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“Best Before…” and “Use By…” dates in relation to Entrustable Professional Activities.

By: Gersten Jonker, MD, PhD

Image generated with AI (deepai.org)

At the beginning of the year, I resurfaced a small container with truffle mayonnaise from the back of my fridge. The date on it was December 23rd… that’s even before Christmas… it looked good, though…

Food may lose some of its qualities over time, like the smell of fresh bread, but it stays perfectly edible for a while longer when stored appropriately. This is reflected in the “Best Before Date.” Nevertheless, perishable food – like my truffle mayonnaise – may still look and smell fine but may actually be unsafe to consume after a certain date. This is the “Use By Date.”

In 2022, my educational role limited my clinical time and made me focus on one clinical area (adult anesthesia), resulting in abandoning the subspecialty that I had worked in for over a decade (pediatric anesthesia). However, in early 2025, 2.5 years later, I was asked to fill in some gaps in the pediatric anesthesia schedule caused by staff shortage.

Returning unexpectedly to pediatric anesthesia initiated a reflection on what happens when a skill set has not been “used” for some time. Almost immediately, my mind went back to the distinction between “Best Before” or a “Use By”dates; this time, not in my refrigerator, but in medical education. It made me think about one of the eight components of an Entrustable Professional Activity (EPA) description: the expiry date. My next thought was: Is the EPA expiry date rather a “Best Before Date” or a “Use By Date”?

The expiry date of an EPA states how long a summative entrustment holds if the activity is never practiced (Taylor et al, 2024). High proficiency levels ask for continued and deliberate professional practice (Ten Cate & Hennus, 2024). The entrustment decision “guarantees” adequate competence, but competence may diminish over time if the activity is not practiced deliberately (Ten Cate & Taylor, 2021). Consequently, the training program cannot uphold the promise that the practitioner is able to provide safe patient care if competence is not maintained with continued practice. There is, however, no evidence to support the half-life of entrustment decisions, and these would likely differ between EPAs. After a period of decline of competence, it might even be recommended to have a period of supervision until trust is reaffirmed (Ten Cate & Taylor, 2021).

I wondered whether I could still be entrusted with activities in pediatric anesthetic care? Could I still be considered proficient? On my first day back, I said to the coordinating pediatric anesthesiologist, “Supervision level 3 for me today, eh?”, which was greeted with a dismissive laugh of ad hoc entrustment.

It occurred to me that, similar to ad hoc entrustment, the factors that enable trainee autonomy (Jonker et al, 2024) apply here largely as well. In an insightful conversation with the anesthetic nurse, we agreed that practitioner characteristics such as Agency, Reliability, Integrity, Capability, and Humility (Ten Cate & Chen, 2019) mattered, as did availability of collegial support and help of team members. We contemplated the complexity of the task and the importance of discerning your limits.

The nurse and I also agreed that restarting subspecialty practice in the setting I knew so well was helpful. Working with familiar nurses, colleagues, and even with familiar materials eased the re-entry to a good extent. The daytime setting with plenty of people around was reassuring, as was experiencing some moments of self-efficacy. Competence is context-dependent.

The period of disuse should be seen relative to the period of deliberately practicing (Ericsson et al, 1993) the EPA before its discontinuation. It matters whether a learner stops practicing an activity immediately after reaching the required level of competence, or whether a seasoned, self-reflective professional abandons the activity.

Another day, an anesthetic nurse argued that working in similar non-pediatric EPAs would be supportive in maintaining (transferable) competence; pediatric skills and attitudes are of benefit in adult anesthesia and vice versa.  For me, this resonated with the concept of adaptive expertise (Croskerry, 2018). A professional must consciously (or deliberately) gather experience and learn from it through feedback and reflection. That is what I have always tried to do – and perhaps am doing now in writing this blog.

If we link the expiry date of dietary products to expiry dates of EPAs, the above mentioned scenario would be akin to a “Best Before Date”. The competence may have lost some of its subtleties and finesse but may be adequate under appropriate conditions.

However, with EPAs, the “Use By Date” is pertinent as entrustment links directly to patient safety. First and foremost, patients should be confident to receive a high standard of care. Also, professional bodies and regulators have the obligation to protect patients’ safety and might want to examine “Use By Dates”. The main question for the health care team to address may be “Would you trust your loved ones to this practitioner?” (Jonker 2020). The nurse on day one had immediately mentioned to weigh in patient factors, such as complexity and acuity, in addition to task difficulty.

Much EPA-related research has focused on attaining an adequate level of competence for summative entrustment. Little attention has been given to the post-entrustment phase with continuing development, maintenance, and/or decay of competence, or to reaching adaptive expertise, and how to assess these elements.

In the end, the truffle mayonnaise served as a useful reminder: appearance alone is an unreliable indicator of safety. The same is true for clinical competence after periods of non-use. If we want to apply evidence-informed expiry dates to EPAs, future research must illuminate both their “Best Before” and “Use By” Dates. Only then can entrustment decisions continue to uphold their most important promise: safe, trustworthy patient cares.

The author owes thanks to Claire Touchie, Adi Marty, and Aleda Chen for their feedback on an earlier version of this blog post.

Refrences:

  1. Taylor DR, Fitzpatrick S, López MJ, Hennus MP, Marty AP, Ten Cate O. Entrustable professional activities and EPA frameworks defined. In: Ten Cate C, Burch VC, Chen HC, Chou FC, Hennus MP (Eds). Entrustable Professional Activities and Entrustment Decision-Making in Health Professions Education, Chapter 8, pp. 87-100. [2024] London: Ubiquity Press. Doi: https:/doi.org/10.5334/bdc.h
  2. Ten Cate O & Hennus MP. Entrustable professional activities and entrustment decision-making for competency-based education in the health professions: an introduction. In: Ten Cate C, Burch VC, Chen HC, Chou FC, Hennus MP (Eds). Entrustable Professional Activities and Entrustment Decision-Making in Health Professions Education, Chapter 1, pp. 3-14. [2024] London: Ubiquity Press. Doi: https:/doi.org/10.5334/bdc.a
  3. Ten Cate O & Taylor DR. The recommended description of an entrustable professional activity: AMEE Guide No. 140. Medical Teacher, 20121; 43 (10): 1106-14.
  4. Jonker G, Klasen JF, Hennus MP, De Graaf J, Schumacher DJ, Ten Cate O. Entrustment with health care tasks: balancing trainee autonomy, supervision, and patient safety. In: Ten Cate O, Burch VC, Chen HC, Chou FC, Hennus MP (Eds). Entrustable professional Activities and Entrustment Decision-Making in Health Professions Education, Chapter 18, 213-223. [2024] London: Ubiquity Press. Doi: https://doi.org/10.5334/bdc.r
  5. Ericsson, K.A., R.T. Krampe & C. Tesch-Römer (1993). The role of deliberate practice in the acquisition of expert performance. Psychological review, 100(3), 363. doi.org/10.1037/0033-295X.100.3.
  6. Croskerry, P. (2018). Adaptive expertise in medical decision making. Medical Teacher, 40(8), 803-808. doi.org/10.1080/0142159X.2018.1484898 Jonker G, Ochtman A, Marty AP, Kalkman CJ, Ten Cate O, Hoff RG. Would you trust your loved ones to this trainee? Certification decisions in postgraduate anaesthesia training. Br J Anaesth 2020 Nov;125(5):e408-e410
  7. Jonker G, Ochtman A, Marty AP, Kalkman CJ, Ten Cate O, Hoff RG. Would you trust your loved ones to this trainee? Certification decisions in postgraduate anaesthesia training. Br J Anaesth 2020 Nov;125(5):e408-e410. doi: 10.1016/j.bja.2020.07.009.
  8. Ten Cate O & Chen HC. The ingredients of a rich entrustment decision. Med Teach 2020; 42(12):1413-1420. doi: 10.1080/0142159X.2020.1817348.

About the Author:

Dr. Gersten Jonker, MD, PhD, is an anesthesiologist with a PhD in medical education. He is the program director of anesthesiology residency training at the University Medical Center Utrecht in the Netherlands. His research interests are competency-based workplace-learning and workplace-based assessment.

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