Alphonsus Chong's Personal Wiki

Reforms in postgraduate medical education (PGME) exposed a gap between educational theory and clinical practice. Entrustable Professional Activities (EPAs) were introduced to assist clinicians in bridging this gap and to create better consonance between the intended and the enacted curriculum. In this viewpoint paper, we discuss the potential and the pitfalls of using EPAs in PGME. EPAs promise an effective way of teaching abstract competencies in a curriculum based on real-life professional activities that are suitable for clinical assessment. Summative judgement is used to entrust a resident step by step in a certain EPA, resulting in an increase of independent practice. However, we argue that the success of EPAs depends on (1) a balance: brief focused descriptions against the requirements for detail and (2) a precondition: a mature and flexible workplace for learning.

The authors provide a brief overview of the concepts behind EPA, and the gap EPA proposes to fill in medical education.

I agree that:

• EPAs help provide a practical way to assess competencies and chart milestones
• a holistic approach to designing and implementing EPAs is necessary to keep a holistic view of training, and avoid a reductionist and “behaviourist” approach

I do not agree (in least in our own Hand Surgery context) that:

• most workplaces are not flexible enough for successful EPA implementation. Most of our trainees manage well enough, and the residency system already allows some more flexibility for both the better and the weaker trainees.

Of course, structures can always be better arranged to support learning. But I find the biggest hurdle is usually not the theoretical foundation of the strategy, nor the resourcing available for it, but the commitment of the people implementing it. The authors allude to this as well:

Achieving transparency in postgraduate medical education is a culture change. The change management scientist Rogers (1995) showed that a theoretically well-designed innovation does not necessarily constitute a successful concept in practice. It can be that EPAs are only a solution for some workplaces and not suitable for all the training programmes in PGME.

van Loon, K. A., Driessen, E. W., Teunissen, P. W., & Scheele, F. (2014). Experiences with EPAs, potential benefits and pitfalls. Medical Teacher, 36(8), 698–702. https://doi.org/10.3109/0142159X.2014.909588