May 2014 – Association of American Medical Colleges
By Rebecca Greenberg
A new set of AAMC guidelines identifies 13 entrustable professional activities (EPAs) medical school graduates should be able to perform on the first day of residency. Published in May, Core Entrustable Activities for Entering Residency serves as a guide for curriculum developers, faculty, and learners to better prepare students for roles as clinicians.
“The primary reason for [developing the EPAs] is for patient safety,” said Carol Aschenbrener, M.D., AAMC chief medical education officer and a member of the report’s drafting panel. “But we also think an equally strong benefit will be to increase the confidence of the learners as they start their residencies.”
The report lists “pre-entrustable” and “entrustable” behaviors for each EPA, which include gathering a patient history, prioritizing differential diagnoses, and recommending tests or prescriptions. The 13th EPA covers “identifying system failures and contributing to a culture of safety and improvement.”
Two manuals will be available: the main report for curriculum developers and an accompanying document for faculty and learners. The Curriculum Developers’ Guide will include details about how EPAs connect to competence domains. The Learner and Faculty Guide will include details about the EPAs and expected behaviors and clinical vignettes that describe pre-entrustable and entrustable learners.
“This will be a pragmatic list for students about some of the real professional activities they will be preparing to do as physicians,” Aschenbrener said. “As they are reading and listening to lectures they will be able to link them to what they will actually be able to do—it takes [medical education] from the theoretical to the practical.”
The Liaison Committee on Medical Education (LCME) requires that all accredited medical schools have educational objectives that are grounded in outcomes. Most schools have “graduation competencies” or “graduation objectives,” but there is no formal agreement about common behaviors that should be expected of all graduates.
This can make the transition from medical school to residency tenuous for some students. Scholarly articles indicate that residency program directors have expressed concern that some graduates are not adequately prepared.
“One of the challenges that medical education has faced for decades has been that education has occurred in silos,” said William Iobst, M.D., vice president for academic and clinical affairs and vice dean at The Commonwealth Medical College. “What happens in medical school does not necessarily link effectively to the next level of training, which would be residency, nor does that training link effectively to what’s required for independent practice.”
An expert in competency-based education and assessment of trainee performance, Iobst said the EPAs are intended to identify a core set of activities that any residency program director can trust a student to do upon entering residency. “I think a big driver [of EPAs] is the need for the program director to be able to attest to the public that the new resident can safely perform certain activities from day one of residency. This is essential for the practice of safe and effective care even at the very start of residency.”
In addition, medical school curricula often are tied to the needs of local patient populations, and implementing EPAs has the potential to create greater consistency, according to Diane Hartmann, M.D., senior associate dean for graduate medical education at the University of Rochester School of Medicine and Dentistry.
“Whether a student stays at their institution or travels 3,000 miles across the country, the residency program can have the sense that the faculty at the medical school has observed them perform basic entrustable activities and feels comfortable with the student doing them,” she said.
The EPAs outline what is expected of medical school graduates, regardless of which school they attend or specialty track they pursue. To develop the EPAs, the AAMC convened a drafting panel of one student and resident, scientists, and leaders in undergraduate and graduate medical education.
The panel built on work that defines requirements at key points in physician training, such as college to medical school, medical school to residency, and residency to practice or fellowship. Specifically, the panel referenced the Accreditation Council for Graduate Medical Education and American Board of Medical Specialties Milestone Project, which defines progressive levels of performance residents should achieve prior to completing training.
Hartmann emphasized that EPAs provide a baseline, but they will not replace the need for supervision during residency. She added that supervision protects residents from being placed in situations that stretch them beyond their capabilities.
“Because [teaching] hospitals are entrusted themselves with the safety of their patients, a safe hospital system is going to err on the side of supervising the new interns very closely in the first several months that they are in the new learning environment,” Hartmann said.
Robert Englander, M.D., M.P.H., AAMC senior director of competency-based learning and assessment and member of the panel, said implementing and refining the EPAs will take time. He noted the AAMC Graduation Questionnaire will provide insight into whether students feel confident performing the 13 core activities in the guidelines. Pilot programs, he said, will answer specific questions about the feasibility of curriculum for each of the EPAs and how entrustment decisions will be made.
“The vision is that five to 10 years from now, all graduates will have been entrusted to do these 13 activities on day one of residency, and the result will be a much safer and effective workforce entering into residency in July each year,” Englander said.
The report is available at www.aamc.org/cepaer.
To provide feedback on the report, please visit http://mededportal.com/icollaborative/resource/887.