By: Linda Snell
There are lots of challenges getting work-based assessments (WBAs), particularly if they focus on entrustable professional activities (EPAs), completed and documented in a timely and effective manner. WBAs facilitate formative assessment … in theory. However, in practice obtaining EPA observations occurs in a complex and sometimes chaotic clinical environment which must integrate the context, supervisor/teacher, learner and content.(1) In this blog I will be addressing a small part of this – trainee negative perceptions of EPAs and how the supervisor might address this.
Consider the following scenarios. These are drawn from typical responses I get when, as a clinical supervisor, I discuss EPAs with residents.
Scenario 1
Resident: ‘Please complete an EPA form online on the patient we saw together last week.’
[this was a non-complex patient where the resident thought they had performed well]
Scenario 2
Supervisor: ‘Shall we “do an EPA” on your first admission work-up today?’, or ‘.. on a procedure you are about to perform?’
Resident: ‘Oooh, I am not ready to be observed! Can we wait until next week please?’
Scenario 3
Resident: ‘the E in EPA is for ‘entrust’ – don’t you trust me to do this on my own?’
The scenarios suggest a few issues with obtaining EPAs.
In scenario 1, the resident is asking for an EPA to be done long after the event has occurred, limiting the amount of timely relevant feedback. Also, the trainee thinks that they performed well on this ‘easy case’ so they are ‘cherry picking’ a ‘good’ case where a favorable judgment on this activity will be achieved. This might suggest they are ‘gaming’ the system. The language of assessment does not help – learners ‘attain’ or ‘achieve’ EPAs, they ‘progress’ through stages: these words suggest the stakes for an individual observation may be perceived as high, as the feedback is documented and submitted to a competence committee. Assuring residents that EPA observations are ‘low stakes’ is not usually effective. We must consider how the consequences of doing well or poorly are perceived by the learner. They may appreciate the feedback but see that these WBAs are used in sum by competence committees to guide decisions on progression and entrustment. Many EPA rating forms include a numeric rating (either implicit or explicit), for example, ‘I had to be there just in case’ is a 4 out of 5. These are viewed as ‘marks’ by trainees, as opposed to a decision to grant autonomy reflecting increasing development.
In scenario 2 not wanting an EPA observation might suggest the trainee has a performance or fixed mindset rather than a growth mindset that is capable of learning from mistakes. Or perhaps ‘not ready’ might be discomfort with not knowing something or being able to do something correctly. This could be a lack of recognition of Vygotsky’s ZPD, the zone of proximal development, where the being at or just beyond the limit of competence causes ‘constructive friction’ and concurrent learning.
In scenario 3 the resident may be conflating or confusing the words ‘trust’ and ‘entrust’. As defined according to the Oxford English Dictionary, trust is “to have confidence in somebody; to believe that somebody is good, sincere, honest, etc”, i.e., a quality or attribute of a person. Entrust is “to make somebody responsible for doing something or taking care of somebody”, i.e., pertains to a specific responsibility or task. In clinical education the supervisor relies on [entrusts] a trainee to perform a given professional task correctly and trusts their self-awareness of limitations and willingness to ask for help when needed.” (2) So, in this case the resident may think that the supervisor is commenting on a personal attribute rather than the performance of a task. And “doing an EPA” is not language we should perpetuate. It reduces the concept of entrustment for an activity to a rating on a form that does not relate to an actual entrustment decision. And EPA is an activity to be done (whether observed or not), not a rating form.
Despite these negative perceptions, trainees need meaningful feedback and coaching to guide learning. So how can we reconcile the need for some documented assessment of performance (‘of’ learning) with the need to provide feedback and coaching (assessment ‘for’ learning)?(3) Here are a few things I have tried that seem to work.
- Explain to your resident that the primary purpose of individual observation with feedback is not pass or fail, and although it contributes, it should be seen as separate from a competence committee decision. The resident may not recognize that a favorable judgment by an individual supervisor on the performance of an EPA does not equal granting full autonomous practice with no oversight. Rather, it leads to a graduate fading of educational supervision. These concepts will likely need reinforcement.
- Insist EPA observations be done in the moment and in person if possible, and not retrospectively – we know feedback is more effective when timely.
- Use more narrative than number – an EPA is supposed to provide formative assessment (‘for’ learning) which implies that there must be detailed comments on what worked well in the trainee performance, what could be improved, and how it could be improved. Whether the supervisor had to be present or not is less relevant. Numbered grading and ranking of learners do not fit well with a competency-based philosophy.(4)
- Change your own language around assessment. Limit words like achieve, pass or fail an EPA. Ensure that the word entrust is linked to a task (‘ready to be entrusted with an EPA’), not to the person being assessed.
- Finally, modify your language when asking for a WBA. Try ‘Can I give you some feedback? [or coaching?] Once we have done it, I will document it.’
- Finally, stop calling individual observations EPAs, as if EPAs were an assessment tool.
About the Author:
Dr. Linda Snell is a Professor of Medicine and Health Sciences Education at McGill University, an active Core Faculty member of McGill’s Institute for Health Sciences Education, and Senior Clinician Educator at the Royal College of Physicians Surgeons of Canada.
References:
- Schuwirth L, Torre D. Assessment stakes and authenticity of learning, can they be reconciled? Adv in Health Sci Educ. 2024 Oct 16;
- ten Cate O, Hart D, Ankel F, Busari J, Englander R, Glasgow N, et al. Entrustment decision making in clinical training. Acad Med. 2016 Feb;91(2):191–8.
- Watling CJ, Ginsburg S. Assessment, feedback and the alchemy of learning. Med Educ. 2019 Jan;53(1):76–85.
- Kelleher M, Kinnear B, Weber D, Martini A, Santen SA, Baker P, et al. A Rollercoaster of Grades Versus Growth in the Clerkship Year: A Phenomenological Study of Medical Student Experience with Competency Development. Perspect Med Educ. 2024 Nov 25;13(1).
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