbosch University: part 2

The pilot

The pilot took place from February – April 2016 and was successful.  Registrars and supervisors valued EPASS to be very user-friendly. New options (see below) were appreciated and used, inconsistencies taken care of by the developers.

We’re proud that since May 2016 all Family Medicine registrars in the Western Cape are using the EPASS digital portfolio.

What is new and innovative in the EPASS-version that is developed for Family Medicine?

In my first blog (Nov. 2014) I presented 5 reasons why a portfolio has to be digital. In EPASS for Family Medicine additional reasons came up, the most important are:

  1. Treating a Learning Plan as an iterative process in which the registrar and supervisor work together via version control.
  2. Linking different forms together, e.g. the registrar can link a ‘Mini-CEX’ to ‘the registration of a specific procedure’.
  3. Providing authentic feedback by the supervisor by validating a feedback form with their password. 
  4. Generating an overview of all narrative feedback that a registrar received (by registrar and by supervisor).
  5. Generating different overviews of the status of the portfolio requirements, i.e. how many more observations, teaching events, learning plans do I need to realise before the end of the year.
  6. Calculating the scores in a feedback form and over a series of assessment forms.
  7. Creating different kind of management reports by the Head of Department: an overview of the feedback that supervisors provide (to use for quality purposes); an overview of the amount of feedback that is provided; an overview of the progress of the registrars.

Follow-up

The Stellenbosch Division of Family Medicine invested time and money in EPASS. They are happy with the new way of digital assessments so they want to make sure all FamMed registrars in South Africa benefit from the way they pioneered the system. This means that the other 7 divisions or departments of Family Medicine in South Africa pay only a fraction of the development costs. They don’t need to spend the same amount of time and money on the development of their EPASS: only a small initial fee for the setup is needed.  After EPASS was presented at the meeting of the Council of Family Medicine  half of May,  Walter Sisulu University, Department Family Medicine and Rural Health already decided to go forward, they plan to start in September 2017.

In August 2017 Intaka Learning is meeting with Stellenbosch University (Family Medicine) again to talk about new developments and options in EPASS and changes in the current version.
We will keep you informed.

The story of EPASS and Family Medicine at Stellenbosch University: part 1

Family Medicine?!

Family Medicine is a relatively new specialisation in South Africa, it started in 2007 based on a need. In Africa 70% of the Family Physicians work in district hospitals in rural areas. Contrary to Family Physicians in North America and Europe they have to perform clinical procedures and operations.

The meeting

On a hot December morning in 2014 my partner Yusri Dien and I had a meeting with 3 professors from the division of Family Medicine and Primary Care (FamMed) at Stellenbosch University: Bob Mash (head of FamMed Stellenbosch University), Louis Jenkins (head of Fammed George hospital) and Julia Blitz (now vice-dean Learning and Teaching). In this meeting we presented EPASS, the ‘open’ digital portfolio that is developed in Maastricht University – the Netherlands.

Assessment

Postgraduate FanMed students (registrars) have to develop knowledge, skills, competences.  To improve the validity of the assessment, workplace-based assessment (WPBA) was implemented. In order to capture this WPBA a national learning portfolio was developed through a consensus process involving all eight universities. It was implemented in 2010.  Registrars must show evidence of satisfactory performance over a three-year period, in an accredited training post, in order to enter the final national exit exam.

Potential

In the meeting we presented a version of EPASS that was developed for Gynaecologists. This version offers lots of different options so Prof. Bob Mash and his colleagues could immediately see its potential. And they did! Intaka Learning was pleased to have found a partner that shared the vision behind EPASS: importance of feedback, focus on development, assessment of ánd for learning.
In May 2015 we agreed to start the process of developing the first version of EPASS in South Africa for Family Medicine.

The development process

EPASS is an ‘open’ system, meaning it has to be adapted to a specific context (assessment policy). All involved knew this would take time and money, so we were prepared.
We started with comparing the paper portfolio of learning with the different options and feedback- and assessment forms that are available in EPASS. From February – May 2015 we worked together on a first version of the specifications: what options are needed, what are the implications, how exactly are they related, etc. In June the specifications were translated in ‘description of work’ and in September and October the developers in the Netherlands could start the actual development. November was used for testing, new insights, adjusting, more testing and de-bugging. In December EPASS for Family Medicine was ready for use and the pilot in Eden district could be prepared.

All of us were excited with the new insights and functionalities that developed on the way. In 2015 the focus was on specifications, development, testing, more development and testing, and preparing for the pilot.
In February 2016 the pilot kicked off in George with a workshop by Intaka Learning in which EPASS was introduced to the staff. Interested to find out what happened at the pilot? Read our next blog post (coming soon)!  

Jenkins L, Mash B, Derese A. Reliability testing of a portfolio assessment tool for postgraduate family medicine training in South Africa. Afr J Prim Health Care Fam Med. 2013;5:1–9.