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January 24, 2018 by Brenessa Lindeman

The Alphabet Soup of Educational Assessment: What are EPAs?

First there were competencies, the fairly abstract and theoretical “big buckets” of skills the Accreditation Council for Graduate Medical Education (ACGME) defined in 2003 that graduates of residency training should be proficient in.  Partially in response to faculty members’ concerns that they weren’t sure how to adequately assess their residents’ “systems-based practice” or “practice-based learning and improvement,” the ACGME subsequently proposed the Next Accreditation System (NAS), that was centered around milestones, or graduated levels of more specific behaviors within each of the competency domains.  While these milestones have been useful for Clinical Competency Committees in assessing how residents progress in different areas throughout the course of their training, one drawback is that they examine progress in each of the competency domains in isolation.

As those of us in clinical practice experience on a daily basis, physicians must integrate skills across competency domains to effectively care for a patient – demonstrating they possess the medical knowledge to arrive at the correct diagnosis, enact patient care to deliver treatment, communicate this in a customized way to ensure patient/caregiver understanding, and continuously assess their performance to identify areas for improvement.  Entrustable Professional Activities (EPAs) were designed to solve this problem of assessment in isolation through integration of the ACGME core competencies across daily practice tasks.

EPAs can be thought of as units of work for a physician, while competencies are abilities of individuals to carry out that work. EPAs are uniquely defined by the need to integrate competencies across performance domains, and they provide a clinical context for demonstrations of competence (e.g., identifying a sick patient and initiating management). As stages of increasing performance levels within each competency, milestones can then be used to help determine whether or not a trainee is ready to be entrusted to perform a specific activity without supervision.

While the formalized concept of EPAs is relatively new, the concept of surgeons making decisions about a trainee’s competence on a daily basis is part of the tradition of surgical training. In the context of an operation, the surgeon considers multiple variables to determine the level of responsibility and autonomy that they will grant to the trainee they are working with, often before or near the beginning of a procedure.  Adoption and integration of EPAs into our daily assessments of trainees can provide a framework for more objective assessment of our trainees’ skills and empower them to more clearly understand the areas in which they need to improve.

For more information, please follow the link to additional resources through the American College of Surgeons Resources in Surgical Education page:  https://www.facs.org/education/division-of-education/publications/rise/articles/entrustable

First there were competencies, the fairly abstract and theoretical “big buckets” of skills the Accreditation Council for Graduate Medical Education (ACGME) defined in 2003 that graduates of residency training should be proficient in.  Partially in response to faculty members’ concerns that they weren’t sure how to adequately assess their residents’ “systems-based practice” or “practice-based learning and improvement,” the ACGME subsequently proposed the Next Accreditation System (NAS), that was centered around milestones, or graduated levels of more specific behaviors within each of the competency domains.  While these milestones have been useful for Clinical Competency Committees in assessing how residents progress in different areas throughout the course of their training, one drawback is that they examine progress in each of the competency domains in isolation.

As those of us in clinical practice experience on a daily basis, physicians must integrate skills across competency domains to effectively care for a patient – demonstrating they possess the medical knowledge to arrive at the correct diagnosis, enact patient care to deliver treatment, communicate this in a customized way to ensure patient/caregiver understanding, and continuously assess their performance to identify areas for improvement.  Entrustable Professional Activities (EPAs) were designed to solve this problem of assessment in isolation through integration of the ACGME core competencies across daily practice tasks.

EPAs can be thought of as units of work for a physician, while competencies are abilities of individuals to carry out that work. EPAs are uniquely defined by the need to integrate competencies across performance domains, and they provide a clinical context for demonstrations of competence (e.g., identifying a sick patient and initiating management). As stages of increasing performance levels within each competency, milestones can then be used to help determine whether or not a trainee is ready to be entrusted to perform a specific activity without supervision.

While the formalized concept of EPAs is relatively new, the concept of surgeons making decisions about a trainee’s competence on a daily basis is part of the tradition of surgical training. In the context of an operation, the surgeon considers multiple variables to determine the level of responsibility and autonomy that they will grant to the trainee they are working with, often before or near the beginning of a procedure.  Adoption and integration of EPAs into our daily assessments of trainees can provide a framework for more objective assessment of our trainees’ skills and empower them to more clearly understand the areas in which they need to improve.

For more information, please follow the link to additional resources through the American College of Surgeons Resources in Surgical Education page:  https://www.facs.org/education/division-of-education/publications/rise/articles/entrustable.

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Brenessa Lindeman

Brenessa Lindeman, MD, MEHP, is an Assistant Professor of Surgery and Associate Designated Institutional Official for the Clinical Learning Environment at the University of Alabama at Birmingham. A native of eastern Kentucky, she completed her undergraduate training summa cum laude at the University of Louisville and was the Founder’s Medalist at the Vanderbilt University School of Medicine. She completed residency training in General Surgery at the Johns Hopkins University School of Medicine, where she served as an Administrative Chief Resident, and completed a fellowship in Endocrine Surgery at Brigham and Women’s Hospital/Harvard Medical School. Brenessa earned a Masters of Education in the Health Professions from Johns Hopkins University and completed Surgical Education Research Fellowships with the Association for Surgical Education and Massachusetts General Hospital. She served as a member of the Association of American Medical Colleges (AAMC) Core EPAs for Entering Residency Drafting Panel as well as the Resident Member of the AAMC Board of Directors from 2012-2016 and is currently working with the American Board of Surgery to define EPAs for General Surgery. Her research interests are in development and assessment of competency in surgical trainees, resident supervision and autonomy, and evaluation of the learning climate/physician wellbeing as an academic surgeon.

Latest posts by Brenessa Lindeman (see all)

  • The Alphabet Soup of Educational Assessment: What are EPAs? - January 24, 2018

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