The Challenge

The entrustable professional activity (EPA) concept allows faculty to make competency-based decisions on the level of supervision required by trainees. Competency-based education targets standardized levels of proficiency to guarantee that all learners have a sufficient level of proficiency at the completion of training.16 Collectively, the competencies (ACGME or CanMEDS) constitute a framework that describes the qualities of professionals. Such a framework provides generalized descriptions to guide learners, their supervisors, and institutions in teaching and assessment. However, these frameworks must translate to the world of medical practice. EPAs were conceived to facilitate this translation, addressing the concern that competency frameworks would otherwise be too theoretical to be useful for training and assessment in daily practice.

What Is Known

Trust is a central concept for safe and effective health care. Patients must trust their physicians, and health care providers must trust each other in a highly interdependent health care system. In teaching settings, supervisors decide when and for what tasks they entrust trainees to assume clinical responsibilities. Building on this concept, EPAs are units of professional practice, defined as tasks or responsibilities to be entrusted to the unsupervised execution by a trainee once he or she has attained sufficient specific competence. EPAs are independently executable, observable, and measurable in their process and outcome, and therefore, suitable for entrustment decisions. Sequencing EPAs of increasing difficulty, risk, or sophistication can serve as a backbone for graduate medical education.6 

How Do EPAs Differ From Competencies?

  • EPAs are not an alternative for competencies, but a means to translate competencies into clinical practice.

  • Competencies are descriptors of physicians, EPAs are descriptors of work.

  • EPAs usually require multiple competencies in an integrative, holistic nature. table 1 shows how different EPAs require proficiency in several competency domains.

table 1

 Examples of EPAs Related to Their Most Important ACGME Competency Domains

 Examples of EPAs Related to Their Most Important ACGME Competency Domains
 Examples of EPAs Related to Their Most Important ACGME Competency Domains

What Is Included in a Full EPA Description?

An EPA must be described at a sufficient level of detail to set trainee expectations and guide supervisor's assessment and entrustment decisions (see table 2 for guidelines).

table 2

Guidelines for full Entrustable Professional Activities Descriptions

Guidelines for full Entrustable Professional Activities Descriptions
Guidelines for full Entrustable Professional Activities Descriptions

How Do EPAs Relate to Milestones?

Milestones, as defined by the ACGME, are stages in the development of specific competencies. Milestones may link to a supervisor's EPA decisions (eg, direct proactive supervision versus distant supervision). The Pediatrics Milestone Project provides examples of how milestones can be linked to entrustment decisions.7,8 

What Do Entrustment Decisions Require?

Entrustment decisions involve clinical skills and abilities as well as more general facets of competence, such as understanding one's own limitations and knowing when to ask for help. Making entrustment decisions for unsupervised practice requires observed proficiency, usually on multiple occasions.

In practice, entrustment decisions are affected by 4 groups of variables: (1) attributes of the trainee (tired, confident, level of training); (2) attributes of the supervisors (eg, lenient or strict); (3) context (eg, time of the day, facilities available); and (4) the nature of the EPA (rare, complex versus common, easy). Entrustment decisions can be further distinguished as ad hoc (eg, happening during a night shift) or structural (establishing the recognition that a trainee may do this activity at a specific level of supervision from now on). In the clinical context, many ad hoc entrustment decisions happen every day. Structural entrustment decisions formally acknowledge that a trainee has passed a threshold that allows for decreased supervision. The certificate awarded at such occasions has been called a statement of awarded responsibility (STAR) and should be carefully documented.2 

Linking an EPA with a competency framework emphasizes essential competency domains when observing a trainee executing the EPA.

How You Can Start TODAY

Decide how many EPAs are useful for training.

While there can be many EPAs that serve to make ad hoc entrustment decisions, EPAs that lead to structural entrustment decisions (ie, certification or STARs) should involve broad-based responsibilities and be limited in number. For a graduate medical education program, no more than 20 to 30 EPAs are recommended.

Use of EPAs in Assessing Trainees

EPAs can be the focus of assessment. The key question is: Can we trust this trainee to execute this EPA? The answer may be translated to 5 levels of supervision for the EPA:

  1. Observation but no execution, even with direct supervision

  2. Execution with direct, proactive supervision

  3. Execution with reactive supervision, ie, on request and quickly available

  4. Supervision at a distance and/or post hoc

  5. Supervision provided by the trainee to more junior colleagues

What You Can Do LONG TERM

  • Review the specialty requirements and milestones, and work with your professional organization and local colleagues to identify EPAs.

  • Detail the EPAs, following table 2.

  • Prepare faculty to provide EPA-based assessments.

  • Use structural entrustment decisions as a “license” for trainees to execute EPAs with distant supervision.

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Author notes

Olle ten Cate, PhD, is Professor of Medical Education and Director of the Center for Research & Development of Education at the University Medical Center Utrecht, the Netherlands.