Entrustable Professional Activities for Entering Residency: Establishing Common Osteopathic Performance Standards in the Transition From Medical School to Residency

The History of EPAs

In 2003, as a result of the ailing US health care system and growing concerns for patient safety, the Board on Health Care Services called for reform in medical education.³ Since that time, medical schools and residency programs have navigated the transition from a process-based delivery system (success measured by time to completion of medical training) to an outcome-based system (success measured by competency that leads to advancement).⁴ Competencies for medical education were implemented in early 2000 and were an important first step in defining learning outcomes and advancing competency-based medical education (CBME).⁵ The osteopathic core competencies⁶ describe characteristics of a fully-qualified graduate in 7 core domains and establish end points for training. However, the core competencies fail to provide a pathway for assessing trainee development across the continuum of medical training. In 2010, the need for standardized educational outcomes across the full continuum of medical education for the successful implementation of CBME was addressed.⁷ Developmental milestones and EPAs were introduced into GME residency training as a method for operationalizing CBME in residency training.⁸ Despite residency director concerns about ill-prepared students, a parallel structure in UME performance assessment has been slow to emerge.^9,10 This gap in medical student preparation and expected performance at the initiation of residency led to an increased concern for patient safety and an urgent need for UME training standards.¹¹

In response to this need, the American Association of Medical Colleges (AAMC) convened a panel of national experts to define professional activities that every medical student should be able to complete without direct supervision on the first day of residency, regardless of specialty choice.¹² The committee used EPAs as the conceptual framework to define the essential skills required of medical students as they transition from undergraduate to graduate training.¹² Following a thorough review of the literature and model curricula, 21 EPAs were proposed and subsequently narrowed to 13 EPAs (Figure 1) that residents must be able to perform without direct supervision on their first day of residency.¹¹

Figure 1.

The 13 entrustable professional activities for entering residency.¹¹

The Impact of the Single Accreditation System

In February 2014, the Accreditation Council for Graduate Medical Education (ACGME), the American Osteopathic Association (AOA), and AACOM announced a collaborative 5-year plan to implement a single accreditation system for GME.¹³ This single accreditation system would fully recognize and incorporate osteopathic distinctiveness and osteopathic milestones in competency-based assessment,¹³ which established a need to review and modify existing assessment paradigms and develop innovative frameworks to address the progress of medical students toward competency and proficiency in clinical practice.

The ACGME core competencies did not address osteopathic principles and practice and were subsequently modified by AACOM and the National Board of Osteopathic Medical Examiners to provide educational alignment and relevance between osteopathic UME and GME. The EPAs put forth by the ACGME and AAMC posed a similar dilemma in that adaptations were required to address specific osteopathic training considerations.

Osteopathic Considerations

In fall 2015, at the direction of the Board of Deans, AACOM established the AACOM EPA Steering Committee to evaluate the applicability of the 13 EPAs to osteopathic medical education, with the goal of advancing the implementation of EPAs into undergraduate osteopathic medical education.¹ The committee included medical education leaders and a student representative from the Council of Osteopathic Student Government Presidents. Deans from the osteopathic medical schools worked in collaboration with the committee and offered insight and feedback via direct communication and survey responses. The Educational Council on Osteopathic Principles carefully guided the deliberations and ensured consistency in the language and definitions used.

The committee deliberated on whether to create distinct osteopathic EPAs or to integrate osteopathic elements into the existing EPAs. With the emerging single accreditation system for GME, the committee felt it was imperative that osteopathic medical students were able to demonstrate the same entrustments as their allopathic counterparts, while maintaining osteopathic integrity.¹ Rather than listing all osteopathic elements of patient care into an additional EPA—and thus relegating osteopathic medicine to a separate professional activity—the committee advocated that osteopathic principles and practice were foundational to all aspects of patient care and should be represented by the addition of osteopathic considerations into the 13 existing EPAs.¹ The committee also felt that integration better aligned with national efforts to establish common standards for residency training and would best support the competitiveness of osteopathic medical students as they graduate and enter residency.

To integrate osteopathic considerations into the EPAs, the committee reviewed each of the EPAs with Q-methodology, a process by which each member ranked and sorted EPAs that required osteopathic adaptations.¹⁴ With feedback from the school liaisons, osteopathic considerations were integrated into 6 of the 13 EPAs.¹ The osteopathic elements added to the EPAs involve the distinct skills of the osteopathic medical profession that are critical to entrustment decisions and are grounded in the tenets of osteopathic medicine, which recognizes the entirety of the body as an interdependent holistic system working to maintain homeostasis and promote healing (Table). The EPAs with osteopathic considerations guide preceptors to more appropriately teach and entrust a learner's approach to a patient as a unit of mind, body, and spirit in alignment with the philosophical underpinnings of the osteopathic medical profession. The adaptations made to the EPAs will guide the GME-readiness assessment process and affect the implementation of EPAs into medical education in 2 ways. First, osteopathic medical students who successfully advance in entrustment, as defined by these revised EPAs, will demonstrate the understanding of the critical relationship between structure and function consistent with the tenets of osteopathic medicine. Second, because of the added osteopathic considerations, the EPAs will provide educators with the tools necessary to evaluate students in accordance with the tradition of the osteopathic medical practice.

The EPA Steering Committee also established 4 subcommittees (faculty development, curriculum, learner assessment, and resources) to support the implementation of EPAs within osteopathic medical schools.¹ The faculty development subcommittee was established to create standard resource materials on EPAs that could be used by schools to educate key stakeholders, including administrators, faculty, preceptors, and students. The curriculum subcommittee was developed to address instructional needs to support EPA implementation in each osteopathic medical school and to develop guides focused on best practices and research-based approaches to integrating EPAs into school curricula. The learner assessment subcommittee targeted the development of an inventory of vetted, validated assessment tools focusing on best practice approaches, and the goal of the resources subcommittee was to establish an online portal to house faculty development, curriculum, and assessment materials in a secure, searchable portal. The resources subcommittee was also tasked with developing a process of peer review for future EPA resources and projects.

Mapping EPAs to AACOM Competencies

Within each EPA, osteopathic competencies intersect with one another and are fundamental to assessing a trainee's level of entrustment and developmental progress across the milestones. ten Cate¹⁵ defined competence as trust in the learner, specifically asking, “Can this trainee be trusted to carry out this activity without your direct supervision?” This question became the foundation of assessing a trainee's developmental progress and milestones. When defining milestone, the ACGME website states,

For accreditation purposes the milestones are competency-based developmental outcomes (e.g., knowledge, skills, attitudes, and performance) that can be demonstrated progressively by residents and fellows from the beginning of their education through graduation to the unsupervised practice of their specialties.¹⁶

Milestones allow for a detailed description of knowledge, skills, attitudes, and performance that describe learner expectations and desired performance. Milestones have a developmental progression of competence that serves as a guide to the trainee and trainer.

Linking EPAs, competencies, and milestones provides a curricular map that can serve as the backbone of a medical school curriculum. An example of these links can be found in Figure 2, which depicts EPA 1, gathering a history and performing a physical examination on a patient, and the way that various curricular milestones map from AACOM competencies. In the AACOM EPA guideline,¹ links connecting EPAs and competencies are provided, allowing individual institutions to tailor mapping exercises to competencies and learning activities specific to the curriculum at each institution.

Figure 2.

The connections between entrustable professional activity (EPA) 1 and the Accreditation Council for Graduate Medical Education's competencies and milestones.

Implementation Challenges

Implementing EPAs in undergraduate osteopathic medical education has distinct challenges. Workplace-based assessment in patient care settings is essential to making entrustment decisions. However, valid and reliable assessment tools are sparse, and standards of reliability cannot easily be met.¹⁷ Because the construct of entrustment is the synthesis of multiple complex factors, entrustment decisions require the use of a variety of instruments across time, in different contexts, and by different evaluators.¹⁸ The capacity of a school to meet these expectations depend on available resources, an alignment of the school's clinical curriculum, adequate patient volume, and access to a range of care settings and trained preceptors.¹⁸ As trainees move from one rotation or clinical setting to another, additional observations are often required to reconfirm the trainee's competency, especially given that skills can diminish over time if not practiced.² The volume of assessments may increase because EPAs and CBME, in general, focus not only on units of work, but also the work process itself. This focus can pose potential challenges, such as defining work that does not easily fit into the EPA framework, introducing additional assessments to better understand the process of work, and creating assessment methods that do not overcomplicate the evaluation process or overburden faculty. This increase in assessments required for entrustment can add stress to an already burdened system and requires a process for tracking over time.¹⁹

Assessment of entrustment establishes an even greater layer of complexity. Within the notion of entrustment reside behaviors such as conscientiousness, honesty, and recognition of one's limitations.^20,21 Ultimately, a decision regarding student readiness to perform a given activity under appropriate supervision must be made. For students entering residency, the level of supervision required may vary by EPA. It may range from co-activity (performance with the aid of a trainer) to independent performance with immediate supervision.²² These types of decisions are multifactorial and depend on complex interpersonal interactions and workplace-based factors. Residency-level entrustment and supervision scales are readily available for use.²³ However, in UME, much work is needed to create scales and tools for these types of assessments.

Entrustment decision making is most successful in an environment that allows for individualized learning trajectories and practice opportunities in the context of longitudinal relationships with preceptors.²⁴ Many institutions cannot fulfill these ideals given health care delivery constraints, patient-safety concerns, and competing demands to meet increasing resident training requirements, which often limit student opportunity to gain hands-on experience and receive valued feedback from mentors.²⁴ Moreover, osteopathic medical schools rely heavily on decentralized clinical education, rather than the more traditional academic health center model, which requires the engagement and trust of community-based preceptors to understand and reliably make entrustment decisions.²⁵ This concept of assumed responsibility for faculty can be daunting, and levels of comfort with this responsibility are still evolving.^25,26

Portfolios are a viable tool for collecting, organizing, and managing assessment data on learners and can be used to keep learners engaged in assessment, foster lifelong learning, and promote professional identity formation across time.²⁷ However, effective use of portfolios also requires a sustained mentoring capacity and the necessary time and resources for the implementation process, as well as for the mentor.²⁴ In addition, feedback mechanisms must be in place to enable improvement in abilities.²⁸ Mentors must be well trained to assess students, to serve in the mentoring role, and to provide feedback that will facilitate student progress. The purpose of the portfolio and the embedded assignments must be explicit to all stakeholders. Learners must understand the benefits of the portfolio to prevent them from perceiving learning as “busy work.”²⁴ For true progress over time, all stakeholders, including faculty, medical students, residents, and national licensure boards, must be invested in conversations regarding evidence supporting learner assessment and mechanisms to document achievement of agreed-upon competence. Without adequate resources, time, training for mentors and assessors, recognized purpose, and communication among all stakeholders, it will be hard to collect and complete a longitudinal snapshot of learner achievement toward EPAs across time and contexts. These conversations must occur at a national level if handoffs of learners from UME to GME are expected to succeed and progress toward entrustment.

Conclusion

Osteopathic Considerations for Core Entrustable Professional Activities (EPAs) for Entering Residency ¹ provides guidelines, approaches, and rationale for implementing and assessing the 13 EPAs using osteopathic approaches. As osteopathic GME continues to move forward with the single accreditation system, it is important that osteopathic medical schools adapt their curricula and assessment outcomes to include EPAs that can help demonstrate entrustment of their graduates as they enter residency training.