Building a Framework of Entrustable Professional Activities, Supported by Competencies and Milestones, to Bridge the Educational Continuum

Abstract

The transition to competency-based medical education (CBME) and adoption of the foundational domains of competence by the Accreditation Council for Graduate Medical Education, Association of American Medical Colleges (AAMC), and American Board of Medical Specialties' certification and maintenance of certification (MOC) programs provided an unprecedented opportunity for the pediatrics community to create a model of learning and assessment across the continuum. Two frameworks for assessment in CBME have been promoted: (1) entrustable professional activities (EPAs) and (2) milestones that define a developmental trajectory for individual competencies. EPAs are observable and measureable units of work that can be mapped to competencies and milestones critical to performing them safely and effectively.The pediatrics community integrated the two frameworks to create a potential pathway of learning and assessment across the continuum from undergraduate medical education (UME) to graduate medical education (GME) and from GME to practice. The authors briefly describe the evolution of the Pediatrics Milestone Project and the process for identifying EPAs for the specialty and subspecialties of pediatrics. The method of integrating EPAs with competencies and milestones through a mapping process is discussed, and an example is provided. The authors illustrate the alignment of the AAMC's Core EPAs for Entering Residency with the general pediatrics EPAs and, in turn, the alignment of the latter with the subspecialty EPAs, thus helping build the bridge between UME and GME. The authors propose how assessment in GME, based on EPAs and milestones, can guide MOC to complete the bridge across the education continuum.

The Promise of Milestones: Are They Living Up to Our Expectations?

“…29,30 EPA descriptors for each level of supervision could be described to standardize entrustment decisions. 27 Milestones could be helpful to drill down where trainees are struggling to facilitate appropriate remediation.…”

“…[26][27][28] EPAs could be mapped to milestones and, along with research, determine whether they were mapped correctly. Each rotation could then assess a limited number of EPAs along supervisory lines, as suggested by Rekman and colleagues' Ottawa Clinic Assessment Tool.…”

Managing tensions in assessment: moving beyond either–or thinking

“…As a consequence, tensions may surface through differing, ambiguous and sometimes conflicting assessment strategies such as the ‘standardisation’ of inherently unstandardised assessments (e.g. standardised narratives for authentic assessments), ‘measurement’ of performance‐in‐context through the use of detailed rating scales and task‐specific checklists, or the ‘objectification’ of competence and competence development through the use of entrustable professional activities and milestones …”

“…standardised narratives for authentic assessments), 57,58 'measurement' of performance-in-context through the use of detailed rating scales and task-specific checklists, 59,60 or the 'objectification' of competence and competence development through the use of entrustable professional activities and milestones. 61,62 In addition, education accountability may entail a 'timekeeping function' of assessment as assessment may (implicitly or explicitly) serve to increase the rate of learning: frequent assessments become 'stopwatches', controlling individual progress and the efficiency of learning processes. 63 Tensions between control and trust, or between standardisation and authenticity may then not only interfere with processes of teaching and learning in classroom settings or work environments, 64-68 but also impact on stakeholders' sense of autonomy, agency and engagement with assessment as a tool for learning.…”

La red de los Centros de Innovación y Formación Ocupacional y la promoción de la equidad, la cohesión social y la ciudadanía activa en Cataluña (España)

“…Some of the contributions that come from this area are: the transition to competency-based medical education, through the entrustable professional activities (EPAs) in order to reduce the gap between theory and practice (ten Cate, & Scheele, 2007;Carraccio et al, 2017); a systematic research of the scientific literature (Greenfield, & Braithwaite, 2008) found that the accreditation programs lead to development of health professionals; or 'the opportunity for residents to learn in innovative programs, and enhanced resident education in quality, patient safety, and the new competencies' (Nasca, Philibert, Brigham, & Flynn, 2012, p. 1055) with the introduction of the Next Accreditation System (NAS) by the Accreditation Council for Graduate Medical Education (ACGME).…”