EPAs: entrustable professional activities in Medicine
Table of contents
On the last day of the rotation, the preceptor says to the intern: "Tomorrow you will do the admission on your own and call me only if you need to." She did not give a test. She decided to trust. That decision, which happens every day in hospitals with no name and no record, is the center of a training model that has spread around the world: entrustable professional activities, known by the acronym EPA.
NEXO is a daily medical diagnosis game: one clinical case a day, six progressive clues, and ICD-10 proximity feedback across five levels.
This guide explains what EPAs are, how the supervision levels work, what a large pilot in the United States showed about their use in undergraduate education, and what the student can do to earn trust in a visible way.
Key points
- An EPA is a clinical practice task that can be entrusted to a learner when the learner shows they can do it with a given level of supervision.
- The model replaces the question "what does the student know?" with "what do I let the student do, and with how much supervision?".
- The authors of the concept proposed adding the level "trustworthy" to the top of Miller's pyramid.
- In the American pilot, trust depends on discernment, responsibility and honesty, in addition to knowledge and skill.
- Some activities, such as handover and patient safety, had few students considered ready and few recorded assessments.
What EPAs are
From competence to task
Competency-based medical education describes what a doctor needs to have: knowledge, communication, professionalism, reasoning. The problem is that competencies are abstract. Nobody observes "professionalism" on a ward; they observe someone doing an admission, a prescription or a handover.
In 2005, Olle ten Cate proposed linking competencies to concrete practice activities that could be entrusted to the learner (ten Cate, 2005). That is how the idea of an entrustable professional activity was born: a unit of clinical work, with a beginning and an end, that a supervisor can delegate.
Activity and competence intersect
An AMEE guide on the topic describes how to build a curriculum from EPAs and how to combine each activity with the competencies it requires, in a kind of matrix (ten Cate et al., 2015). An admission, for example, draws on clinical knowledge, communication, diagnostic reasoning and record keeping. Observing the activity is a way of observing several competencies at the same time.
The EPAs for entering residency
In May 2014, the Association of American Medical Colleges published 13 EPAs that every student should be able to perform upon entering residency, regardless of future specialty (AAMC). The choice came from literature that documented a performance gap in the transition from medical school to residency (AAMC).
This gap has relatives on this blog. The guide on the distance between theory and practice shows how recent graduates report feeling prepared to examine and less prepared to decide.
The supervision levels
A ladder of autonomy
In EPAs, assessment in the workplace becomes a decision to trust for defined levels of autonomy, ranging from acting under full supervision to supervising a newer learner (ten Cate et al., 2015). A common way to describe the ladder is this:
| Level | What the learner does |
|---|---|
| Observe | Follows the activity performed by someone else |
| Direct supervision | Performs the activity with the supervisor present in the setting |
| Indirect supervision | Performs the activity with the supervisor available, but outside the setting |
| Full autonomy | Performs the activity alone, with feedback afterward |
| Supervise | Supervises a newer learner in the same activity |
The point that matters to the student is the move from direct to indirect supervision. It is what separates "does it well with someone watching" from "can do it with no one watching".
One step above "does"
The Miller pyramid, proposed in 1989, separates four levels of assessment: knows, knows how, shows how and does (ten Cate et al., 2021). The authors of the EPA concept argue that trusting a learner to work without supervision requires more than seeing them do it well: it requires the educator to accept the risks of the task and to judge that the learner will know how to act in the face of the unexpected (ten Cate et al., 2021). For this reason, they proposed adding the "trustworthy" level to the top of the pyramid (ten Cate et al., 2021).
What weighs on the decision to trust
Three qualities beyond knowledge
In the American pilot, a working group with representatives from the participating schools described what sustains a trust decision in undergraduate education (Brown et al., 2017). Beyond knowledge and skills, three qualities appeared as central: knowing one's own limits, or discernment; being someone who can be trusted to carry the task through to the end, or responsibility; and telling the truth even when it brings discomfort, or honesty (Brown et al., 2017).
All three have to do with reasoning. Discernment is knowing when the hypothesis is solid and when it is time to call someone. The metacognition guide deals with exactly this look at one's own thinking.
Group decisions, with many observations
The same group recommended that formal trust decisions be made by a trained committee, based on longitudinal assessments from several evaluators, and that they incorporate supervisors' day-to-day decisions (Brown et al., 2017). In other words, formal trust adds up many small everyday trusts.
What the supervisor observes
In practice, the supervisor usually observes simple things: does the student arrive with a hypothesis or only with data? Do they say when they do not know? Do they come back to check what they requested? The presentation to the preceptor is one of the moments when this becomes visible, and the clinical reasoning in the internship guide shows how to structure it.
The American pilot of EPAs in undergraduate education
Ten schools, seven years
Soon after publishing the 13 EPAs, the association brought ten schools together in a pilot to test the application of the model in undergraduate education, which ended in 2021 (AAMC). Members of the schools and the association then reviewed, activity by activity, which ones worked well as EPAs and which had practical or theoretical limits for being assessed and trusted (Amiel et al., 2021).
The numbers from two graduating classes
In four schools of the pilot, trained committees made 4,525 readiness decisions, activity by activity, for 732 graduates of 2019 and 2020 (Brown et al., 2022). The proportion of "ready for indirect supervision" decisions rose from 43.4% in 2019 to 60.1% in 2020 (Brown et al., 2022). The proportion of decisions supported by four or more workplace assessments rose from 19.9% to 42.1% (Brown et al., 2022).
Where trust did not reach
In five activities, few students were considered ready and there were few assessments per student: prescribing and orders, handover, emergency care, informed consent and patient safety (Brown et al., 2022). In the patient safety activity, none of the 125 students assessed in 2019 and none of the 127 assessed in 2020 was considered ready (Brown et al., 2022).
The data says as much about the curriculum as about the students: these are activities in which the student rarely acts for real during undergraduate education, and therefore is rarely observed.
What the schools learned
In a qualitative study with teams from nine of the ten schools, participants reported that the EPAs fit naturally into the clerkships and gave the schools a chance to review curriculum and assessment (Encandela et al., 2023). The schools used the results as formative feedback for students, without high-impact decisions such as promotion or graduation (Encandela et al., 2023). The teams also agreed that there is still much work to apply the model to entire classes, with enough assessments per activity and with reliable data (Encandela et al., 2023).
How the student can prepare
Ask to be observed
The trust decision depends on recorded observations. On the rotation, ask your supervisor to watch part of your consultation and say what they would do differently. The more observations, the more ground trust has.
Arrive with a hypothesis, not just with data
Presenting the patient with a prioritized hypothesis and a proposed plan shows reasoning, not just data collection. The differential diagnosis guide helps you build and order the list before you speak.
Say when you do not know
Discernment and honesty weigh on the decision (Brown et al., 2017). Saying "I am not sure, I would like you to take a look" is a sign that you can receive more autonomy, not less. The calibrating confidence guide shows how to measure whether your certainty matches your accuracy.
Close the loop
Responsibility means going back to check the test you ordered, the patient who was to be reassessed and the family who asked for news. These are small gestures that the supervisor notices.
Train the activities almost no one trains
Handover and patient safety were the activities with the fewest students ready in the pilot (Brown et al., 2022). Ask to take part in the handover, even if only to listen at first, and to do part of it later. The guide on reasoning in the medical record helps make your reasoning clear to whoever receives the patient.
Diagnostic reasoning and the case of the day on NEXO
EPAs are decided in the workplace, by supervisors who observe the student with patients. NEXO comes before that, in training the reasoning that supports several of these activities: reaching a hypothesis and knowing when it is solid.
In the case of the day, the diagnosis comes in up to six clues, and the ICD-10 proximity in five levels shows how far each guess landed. The distribution of correct answers by clue, on the home screen, shows how many clues you usually need to reach the diagnosis. The cases are fictional with a real clinical presentation, and the what NEXO is guide explains how to play. How the modes are unlocked is on the NEXO Economy page.
If you coordinate a medical school or a residency and want to use cases to discuss reasoning with your class, see NEXO Closer. Researchers in assessment and medical education can propose studies through NEXO Researcher. Doctors who review cases take part through NEXO Curator, and those who create health content on social media can take part through NEXO Creators.
Frequently asked questions
What does EPA mean in medical education?
It stands for entrustable professional activity: a task from clinical practice that can be delegated to the learner when they show they can do it with a given level of supervision (ten Cate et al., 2015).
What is the difference between an EPA and a competency?
A competency is a quality of the professional, such as communication or reasoning. An EPA is an observable task, such as an admission, that requires several competencies at the same time.
What are the levels of supervision?
They range from observing and acting under full supervision to supervising a newer learner (ten Cate et al., 2015). The move to indirect supervision is the most important one in medical school.
How many EPAs did the American association define for entry into residency?
There were 13 activities, published in 2014 and tested in a pilot with ten schools (AAMC).
What makes the supervisor trust the student?
Beyond knowledge and skill, discernment about one's own limits, responsibility and honesty (Brown et al., 2017).
Does NEXO assess EPAs?
NEXO trains diagnostic reasoning with cases in up to six clues and ICD-10 proximity. EPAs are decided by supervisors in the workplace.
Checklist to gain trust on the rotation
- Ask to be observed and to receive feedback.
- Present with a prioritized hypothesis and a proposed plan.
- Say when you do not know and ask for help early.
- Go back to check what was left pending.
- Take part in the handover.
- Write progress notes that another person can understand.
- Train your reasoning outside the shift, with cases.
Want to train the hypothesis before the shift? Play the case of the day on NEXO.
References
- ten Cate O. Entrustability of professional activities and competency-based training. Med Educ. 2005. https://pubmed.ncbi.nlm.nih.gov/16313574/
- Ten Cate O, Chen HC, Hoff RG, Peters H, Bok H, van der Schaaf M. Curriculum development for the workplace using Entrustable Professional Activities (EPAs): AMEE Guide No. 99. Med Teach. 2015. https://pubmed.ncbi.nlm.nih.gov/26172347/
- Ten Cate O, Carraccio C, Damodaran A, Gofton W, Hamstra SJ, Hart DE, et al. Entrustment Decision Making: Extending Miller's Pyramid. Acad Med. 2021. https://pubmed.ncbi.nlm.nih.gov/33060399/
- Brown DR, Warren JB, Hyderi A, Drusin RE, Moeller J, Rosenfeld M, et al. Finding a Path to Entrustment in Undergraduate Medical Education: A Progress Report From the AAMC Core Entrustable Professional Activities for Entering Residency Entrustment Concept Group. Acad Med. 2017. https://pubmed.ncbi.nlm.nih.gov/28557941/
- Amiel JM, Andriole DA, Biskobing DM, Brown DR, Cutrer WB, Emery MT, et al. Revisiting the Core Entrustable Professional Activities for Entering Residency. Acad Med. 2021. https://pubmed.ncbi.nlm.nih.gov/34183597/
- Brown DR, Moeller JJ, Grbic D, Andriole DA, Cutrer WB, Obeso VT, et al. Comparing Entrustment Decision-Making Outcomes of the Core Entrustable Professional Activities Pilot, 2019-2020. JAMA Netw Open. 2022. https://pubmed.ncbi.nlm.nih.gov/36156144/
- Encandela JA, Shaull L, Jayas A, Amiel JM, Brown DR, Obeso VT, et al. Entrustable professional activities as a training and assessment framework in undergraduate medical education: A case study of a multi-institutional pilot. Med Educ Online. 2023. https://pubmed.ncbi.nlm.nih.gov/36794397/
- Association of American Medical Colleges. The Core Entrustable Professional Activities (EPAs) for Entering Residency. https://www.aamc.org/about-us/mission-areas/medical-education/cbme/core-epas