Update from the American Association of Medical Colleges

As the AAS Representatives to the American Association of Medical Colleges (AAMC), we would like to remind all AAS members of some of the resources provided through the AAMC.

As many of you know, the AAMC represents all accredited medical schools (141 in US, 17 in Canada), major teaching hospitals and health systems, VA Medical Centers, and many academic and scientific societies (including our Association for Academic Surgery).

The AAMC publishes frequently updated data on the physician workforce. Recent publications of note include the Physician Specialty Data Book and Total Enrollment by U.S. Medical School and Race and Ethnicity. One of the principal AAMC resources which can be useful to academic surgical faculty is the Report on Medical School Faculty Salaries, which can be purchased through the AAMC website. However, most medical schools and medical centers usually purchase a copy of this report and have it available in their libraries for staff review. This report gives salary ranges for surgeons (and all specialties) in academic practice by rank and geographic location. Many other data and reports regarding undergraduate and graduate medical education are available on the AAMC Data and Analysis website. This includes several press releases and fact sheets regarding estimated physician shortages in the next decade.

We would also like to highlight some of the work of the AAMC as it might relate to academic surgery. Below we touch on a recent AAMC initiative which may change a major aspect of surgical education – the transition from medical school to residency…

What in the world are “Core Entrustable Professional Activities (EPAs) for Entering Residency?”

Across specialties and level of training, there is often a gap between what trainees and learners feel ready to do and what they are expected to be able to do. This may be evident in surgical training, where increasing numbers of residents feel compelled to complete fellowship training to gain competency and independence at the end of their training. One project looking at resident performance and competencies has been “The General Surgery Milestone Project” by the ACGME and ABS, which defines levels of performance for each competency with the expectation that residents will achieve specific milestones before graduating.

But what if we could address any deficiencies before starting residency? At the other end of the academic spectrum, there is increasing awareness that medical students may not feel prepared for all of the tasks they may be asked to do as beginning residents. While most medical schools do have “graduation competencies” within their curriculum, there has been no consistency as to what graduates should be expected to be able to do.

To address this issue, the AAMC recently released a report: “Core Entrustable Professional Activities (EPAs) for Entering Residency”, which provides guidance on bridging that performance gap. As per the AAMC website, “This is the first standardized set of guidelines defining what activities a resident should be able to perform without direct supervision on the first day of their PGY-1 year.  As such, the Core EPAs are an important step forward in ensuring the professional progress of our students, as well as improving care for patients.”

EPAs and competencies are not mutually exclusive; the EPAs require integration of often multiple competencies, and the competencies need to be assessed in the context of performance (as demonstrated by specific activities which can be evaluated). This table summarizes the two concepts.

©2014 Association of American Medical Colleges

In order to better define what activities are appropriately done by new trainees, the AAMC panel drafting the report agreed upon the following definition: Entrustable Professional Activity (EPA): EPAs are units of professional practice, defined as tasks or responsibilities that trainees are entrusted to perform unsupervised once they have attained sufficient specific competence. EPAs are independently executable, observable, and measurable in their process and outcome, and, therefore, suitable for entrustment decisions.

The following is a list of the thirteen Core EPAs for Entering Residency:

EPA 1: Gather a history and perform a physical examination
EPA 2: Prioritize a differential diagnosis following a clinical encounter
EPA 3: Recommend and interpret common diagnostic and screening tests
EPA 4: Enter and discuss orders and prescriptions
EPA 5: Document a clinical encounter in the patient record
EPA 6: Provide an oral presentation of a clinical encounter
EPA 7: Form clinical questions and retrieve evidence to advance patient care
EPA 8: Give or receive a patient handover to transition care responsibility
EPA 9: Collaborate as a member of an interprofessional team
EPA 10: Recognize a patient requiring urgent or emergent care and initiate evaluation and management
EPA 11: Obtain informed consent for tests and/or procedures
EPA 12: Perform general procedures of a physician
EPA 13: Identify system failures and contribute to a culture of safety and improvement

So how does this affect academic surgeons? Many of our medical schools have instituted “boot camps” for 4th year students to become better prepared for the start of their residencies. And many surgery residency programs have added similar “boot camp” sessions to their orientation programs at the commencement of internship. Will EPAs help better define and enforce the activities that medical students must be facile with before graduation? Will these changes help “level the playing field” for new trainees across medical schools?

Tell us your view….