You are an attending working with a fourth-year medical student on their emergency medicine clerkship. The student sees a patient with the chief complaint of dizziness. After an initial assessment, the student says that there are no red flags in the history and the patient has a normal neurological exam. In the back of your mind you are thinking, “Does this student know the risk factors, comorbidities, and red flags? Was a thorough neurological exam performed?” How do you know the trainee should be trusted?
You are an attending working with a fourth-year medical student on their emergency medicine clerkship. The student sees a patient with the chief complaint of dizziness. After an initial assessment, the student says that there are no red flags in the history and the patient has a normal neurological exam. In the back of your mind you are thinking, “Does this student know the risk factors, comorbidities, and red flags? Was a thorough neurological exam performed?” How do you know the trainee should be trusted?
There is now a framework for answering this question. The Association of American Medical Colleges (AAMC) developed the Entrustable Professional Activities for Entering Residency (EPAs), a list of 13 skills that every graduating medical student should be able to perform at the start of residency, regardless of specialty [1]. This assessment system will help educators evaluate their learners and determine if the student can be relied upon to perform specific skills independently. Below is a quick review of this framework and how it relates to teaching and learning within emergency medicine.
1. What is an EPA?
An EPA is a ‘unit of professional activity,’ a task that a physician performs daily in the clinical environment [2]. Examples of EPAs include: gathering a history and performing a physical exam (EPA 1), forming clinical questions and retrieving evidence to advance patient care (EPA 7), and obtaining informed consent for tests and/or procedures (EPA 11). Some of the EPAs build on each other, such as:
- EPA 1: gathering a history and performing a physical exam.
- EPA 2: prioritizing a differential diagnosis following a clinical encounter.
- EPA 3: recommending and interpreting common diagnostic and screening tests.
However, others stand independently and are a necessary component of a physician’s daily work. For example, EPA 9 evaluates a medical student’s ability to collaborate as a member of an interprofessional team. It is expected that, upon graduation, medical students are able to demonstrate competency performing each of these tasks. A full list of the undergraduate medical education (UME) EPAs can be found in the AAMC’s EPA toolkit.
2. What is entrustment?
Entrustment means that the learner is competent to perform the task without supervision. The process of entrustment represents a gradual progression from a novice trainee to an individual exhibiting skills expected of a practicing physician. The EPAs for graduating medical students represent skills that they should have before the start of residency.
3. Why make a new system? Wasn’t the old system working? Will this make me a better educator?
Prior to this initiative, there was no agreement on a standardized set of expectations for graduating medical students. Additionally, it has been observed that medical students entering residency have vastly different skill sets, and residency program directors were concerned that some medical students were not prepared for their internships [3]. This was the premise for defining the 13 core EPAs. The 13 EPAs are oriented around well-defined tasks that can be evaluated in the workplace, and with that, a more intuitive way to evaluate students. From an educator’s perspective, using EPAs as a new framework for evaluation may help better target the goals for each individual medical student. For example, a student may have already mastered EPAs 1-3 prior to coming to your rotation. Knowing this information, you could then hone in on other EPAs.
4. Then what are “observable professional activities,” and milestones? How are these different than EPAs?
Think of these as building block units of different sizes. The smallest size unit is the OPA, or an ‘observable professional activity.’ This is an action that can be observed in the professional workplace. Many OPAs will map to an EPA [4]. For example, EPA 1 is “gathers a history and performs a physical exam.” This EPA is comprised of many OPAs that must be performed to fulfill the EPA, including obtaining a past medical history, obtaining allergy history, obtaining a social history, performing an abdominal exam, performing a chest exam, etcetera. The summation of these OPAs is EPA 1.
Figure 1: Milestones, EPAs, and OPAs all describe clinical competencies.
The EPAs can then be mapped to milestones [5]. Milestones are describe the knowledge, skills, and attitudes required to be competent in a particular speciality [6]. Milestones have largely been used by the ACGME as a framework to evaluate residents. For instance, Milestone 2 in emergency medicine requires residents to “perform a focused history and physical exam, abstract current findings in a patient with multiple chronic medical problems and, when appropriate, compares with a prior medical record and identifies significant differences between the current presentation and past presentations.” This milestone is comprised of many EPAs including EPA 1 (gather history and perform a physical exam), EPA 2 (prioritize a differential diagnosis), EPA 7 (form clinical question and retrieve evidence to advance patient care), and EPA 10 (recognize a patient requiring urgent or emergent care).
Figure 2: An example of the intersection of milestones, OPAs, and EPAs.
5. How do EPAs apply to training in emergency medicine?
Emergency medicine is the ideal rotation for students to be assessed on EPA 10, which is “Recognize a patient requiring urgent or emergent care and initiate evaluation and management.” This EPA requires students to recognize abnormal vital signs, determine “sick” from “not sick,” gather pertinent history in an urgent or emergent situation, monitor response to initial interventions, and communicate to patient/family/staff accurately about their condition. This is an EPA built for the emergency department.
6. How will EPAs be incorporated in a daily shift in the emergency department?
If you are an emergency physician that supervises students, you will likely be asked to evaluate medical students using EPAs. For example, you may be asked at the end of a shift to evaluate EPA 1 (gather a history and perform a physical). This will likely look similar to previous evaluations:
How often did you need to prompt the student on history taking and physical examination?
- Often
- Sometimes
- Rarely
- Never
Level four would be entrustment, which demonstrates the student has successfully achieved this EPA. Achievement of specific EPAs on various clerkships may be used to determine a student’s progress toward residency-readiness. While this framework may not be integrated at all institutions at this time, this framework is becoming the new standard of assessment per the AAMC.
Case Conclusion:
After your student presents the case on dizziness, you realize that EPA 1 is “Gather a history and perform a physical examination,” and that you are trying to determine if this medical student can be entrusted to perform this professional activity.
You ask the medical student some additional questions about the patient’s chief complaint of dizziness, and the student identifies that the patient is experiencing vertigo. You ask the student to list red flag symptoms for a patient with vertigo, which she is able to do without difficulty. You then bring the student into the room and confirm that the history is accurate with no red flags. You ask the student to perform a neurologic exam in front of you. The student performs a complete neurologic examination and identifies the pertinent negative findings reassuring against the central causes of vertigo. You conclude that the student can be entrusted to perform a history and physical exam for a patient with vertigo on your next shift.
Want more? learn about the nuts and bolts of competency based education.
References
- Carroll R, Frank J, Fulton T, et al. Core Entrustable Professional Activities Curriculum Development Guide. American Association of Medical Colleges. 2013. Accessed Oct 1 2019. https://store.aamc.org/downloadable/download/sample/sample_id/66/.
- Ten Cate O. Nuts and bolts of entrustable professional activities. J Grad Med Educ. 2013;5(1):157–158. PMID: 24404246.
- Lyss-Lerman P, Teherani A, Aagaard E, et al. What training is needed in the fourth year of medical school? views of residency program directors. Acad Med. 2009;84(7):823-9. PMID: 19550170.
- Teherani A, Chen HC. The next steps in competency-based medical education: milestones, entrustable professional activities and observable practice activities. J Gen Intern Med. 2014;29(8):1090–1092. PMID: 24737226.
- Hart D, Franzen D, Beeson M, et al. Integration of entrustable professional activities with the milestones for emergency medicine residents. West J Emerg Med. 2019;20(1):35-42. PMID: 30643599.
- Beeson M, Christopher T, Heidt J, et al. The development of emergency medicine milestones. Acad Emerg Med. 2013;20:724– 729. PMID: 23782404.
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