The A in EPA doesn’t stand for assessment

By: Jolanta Karpinski (nephrologist and clinician educator, University of Ottawa)

When I work with residents (and occasionally students) in the clinic and in patient services, I think of myself as a teacher and clinical supervisor – so how does the introduction of EPAs affect me?

In many implementations of competency based medical education, EPAs have become synonymous with work-based assessment and designations of competence. Criticisms of CBME often target the impact of that focus on assessment (1-4): reducing medicine to a “tick-box exercise”; placing a burden on residents to “get the EPA”; overemphasizing medical expert skills (to the detriment of the other competencies); placing too much attention on easily observable tasks, etc.

But what if EPAs aren’t just about work-based assessment? Before the learner can be entrusted to perform a professional activity, they need to learn about the activity, be provided with opportunities for practice, and be supervised to ensure safe patient care as well as to provide observation and coaching for learner improvement. Do we place enough emphasis on the role of EPAs in guiding the curriculum, learning experiences, and teaching?

An appropriately robust body of EPAs encompasses the scope of the discipline. With the EPAs as a starting point, we can:

• Revise or design the curriculum to provide the knowledge and skills needed in the clinical environment (5)
• Select and arrange clinical experiences so that learners encounter professional activities across the breadth of patients and contexts relevant to the discipline
• Guide learners to seek out opportunities for practice
• Shift the learner/teacher conversation away from topics to tasks (i.e., from knowledge to the integration of competencies in the context of that patient and that setting)

The first two of these four points have significance for the relatively small number of educators and administrators that organize the curriculum and make the decisions about selection and scheduling of clinical experiences. The latter two points have significance for the larger group of clinical teachers that supervise learners in clinical work; let’s focus on the role of EPAs in work-based teaching.

EPAs help identify learning opportunities: there’s an EPA for that!

EPAs help us transform the mundane work of clinical practice into opportunities for learning. What needs to be done today: discharge the patient in room 7516? There is an EPA for that! Let’s focus our learning on how we communicate the discharge plan with the patient/family and how we write the discharge summary for the primary care physician. What needs to be done today: clinic with 16 scheduled patients? There is an EPA for that! Let’s focus our learning on time management in the outpatient setting. What needs to be done today: a central line insertion? There is an EPA for that! Let’s review the video on ultrasound guided line insertion before we set up for the procedure. EPAs can make explicit the learning that needs to occur within day-to-day work.

Conversely, the catch-as-can nature of clinical work can leave inadvertent “gaps” in students’ and residents’ clinical experiences and learning (6). By focusing learning on EPAs, we can ensure that learners take advantage of rare, unusual, or unevenly distributed presentations or procedures. As an example, in my practice, assessment and allocation of deceased donor organs for transplantation is an expectation of the nephrology graduate but organ donor offers come directly to the staff, often at night, and need an urgent response; trainees miss opportunities to participate in donor organ allocation because they don’t get called, it takes too long to reach them, or it’s just easier for the staff to do it without involving the trainee. But, there is an EPA for that!  Identifying this work as an EPA highlights for the supervisor that they should make the effort to involve the resident and helps the resident advocate for the experience for themselves. A fulsome set of EPAs covering the breadth of the expected scope of practice in the discipline can guide teachers and learners to identify, seek out, and take advantage of needed but limited experiences.

EPAs can shift the learner/teacher conversation from a focus on discipline specific knowledge and topics to the clinical application of knowledge and skills in patient care

I’m a nephrologist, I love to talk about the approach to hyponatremia (yes, the Glaucomflecken videos are accurate). But students and residents have algorithms and topic reviews at their fingertips. My time with them is better spent going over how their history, physical exam, and investigations help them assess volume status so as to correctly place our patient on the algorithm. Instead of a table talk about the topic, an EPA focused on how to assess and manage patients takes the learning to the bedside, and integrates medical expertise, communication, and health advocacy competencies into my work-based teaching. EPAs help me, as a teacher, focus on the task and not a diagnosis.

Health professions education, especially after the initial undergraduate/classroom phase, occurs primarily in the clinical setting. Students and residents share our work; expressing the work of a discipline as EPAs serves purposes beyond just assessment. It aligns and highlights our activities as opportunities for work-based teaching and learning.  So after morning handover, instead of saying “let’s get to work” perhaps we should see if “there is an EPA for that” and say “let’s go learn”.

References

1. Only as Strong as the Weakest Link: Resident Perspectives on Entrustable Professional Activities and Their Impact on Learning. Ahn E, LaDonna KA, Landreville JM, Mcheimech R, Cheung WJ. J Grad Med Educ (2023) 15 (6): 676–684.
2. Resident Perceptions of Assessment and Feedback in Competency-Based Medical Education: A Focus Group Study of One Internal Medicine Residency Program. Branfield Day L, Miles A, Ginsburg S, Melvin L. Acad Med. 2020 Nov;95(11):1712-1717
3. The Most Crushing Thing”: Understanding Resident Assessment Burden in a Competency-Based Curriculum. Ott MC, Pack R, Cristancho S, Chin M, Van Koughnett JA, Ott M.  J Grad Med Educ. 2022 Oct;14(5):583-592.
4. An Audit of CanMEDS Roles in Entrustable Professional Activities. LoGiudice AB, Sibbald M, Monteiro S, Sherbino J, Keuhl A, Norman GR, Chan TM. Intrinsic or Invisible? Acad Med. 2022 Aug 1;97(8):1213-1218.
5. Curriculum development for the workplace using Entrustable Professional Activities (EPAs): AMEE Guide No. 99. Ten Cate O, Chen HC, Hoff RG, Peters H, Bok H, van der Schaaf M. (2015). Medical Teacher, 37(11), 983–1002.
6. An analysis of core EPAs reveals a gap between curricular expectations and medical school graduates’ self-perceived level of competence. Marty A., Frick S., Bruderer Enzler H. et al. BMC Med Educ 21, 105 (2021).

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