What’s in an EPA?

I’ve read two interesting and practical articles about entrustable professional activities (EPAs) recently. The first article gives some great insights into how EPAs relate to each other, to training levels, and competency milestones. The second article, which I came across from the KeyLime Podcast (episode 91), shares the experiences of a few Canadian family medicine programs as they implemented EPAs.

There is much that the authors of the two articles agree upon. For example, both articles share a similar outlook on how competency milestones influence different levels of entrustment decisions. For example, to reach an oversight-only level of entrustment for a given EPA, a learner needs to have achieved the third milestone of a medical knowledge competency.

One of the challenges of EPAs is thinking about the information that someone making a summative entrustment decision needs to see. Clearly defined rules such as competency attainment at a given milestone provide some insight into some of what we need to do in Altus.

I thought that the article by Ten Cate et al. did a great job of illustrating some of the other relationships between EPAs and the competency framework. Of particular interest to me was the concept that EPAs can be nested within one another, so that the EPAs a medical student is working to achieve fit into a broader set of EPAs for an intern, junior resident, and so on. The article also lays out how levels of entrustment might be restricted by the level of training, which was a new concept for me.

I also learned something new from the article by Schultz et al. about how an EPA can be linked to phases of a clinical encounter. In their work, levels of entrustment are described, not just for the EPAs as a whole, but at each step of a clinical encounter, from hypothesis and history to treatment and follow-up. I haven’t seen this additional level of detail for entrustment described elsewhere, and it will be interesting to see what other creative additions people make to EPAs as they start to integrate them into their assessment practice.

Are there any other rules for entrustment not described in either of these articles that you’ve seen come up in your own practice, or elsewhere in the literature?