No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Viewpoint: Competency-Based Postgraduate Training: Can We Bridge the Gap between Theory and Clinical Practice?
Abstract
The introduction of competency-based postgraduate medical training, as recently stimulated by national governing bodies in Canada, the United States, the United Kingdom, The Netherlands, and other countries, is a major advancement, but at the same time it evokes critical issues of curricular implementation. A source of concern is the translation of general competencies into the practice of clinical teaching. The authors observe confusion around the term competency, which may have adverse effects when a teaching and assessment program is to be designed. This article aims to clarify the competency terminology. To connect the ideas behind a competency framework with the work environment of patient care, the authors propose to analyze the critical activities of professional practice and relate these to predetermined competencies. The use of entrustable professional activities (EPAs) and statements of awarded responsibility (STARs) may bridge a potential gap between the theory of competency-based education and clinical practice. EPAs reflect those activities that together constitute the profession. Carrying out most of these EPAs requires the possession of several competencies. The authors propose not to go to great lengths to assess competencies as such, in the way they are abstractly defined in competency frameworks but, instead, to focus on the observation of concrete critical clinical activities and to infer the presence of multiple competencies from several observed activities. Residents may then be awarded responsibility for EPAs. This can serve to move toward competency-based training, in which a flexible length of training is possible and the outcome of training becomes more important than its length.
... In recent years, graduate medical education has embraced the principles of competency-based education (CBE), ie, focus on outcomes, emphasis on abilities and skills, de-emphasis on time-based training, and promotion of learnercenteredness. [1][2][3][4] CBE has been adopted globally across various professions and by numerous institutions and countries. Several medical regulatory bodies, including the General Medical Council (GMC) in the United Kingdom, the Royal Australasian College of Physicians in Australia, the Royal College of Physicians and Surgeons of Canada (RCPSC), and the Accreditation Council for Graduate Medical Education (ACGME) in the United States have incorporated CBE principles through different frameworks for the training and evaluation of learners. ...
... Several medical regulatory bodies, including the General Medical Council (GMC) in the United Kingdom, the Royal Australasian College of Physicians in Australia, the Royal College of Physicians and Surgeons of Canada (RCPSC), and the Accreditation Council for Graduate Medical Education (ACGME) in the United States have incorporated CBE principles through different frameworks for the training and evaluation of learners. [1][2][3] The ACGME implemented the Next Accreditation System in 2013 based on CBE. 5,6 In response, all ACGME-accredited United States (US) residency programs were required to establish a Clinical Competency Committee (CCC) to assess residents according to the Milestones framework and submit a semi-annual report to the ACGME. ...
Background
Several challenges regarding Clinical Competency Committee (CCC) processes have been previously reported. Few studies have addressed the cost of assessment in healthcare professional education. This study aimed to assess the time spent on and the cost of CCC processes, and faculty perception of the Milestones assessment in three residency programs.
Methods
We surveyed CCC faculty members to capture time devoted to, and satisfaction with, CCC processes from three residency programs at the University of Michigan: Anesthesiology, Emergency Medicine, and Surgery. During preparatory periods before CCC meetings, administrative staff used daily logs to record time spent in the CCC preparatory period to develop meeting documents and resident reports. CCC faculty members supplied estimated time spent preparing residents' assessments through a survey administered the day following the meeting. Additionally, the duration of each CCC meeting was recorded, and salaries were confirmed to estimate total cost. Total faculty and staff time was summed and reviewed by each departmental CCC program director.
Results
CCC members found the unstandardized semi-annual report compiled by the programs was poorly organized, not easy to review, and did not provide high-quality information for setting Milestones. The majority of CCC members reported the current CCC process does not allow enough time for review of resident data, does not provide valuable feedback to inform resident progression, and does not provide adequate rigor to defend CCC decisions. Annually, administrative staff spent 162.9 ± 151.7 h preparing the reports. Faculty spent 147.0 ± 78.4 h for the resident assessment preparation and 97.3 ± 24.1 h in CCCs meeting. Based on salaries, the cost of CCC processes for Milestone assessment totaled USD83,437, with USD22,776, USD31,764, and USD28,897 for Anesthesiology, Emergency Medicine, and Surgery, respectively. With an average of USD395.44 per resident, the total annual CCC cost for University of Michigan Medical was extrapolated to be USD404,531.
Conclusions
Though Milestones were implemented more than ten years ago, CCC processes are still unsatisfactory to faculty and pose a significant institutional cost. Alternative approaches are still needed to improve resident competency assessment processes.
... This approach aims to facilitate a gradual increase in responsibility and autonomy during training, while maintaining tailored supervision and high standards of patient care [3]. Many residency programmes worldwide have adopted EPA-based structures, contributing to a growing understanding of how professionals experience learning and working within these frameworks [2][3][4][5][6]. Typically, residents begin with close supervision and gradually have more autonomy to perform professional tasks independently, with supervision remaining available upon request [1]. ...
... In the self-reflection phase, residents reflect on their development and readiness for entrustment, often together with a supervisor. The structure of entrustment decision-making may support residents in goal setting, selfassessment, and feedback-seeking, thereby reinforcing their involvement in strategic learning processes [5]. In our study, most residents described feelings of happiness, confidence, and motivation upon being entrusted with an EPA, while the thought of a delayed entrustment decision evoked emotions such as anxiety, sadness, and disappointment. ...
Introduction
Entrustable Professional Activity (EPA)-based residency programmes are designed to offer structure, flexibility, and a gradual increase in autonomy. While residents are expected to take an active role in their learning, little is known about how they actually experience learning and working within the EPA framework. This study explores paediatric residents’ experiences of learning, working, and developing within an EPA-based training programme.
Methods
We conducted a qualitative study using semi-structured interviews with 11 paediatric residents from three of the seven Dutch training regions. Interviews were transcribed verbatim, anonymised, and analysed using template analysis to identify themes related to residents’ learning and professional development within EPA-based training.
Results
Residents described increasing confidence and competence in the phase prior to entrustment. Some linked this development to the EPA structure, as it supported goal setting and feedback-seeking, while others attributed this development primarily to learning through clinical experience.
The entrustment decision process—particularly the Clinical Competence Committee (CCC) feedback—was seen as reassuring, though residents also described discomfort with being evaluated by a group. After entrustment, residents experienced greater autonomy but noted variation in supervision practices. Some felt unsure about when to request supervision, particularly in apparently straightforward settings. Others described feeling empowered to pursue individualised learning opportunities.
Discussion
In reflecting on these findings, we drew on the concept of Self-Regulated Learning to explore how residents engaged with their training. Making these principles more explicit within EPA-based programmes may support residents in optimising their learning and strengthen their preparation for independent practice.
... Por conta, disso facilitam a mensuração da evolução do residente na sua prática. Com a avaliação mais acurada da progressão do residente, há como consequência um aumento da qualidade da assistência prestada e um aumento da segurança do paciente, dos educadores e dos residentes 9,10 . ...
... Todas as APC propostas descreveram atividades observáveis na prática do residente em MFC, sendo inovadoras na tentativa de descrever a especialidade com base em suas principais tarefas. Com o uso da descrição da especialidade baseada nas APC, espera-se, de acordo com a literatura, proporcionar maior clareza ao conteúdo a ser ensinado e às ofertas práticas oferecidas pelos programas de residência 9 ...
Introduction: Entrustable professional activities (EPAs) describe units of professional practice of a specialty and, therefore, fundamental to be offered as training by residency programs. EPAs for residency in Family and Community Medicine (FCM) have already been described in other countries. In Brazil there is still no description of these EPAs for the specialty.
Objectives: Develop EPAs for FCM in the Brazilian context and validate them using the Delphi technique.
Method: FCM experts and teachers with expertise in medical education analyzed the national competency matrices for FCM residency and the EPAs previously described in other countries for the specialty. This core group formulated EPAs considering the population’s health needs, the legislation of the Brazilian Unified Health System (SUS) and the specificities of FCM training in the country. FCM specialists with experience working in medical residency were invited to form a Delphi panel to evaluate the proposed EPAs. A Content Validation Index of 80% was considered for consensus.
Results: 14 EPAs were defined by the core group. The Delphi panel consisted of a group of 24 preceptors and program supervisors, with an average length of experience as educators in FCM residency of eleven years. It took two rounds to establish the consensus and all 14 EPAs were approved.
Discussion: Brazil has specificities related to its population and the health system organization that differentiate it from countries where EPAs for FCM have been described. There is a uniqueness in FCM training in the country, with the need to develop local EPAs. This was demonstrated by the need to formulate EPAs considering operations in health care networks, addressing vulnerabilities and health care considering the operation territory.
Conclusion: This study describes a proposal for the development and validation of EPAs for the Family and Community Medicine residency in Brazil. The specification of these activities has the potential to support the orientation of residency programs in the specialty and reduce differences in FCM training in the country.
... With a more accurate assessment of the resident's progression, the result is an increase in the provided quality of care and an increase in the safety of patients, educators and residents 9,10 . ...
... All the proposed EPAs described observable activities in the practice of the Family and Community Medicine resident, being innovative in the attempt to describe the specialty based on its main tasks. The use of the specialty description based on the EPAs, according to the literature, is expected to bring greater clarity to the content to be taught and in the practical offers provided by the residency programs 9,10 . ...
This study describes a proposal for the development and validation of EPAs for the Family and Community Medicine residency
in Brazil. The specification of these activities has the potential to support the orientation of residency programs in the specialty and reduce
differences in FCM training in the country.
... especially critical due to the complexity of procedures and the vital importance of patient care. 7,8 Entrustable Professional Activities (EPAs) have emerged as a key framework within CBME, 5 offering a structured approach to evaluate residents' readiness for unsupervised practice. 9,10 EPAs encapsulate the essential tasks that residents must perform independently, ensuring educational outcomes are directly linked to clinical responsibilities. ...
... To evaluate autonomy, the platform employs a 5-level entrustment-supervision scale for workplace assessments: level 1 (allowed to observe without active participation), level 2 (permitted to perform the EPA under direct and proactive supervision), level 3 (permitted to perform the EPA with indirect and reactive supervision), level 4 (authorized to work independently), and level 5 (qualified to supervise junior learners). 5,34,35 Both registered residents and faculty members on the EMYWAY can initiate an EPA assessment through a streamlined process. To begin an assessment, a resident logs into the platform (Supplemental Figure S2, available online), follows the steps (Figure 1), and submits the assessment. ...
Objective
To present workplace‐based entrustable professional activities (EPAs) assessment data from the first 2 years of the EMYWAY platform in otolaryngology residency training in Taiwan.
Study Design
Two‐year cross‐sectional study.
Setting
Otolaryngology training programs.
Methods
In 2020, the Taiwan Society of Otorhinolaryngology–Head and Neck Surgery (TSO‐HNS) developed a workplace‐based assessment (WBA) framework with 11 EPAs, integrating milestones to evaluate resident competency. In 2021, TSO‐HNS piloted the EMYWAY platform for WBAs, which includes an EPA‐based assessment workflow, coaching feedback, and a dashboard displaying residents' entrustment‐supervision levels. Data are analyzed annually for accreditation and curriculum enhancement. This study reports on the pilot year and the first full‐scale year of implementation.
Results
Eleven programs participated in the pilot year. Subsequently, 362 faculty members and 274 resident physicians from 34 programs nationwide engaged with EMYWAY. In the full‐scale year from August 2022 to July 2023, 9805 responses were recorded, primarily from surgical theaters (45.9%; 4502/9805) and third‐year residents (23.8%; 2331/9805). The most frequently evaluated EPAs were “head and neck” (17.5%; 1716/9805), “sinonasal” (13.5%; 1324/9805), and “ear” (12.2%; 1193/9805), with task complexity increasing with resident seniority ( P < .0001). A positive correlation was found between residents' self‐assessments and faculty members' ratings ( r = 0.531; P < .001). Over 98.2% of residents and 88.4% of faculty members provided substantial feedback (>10 words). Analysis of WBAs reported by training programs identified faculty development targets and teaching‐intensive tasks.
Conclusion
EMYWAY effectively documents workplace learning and tracks resident competency progression. Continuous improvement of WBA quality is essential for advancing the competency‐based medical education ecosystem.
... However, the widespread adoption of the WPBA approach has also highlighted some drawbacks. These include purpose confusion, time constraints, untrained supervisors, the lack of synchronicity with training needs, and dissatisfaction with the amount and quality of feedback received (ten Cate 2007Cho 2014; O'Leary 2016; Prentice 2020; Hung 2021; Martin 2023). ...
... Definition An entrustable professional activity (EPA) has been defined as 'a unit of professional practice that may be entrusted to a learner to execute tasks (critical specialized activities) unsupervised once he or she has demonstrated the required competence' (ten Cate 2005(ten Cate , 2007. To expand on this definition: (a) it is a method of trainee assessment by the trainee's supervisor; (b) entrustment is given when the supervisor acknowledges that the trainee has sufficient knowledge and supervised experience to carry out a task independently; (c) it can only assess medical specialised tasks, i.e. tasks that require training and are relevant to the trainee's specialty, and (d) it is objective, observable and measurable in a given time frame (ten Cate 2007). ...
Entrustable professional activities (EPAs) have gained traction in the medical education field as a means of assessing competencies. Essentially, an EPA is a profession-specific task that a trainee is entrusted to conduct unsupervised, once deemed competent by their supervisor through prior evaluations and discussions. The integration of EPAs into postgraduate assessment strategies enhances the delivery of capability-based curricula. It strategically bridges the theoretical–practical divide and addresses existing issues associated with workplace-based assessments (WBPAs). This article aims to (a) provide an overview of EPAs, (b) review the application of EPAs in postgraduate psychiatry so far, exploring their conceptual framework, implementation, qualities and potential benefits and concerns, and (c) propose a theoretical framework for their integration into the UK psychiatry curriculum.
... Traditional competencebased assessments often break down competencies into specific, detailed abilities of learners, which necessitates fragmented and isolated assessment methods. These methods, while detailed, may lack the authenticity and holistic approach needed to accurately reflect real-world professional practice [13]. In CBME, learners should progress at their own pace until they master specific competencies, tracked through Entrustable Professional Activities (EPAs) [14]. ...
... 50% EPA. 13 Write a manuscript for publication. 45% ...
Background
Competencies-based education has gained global recognition, emphasizing the need for educators to align educational outcomes with healthcare system requirements. However, limited literature exists on competency frameworks and Entrustable Professional Activities (EPAs) specific to health professions educationists, hindering the development of tailored Master’s programs.
Aim
This study aimed to develop a competency framework outlining the roles and functions for Master’s learners in Health Professions Education (MHPE) and identify the key EPAs that form the foundation of a task-based MHPE curriculum, along with the expected levels of entrustment.
Methods
An international Delphi study was conducted involving three rounds of surveys and qualitative discussions with an expert panel of health professions educationists from diverse contexts (n = 29). The Delphi technique, including open-ended and quantitative rating scales, was employed to reach consensus on the EPAs and their levels of entrustment. The final list of EPAs was validated using the EQual rubric.
Results
A total of 16 EPAs were identified and validated, mapped to core and potential roles and functions of health professions educationists. There is less agreement on the level of entrustment that should be attained at the master level, resulting in EPAs that must be fully entrusted before graduation and others which need further development afterwards.
Conclusion
The study presents a comprehensive competency framework and a set of EPAs tailored for MHPE programs, providing a structured approach to curriculum design and learner assessment. The findings underscore the importance of incorporating context-specific considerations and aligning educational objectives with the evolving roles and responsibilities of health professions educationists.
... Medical, nursing, and allied health curricula must be restructured to integrate movement science not as an elective, but as a core competency. This includes practical instruction in gait assessment, strength testing, and exercise prescription, supported by evidence-based frameworks and rigorous competency evaluation (Ten Cate and Scheele, 2007;van der Vleuten et al., 2012). Continuing education must also address the substantial knowledge gap among practicing clinicians who were never trained in movementfocused approaches. ...
Modern healthcare systems prioritize diagnostic technologies such as blood tests, imaging, and genetic screening, while systematically neglecting the fundamental human capacity for movement. This paradox is especially striking given that movement is the primary evolutionary function of the human body and a powerful predictor and determinant of health outcomes across the lifespan. Growing evidence suggests that limitations in movement may initiate the cascade of age-related decline, leading to physiological deterioration that manifests as frailty, cognitive impairment, and premature mortality. Yet despite its centrality to human function, movement remains peripheral in clinical practice, often evaluated informally or only after significant decline has occurred. Here, we argue for a movement-centered healthcare infrastructure that places mobility assessment and intervention at the core of clinical decision-making. We examine the scientific rationale, economic consequences, and broad societal benefits of prioritizing locomotion alongside traditional diagnostics. Ultimately, we propose that movement analysis should be elevated to the level of routine, sophisticated practice—on par with today's laboratory diagnostics—restructuring healthcare around the proactive enhancement and lifelong preservation of human mobility.
... This theoretical foundation may allow them to better integrate clinical dysphagia content into their knowledge base and apply this knowledge in direct patient care settings. A previous article describing a conceptual framework for dysphagia instruction similarly describes improved clinical dysphagia content understanding with increased dysphagia management experiences [14]. This would explain why students with previous dysphagia patient exposure also scored high on DCVT self-competency ratings related to General Skills and Direct Patient Care domains. ...
Purpose
Training programs focused on dysphagia have been identified as an area needing improvement due to the specialized skills required to provide clinical care to patients with dysphagia. Globally, a lack of standardized training has been recognized and has led to the introduction of competency and training frameworks in the clinical practice of dysphagia. Previous studies have explored the experiences of students in training programs and their self-perceived competency; however, none have explored this in the Ethiopian context due to the infancy of the Speech Language Therapy (SLT) profession within this region. The objectives of this study were to explore patterns in self-perceived competency ratings for SLT students at AAU and determine the impact of clinical experiences during student training.
Methods
First- and second-year students enrolled in the two-year SLT Master's program in Ethiopia were taught the dysphagia course in a combined class in English by visiting faculty. A modified Dysphagia Competency Verification Tool (DCVT) was used to assess self-perception of competency in dysphagia. The tool was administered in April 2024, before any dysphagia-related clinical exposure occurred and once again in May 2024, after clinical exposure to patients with dysphagia occurred. Generalized estimating equations (GEE) models were used for the General Skills (DCVT-GS) and Direct Patient Care (DCVT-DPC) subtests to study variations in responses for self-perceived competency. The models included covariates of sex, background in SLT, dysphagia-specific patient exposure and a repeated factor of survey timepoint.
Results
In total, 38 responses were collected across two time points and from all 19 participants. The SLT students were mostly female (n = 16; 84%) with ages ranging from 21 to 46 years. The GEE model for DCVT-GS identified significant main effects of background in SLT (p = 0.018), dysphagia patient exposure (p = 0.019), and survey timepoint (p < 0.001). The GEE model for DCVT-DPC demonstrated significance for background in SLT (p < 0.001), dysphagia patient exposure (p = 0.009), and sex (p = 0.031).
Conclusion
Regardless of DCVT domain, SLT graduate student clinicians were more likely to perceive themselves as “adequate” in their ratings at the second timepoint following clinical interactions, if they had prior SLT experience, including prior dysphagia experience. Training programs exploring dysphagia competency are encouraged to provide increased exposure to patients with dysphagia to support increased self-perceived competency scores.
... A challenge faced by universities and other educational institutions when working within competency frameworks lies in the assessment of performance, particularly in specific workplace settings. Hence Entrustable Professional Activities(EPAs) have emerged as efficient vehicles for assessing physicians [1,2,3]. EPAs are defined as "units of professional practice, defined as tasks or responsibilities to be entrusted to unsupervised execution by a trainee once he or she has attained sufficient specific competence" [4]. ...
Background and objectives
Outcome-based medical education is the latest focus in the past decade, and Entrustable Professional Activities(EPAs) have emerged as efficient vehicles to assess physicians. However, few studies have discussed the use of EPAs for residency training in pediatric medicine and its subspecialties. We conducted a pilot study to examine the feasibility of EPAs as a component of the clinical program of assessment in pediatric standardized residency training.
Methods
We conducted a cross-sectional study for standardized residency training in different subspecialties within pediatric medicine at Qilu Hospital of Shandong University. Totally 65 residents and 35 directors joined in this study. An electronic EPA survey using 8 scales composed of 15 categories was distributed among residents and directors. Kruskal-Wallis test and Mann-Whitney U test were applied for comparing the self-assessments and director-assessments. Generalized estimated equation (GEE) was used to analyze the effect of postgraduate year(PGY), gender, and position on the EPA scores of director assessments.
Results
A total of 401 director-assessment and 65 residents’ self-assessment ( response rate 100%) questionnaires were collected, both demonstrating rising trends in scores across PGYs. Significant differences were found between PGY1 and PGY2 (p < 0.01) and between PGY1 and PGY3 (p < 0.01), but not between PGY2 and PGY3 (p > 0.01). With an effect analysis of PGY, gender, and position on EPA scores performed, PGY had a significant effect on 13 out of 15 EPA scores, while gender affected only four EPA scores significantly, and position affected only three EPA categories. Meanwhile, some EPA categories revealed significant differences across various pediatric subspecialties (p < 0.01).
Conclusions
The study findings suggest that EPA assessments is feasible among different PGYs in standardized Chinese residency training in pediatric medicine and its subspecialties. Postgraduate year had a significant impact on EPA scores, while gender and resident position also affected EPA scores to a certain extent. Improved stratified teaching programs are required for better subspecialty consistency.
... Descriptive statistics such as mean, median, and interquartile ranges were used to summarize the data. The analysis was further deepened by aligning these results with established medical education frameworks [34][35][36][37]. ...
Background
Diversity competence, diversity itself, and a corresponding awareness of possible (intersectional) discrimination mechanisms have not been anchored in the German National Competence based Learning Objectives Catalogue for Medicine 2.0 (Nationaler Kompetenzbasierter Lernzielkatalog 2.0., NKLM) yet, highlighting a systemic gap in national competency frameworks. We present our first experience with a prospective diversity-specific intervention in medical students to assess its short-term impact on students' diversity acceptance (DA) and to develop actionable recommendations for integrating diversity into medical education.
Methods
We designed a prospective cohort study using a control group (CG) and intervention group (IG) design. The IG absolved a five-day diversity-specific intervention (50 h; field trip; seminar). Quantitative data were collected using the validated DWD-O5 scale at baseline (T0), three months (T3), and six months (T6), complemented by qualitative responses (diversity issues in the medical curriculum; perceptions and criticisms) categorized using Mayring’s content analysis. Descriptive and non-parametric statistics were performed.
Results
Thirty-one medical students (n = 10, IG vs n = 21, CG) were enrolled. The IG demonstrated a short-term improvement in diversity competence (+ 9.72%) across all DWD-O5 factors during the intervention. While scores slightly declined at T6, they remained above baseline levels. 35% (CG) vs. 56% (IG) have experienced discrimination in context of medical studies on their own. Participants in both groups stressed the importance of integrating diversity criteria into curricula at an early stage (100% agreement). Findings revealed three key themes: perceived inadequacies in current curricula, self-reported discrimination experiences, and a strong desire for practical diversity training, such as simulation-based learning.
Conclusion
The intervention shows promise as an initial step toward addressing diversity gaps in medical education. By combining historical, cultural, and experiential learning approaches, the program fosters essential competencies such as empathy, self-reflection, and bias recognition. More broadly, sustained improvements in diversity competence require longitudinal integration of diversity training across curricula and systemic reforms to national frameworks like the NKLM. Future research should explore the long-term impact of such interventions and strategies for institutionalizing equity-focused medical education.
... In medical education, it has long been discussed whether and how individual differences that go beyond specific clinical knowledge can be measured and quantified. Some authors have argued that many desirable skills are not objectifiable phenomena and therefore may not be measurable at all [14,19,20]. The approach presented here addresses this issue by focusing on reliable and clearly measurable skill dimensions. ...
Social skills (e.g., assertiveness, empathy, ability to accept criticism) are essential for the medical profession and therefore also for the selection and development of medical students. However, the term “social skills” is understood differently in different contexts. There is no agreed upon taxonomy for classifying physicians’ social skills, and skills with the same meaning often have different names. This conceptual ambiguity presents a hurdle to cross-context communication and to the development of methods to assess social skills. Drawing from behavioral psychology, we aim to contribute to a better understanding of social skills in the medical context. To this end, we introduce a theoretically and empirically informed taxonomy that can be used to integrate the large number of different social skills. We consider how skills manifest at the behavioral level to ensure that we focus only on skills that are actually observable, distinguishable, and measurable. Here, behavioral research has shown that three overarching skill dimensions can be seen in interpersonal situations and are clearly distinguishable from each other: agency skill (i.e., getting ahead in social situations), communion skill (i.e., getting along in social situations), and interpersonal resilience (i.e., staying calm in social situations). We show that almost all social skills relevant for physicians fit into this structure. The approach presented allows redundant descriptions to be combined under three clearly distinguishable and behavior-based dimensions of social skills. This approach has implications for the assessment of social skills in both the selection and development of students.
... EPA-based assessment tracks the progression of competence for each EPA resulting in summative entrustment decisions to act according to a specified level of supervision. The level of mastery of an EPA is reflected by five stages of decreasing supervision requirements (Mulder et al., 2010;ten Cate & Scheele, 2007). ...
In New Zealand, an increasing number of physiotherapists have been engaged in orthopaedic triage and assessment (OTA) roles within elective orthopaedic departments to help optimise surgeon clinic time and improve timely access to diagnostic assessment and treatment planning for people with musculoskeletal conditions. To date no framework has been available to guide physiotherapists and surgeons in developing these roles. This commentary describes the development of an Entrustable Professional Activity (EPA) framework for physiotherapists in OTA roles in which five key clinical activities were identified. The framework defines the context, limitations, knowledge, skills, attributes, and behaviours needed for each activity. The EPAs were mapped to existing New Zealand physiotherapy competencies and key competencies identified that are needed for safe and effective practice with minimal or no supervision. This EPA framework is intended for use in elective orthopaedic departments, to support the development of physiotherapists working in orthopaedic triage and assessment roles in clinical subspecialty areas.
OBJECTIVE
Assessing pediatric subspecialty fellows using entrustable professional activities (EPAs) to determine readiness for graduation has not been described. We aimed to determine whether graduating pediatric fellows are meeting the minimum supervision level at graduation previously identified by program directors for the clinical EPAs and the relationship between meeting these levels and initial subspecialty board certification.
METHODS
Pediatric fellows in 14 subspecialties were assessed by clinical competency committees in the spring before graduation in 2019 to 2022 on 3 EPAs common to all subspecialties that involve direct patient care and the subspecialty-specific EPAs. Publicly available board certification data were obtained from the American Board of Pediatrics.
RESULTS
EPA supervision levels were collected on 1480 fellows, representing approximately 27% of all graduating fellows. A total of 117 (7.9%) fellows did not meet the minimum supervision level for at least 1 EPA, with some requiring direct supervision. Of fellows who did not achieve the expected level at graduation, 83 (70.9%) were certified. Those who met the minimum level for all clinical EPAs had a higher certification rate compared with those who did not meet the minimum for at least 1 EPA (80.6% vs 70.9%; P = .01).
CONCLUSIONS
Almost 10% of pediatric fellows are not meeting the expected supervision level for the clinical EPAs at graduation, and yet over 70% of them passed their subspecialty certification examination. This study provides support for using EPAs to determine readiness for graduation and demonstrates that some fellows may need additional training or continued supervision after completion of their fellowship.
Veterinarians undergo several years of rigorous education in order to qualify in their chosen profession. As they enter clinical practice, or work within other areas of the profession, they embark upon a career-long journey of learning, whether that be ‘formal’ or ‘informal’ education and training, in order to develop themselves professionally and remain up to date. However, the vast majority of published educational literature within the veterinary sector relates to undergraduate programs. Research and scholarship relating to veterinary education and training beyond graduation is extremely sparse in comparison. This is somewhat different to what is seen in other health professions, including medical education, where a significant proportion of the literature focuses on education and training beyond graduation, from early career training and residencies through to continuing education. The advantages of publishing high-quality scholarship and research in any field are well known. Sharing more evidence and best practice in post-graduation education and training will inform international advances in this area. Although the specific educational challenges facing the profession at different career stages are distinct, evidence-informed approaches to educational interventions—whether that be supporting graduates’ transition into the workplace, specialty training, or continuing education—have the potential to have a positive impact on many levels, from improved patient outcomes and client satisfaction, to enhancing veterinarians’ job satisfaction and retention in the workplace. This article discusses the gaps in evidence in veterinary education and training beyond graduation, identifying some of the current challenges that could be addressed through a greater focus in this area, and their importance. In relation to graduate transition into the workplace, further work is needed to understand the optimal design and effectiveness of support programs, including coaching and mentoring for graduates. For formal post-graduate education leading to a more advanced level of practice, there is a need to better understand which approaches to teaching and assessment promote high-quality, consistent, learning experiences and outcomes. Further evidence regarding how continuing education is identified and undertaken by learners, and the corresponding impact on practice, would be valuable, and a greater understanding into feasible yet robust licensure assessments and mechanisms for revalidation are needed.
Competency-Based Medical Education (CBME) has evolved over decades, prioritizing real-world pro ciency over traditional, time-based training. While its application has been well established in clinical education, its integration into the preclinical phase is gaining traction, particularly in response to the challenges highlighted by the COVID-19 pandemic. The shift to digital learning formats disrupted hands-on training, peer interaction, and professional identity formation, underscoring the need for structured competency development early in medical education. This systematic review explores how CBME principles are being incorporated into preclinical education, examining diverse teaching methodologies and their role in bridging the gap between foundational knowledge and clinical application. By employing a structured analysis of competency frameworks, we identi ed recurring patterns in the alignment of educational strategies with targeted learning outcomes. Our ndings reveal that certain competency domains frequently co-occur in more elaborate instructional designs, suggesting inherent synergies that may support both knowledge retention and transferability. While these developments mark progress, the eld still lacks a comprehensive, empirically validated framework for CBME implementation in preclinical education. More systematic research is needed to re ne best practices, optimize instructional approaches, and harness the potential synergy between competencies. Strengthening the evidence base will be essential for guiding the future integration of CBME, ensuring that competency-driven education begins early and effectively prepares students for the evolving demands of medical practice.
The debate on competency-based education has gained increasing interest in the medical education lit-erature over the past thirty years. The “competency-based” approach to medical training has been pri-marily discussed considering its underlying assumptions, implementation methods, and impact on the summative evaluation of medical students and residents. However, a recent scoping review has pointed out weak evidence that this educational approach produces “better” doctors.
This paper will analyze some aspects of competency-based education and discuss, from a pedagogical perspective, key related concepts such as the contextual and phronetic nature of competence, the issue of “transversal” (soft) skills, the relationship among competence, performance, and, consequently, summa-tive evaluation. This analysis will pursue an approach to medical education – and, more generally, to training healthcare professionals – that goes beyond competencies understood as isolated knowledge and skills. Instead, it will advocate for an educational perspective integrating competencies with capability, fostering “practical wisdom” in applying knowledge to individual patients.
College students are important contributors to global innovation and entrepreneurship, making it increasingly important to improve related education, especially in medical schools. However, challenges remain due to the specific nature of medical training, economic differences across countries, and the lack of a well-developed system. In some regions, limited understanding has led to ineffective efforts and poor results, which has hindered progress, underscoring the need for a strategic, context-aware approach to innovation and entrepreneurship education in medical schools. This study employs bibliometric methods including Microsoft Excel, CiteSpace, VOSviewer and R language package of Bibliometricx software to analyze global publications published on Web of Science database from 2000 to 4 December 2024.The findings indicate that innovation and entrepreneurship education for medical students began later than in other fields and has faced implementation challenges. Publication trends align with national policies and significant events, such as the COVID-19 pandemic. Developed countries dominate this field, while international collaboration has exacerbated regional disparities. Higher medical schools remain the primary contributors, reflecting the limited scope of this research area. Current studies emphasize the learning aspects of medical education but insufficiently address students’ innovation and entrepreneurship abilities. The results also highlight critical gaps in current education models and suggest that integrating innovation and entrepreneurship more comprehensively into medical curricula is crucial for preparing students for the evolving healthcare landscape.Medical education must adopt an interdisciplinary approach, as global public health developments have shaped its trajectory. This study informs health policy by showing that innovation and entrepreneurship education strengthens medical students’ ability to address global health challenges. It provides guidance for curriculum integration through interdisciplinary and context-driven approaches, underscoring the need to cultivate a culture of innovation to advance medical education and global health outcomes.
Objetivo: Avaliar as evidências sobre a aplicação de Atividades Profissionais Confiáveis na residência médica de Otorrinolaringologia. Métodos: Realizou-se, em dezembro de 2024, uma revisão integrativa da literatura por meio de artigos publicados nos últimos cinco anos, disponíveis na Biblioteca Virtual da Saúde (BVS), Web of Science, Embase e Google Schoolar. A estratégia de busca retornou 1294 artigos, após aplicação de filtros 7 foram incluídos. As variáveis categoriais avaliadas foram: 1- metodologia, 2- implementação, 3- pontos fortes e 4- fragilidades. Resultados: Dos 7 artigos, 4 desenvolveram estudo metodológico para criação das APCs voltadas a Otorrinolaringologia e algumas subáreas com variações na quantidade de 46 a 335, enquanto 2 estudos realizaram avalição de desempenho das APCs através de aplicativo (11 APCs). Em 2 estudos foi possível realizar uma avaliação longitudinal dos residentes com identificação de padrões de progressão nos níveis de competências. Apenas 2 estudos contemplou uma avaliação multicêntrica das APCs. Considerações Finais: Atividades Profissionais Confiáveis oferecem uma abordagem estruturada para o aprendizado baseado em competências, permitindo que os residentes adquiram habilidades práticas essenciais de forma progressiva e com avaliação continua. Mas enfatiza-se os desafios de padronização de APCs únicas que possam ser utilizadas por vários centros.
Objectives
Entrustable professional activities (EPAs) have been used in undergraduate and graduate medical education and in other health professions for a long time. They are regarded as a suitable way for bridging the gap between competency-based education and actual work tasks in the workplace. In nursing education, EPA development started later, and it is unclear which EPAs have been developed and implemented yet. This scoping review aims to identify which EPAs have been developed in nursing education, which of these have even been implemented and what the empirical evidence supports any effects of implementation.
Design
Scoping review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews.
Data sources
MEDLINE and EMBASE via OVID, CINAHL and ERIC via EBSCOhost were searched for the period 1 January 1995 to 31 December 2023.
Eligibility criteria
Publication period from the first mention of EPAs in 1995 to 2023, no language restrictions, all types of literature if they had a clear mention of EPAs, all academic nursing education fields, EPAs had to be mentioned in the title or abstract.
Data extraction and synthesis
Screening was conducted in a two-stage process with two authors. 13 suitable articles were included which describe either the development, implementation or assessment of EPAs.
Results
Results indicated that EPAs have been developed in 16 areas of nursing education, including special areas such as palliative care or emergency/intensive care. The activities health status assessment, care measures, leadership/management, diagnoses, care plans and protocols, emergency care measures and participation in diagnostics and/or therapy were described most often. In 4 out of 13 cases, EPAs were implemented. Described evidence indicated that the use of EPAs improved critical thinking, promoted flexibility in teaching and led to a mindset change.
Conclusions
EPAs are increasingly developed and implemented in nursing education. There seem to be overlaps between EPAs mainly covering the steps of the nursing care process.
Transformative digitally integrated pedagogy can enrich learning experiences, diversify the curriculum and broaden access to industry-relevant advanced clinical education for remote learners in medical education. Clinical skills are characterised as the portfolio of practical and interpersonal skills required by practicing clinicians. The purpose of this project was to design a new wholly online post-professional university subject for clinicians in different healthcare disciplines to advance these skills, which would traditionally be taught and assessed in-person. Our methodology included critically reviewing existing evidence of relevant medical skills which need to be included in the curriculum and approaches to their assessment. We designed a subject which dovetailed learning experiences with continuing clinical practice, and developed a new framework for remote video assessment of practical skills. Our pedagogical approaches included a backwards design coupled with a Four-Component Instructional Design Model (4C-ID) approach, which increased access and contextualised learning opportunities for diverse and practicing clinicians. Our narrative synthesis critically shares our experience and insights of embracing digital-technology opportunities while problem-solving to move past barriers. Our impact evaluation and experiential insights offer a platform to reimagine emerging possibilities for future digitally integrated education in medical education and other clinical-skills professions.
Objetivo: Validar uma EPA do tratamento cirúrgico da fratura da extremidade distal do rádio na Residência Médica de Ortopedia e Traumatologia. Métodos: Uma EPA previamente elaborada foi aplicada em residentes do Complexo Hospitalar São Francisco de Assis. Comparou-se a média das notas obtidas de acordo com o ano de curso. Utilizou-se o teste t de Student para a comparação das médias e o teste alfa de Cronbach para a avaliação da consistência interna. Resultados: A EPA foi aplicada em 23 médicos residentes entre setembro e outubro de 2019, totalizando 73 cirurgias, com média de 3,2 procedimentos por residente. Em praticamente todos os itens avaliados, as médias obtidas pelos residentes do terceiro ano foram maiores que as do segundo e primeiro anos e as notas dos residentes do segundo ano foram maiores que as do primeiro. Essas diferenças foram estatisticamente significativas. A consistência interna foi muito alta de acordo com o alfa de Cronbach. Conclusão: A EPA foi validada com sucesso gerando um instrumento capaz de discriminar os médicos residentes de acordo com o ano de formação.
Background
The Royal Australasian College of Surgeons' Board in General Surgery implemented Entrustable Professional Activities (EPAs) in its competency‐based training programme in 2022. As this is a new method for surgical trainees, a qualitative study was performed to evaluate its implementation and use by exploring the pioneer trainees' perceptions and experiences of EPAs.
Methods
Seven first‐year general surgery trainees were recruited to participate in semi‐structured interviews. The interviews explored the trainees' experiences of EPAs, their perceptions of the effect on their independence with completing clinical activities and patient safety, and their suggestions for how to improve this form of assessment in the training program.
Results
The findings of the study suggest that EPAs can be a useful tool for assessing the competence of trainees. However, the study also found that EPAs can be challenging for trainees, particularly in terms of the level of self‐regulation and independence required.
Conclusion
Although EPAs may positively contribute to a trainee's experience, considerations to support trainees and trainers in their practical implementation may increase the value of the learning encounter. Graded assessment of entrustment and explicit year‐level milestone progress points could promote more effective learning and support developmental feedback by trainers.
Introduction
In medical education, entrusted professional activities (EPAs) have been an integral part of the curriculum, primarily being used in clinical traineeships and postgraduate medical education. The use of EPAs in postgraduate medical education is transferable to dental training, as clinical skills are already part of the curriculum. The data from this study could help propose dental EPAs that reflect competencies expected in the professional field, potentially aiding in more effectively evaluating student competencies and standardizing assessment criteria.
Methods
After research on the use of EPAs in dental education across Europe, Asia, and the United States, 21 EPAs were chosen, covering all areas currently taught in the German dental graduate program, and matched with the domains of the National Catalog of Learning Objectives in Dentistry. Following, an electronic survey was developed and distributed to dentists working at university hospitals in the Rhine‐Main region, as well as in private practices. Participants were asked to evaluate each EPA statement on a 6‐point Likert scale and encouraged to provide qualitative feedback on the EPAs.
Results
120 participants responded to the survey (20.7%). Overall, there was substantial agreement on the EPAs chosen to represent the tasks expected of young dentists on their first day in practice. Participants also provided qualitative feedback in the form of optional comments. Concerns raised included the perceived lack of experience for certain tasks.
Conclusion
The data from this study suggest that the proposed EPAs accurately reflect the professional tasks expected of newly graduated dentists on their first day in practice.
Objective
The objective was to scope the literature and describe the extent and type of evidence about entrustable professional activities (EPAs) in postgraduate emergency medicine (EM) education.
Methods
Joanna Briggs Institute's methodology was used to find and extract relevant data from documents found in Ovid MEDLINE, EMBASE, and CINAHL, supplemented by a gray literature search using Google Advanced for EPA frameworks. Eligible documents discussed EPAs for doctors in structured EM training programs. Data extracted included research methods, research approach, participants, scope, EPA element addressed, and dominant logic used by EPA creators.
Results
Data were extracted from 58 documents. Thirty‐four of the documents (58.6%) were peer‐reviewed journal articles, 18 (31.1%) were conference abstracts, and six (10.4%) were curriculum documents from EM organizations. Thirty documents were from Canada (51.7%). Twenty‐five documents (43.1%) took an explorative approach. Twenty‐one documents (36.2%) were translational in approach. Thirteen EPA frameworks, containing a total of 158 EPAs, were found.
Conclusions
EM is an expanding area of EPA development, but frameworks remain highly variable and unstandardized. Most studies are explorative or translational, leaving gaps in experimental research to justify EPA adoption and observational research to assess real‐world outcomes.
OBJECTIVE
This study sought to determine whether graduating residents were deemed ready for unsupervised practice for each of the 17 general pediatrics entrustable professional activities (EPAs).
METHODS
At the end of the 2021–22, 2022–23, and 2023–24 academic years, the authors collected entrustment-supervision levels assigned by clinical competency committees for graduating residents from pediatric and medicine/pediatrics residency training programs to determine readiness for unsupervised practice at the time of graduation. They did this for each of the general pediatrics EPAs and examined the levels reported to determine the proportion of residents ready for unsupervised practice on each EPA and on all EPAs. They compared rates of readiness by academic year using a mixed-effects logistic regression model.
RESULTS
Across all EPAs, 33 190 total entrustment-supervision levels were reported for 2276 graduating pediatrics residents, and 2607 entrustment-supervision levels were reported for 168 graduating medicine/pediatrics residents. There were no EPAs in which programs reported more than 89% of residents as ready for unsupervised practice at the time of graduation. Only 31.3% of graduating residents with observations on all EPAs (414/1322) were deemed ready for unsupervised practice for all EPAs. Graduating medicine/pediatrics residents were more likely than pediatrics residents to be deemed ready for all EPAs (P = .002). Across study years, the rates of readiness at graduation for all EPAs rose from 18.0% to 38.5% (linear contrast P < .001).
CONCLUSION
While there are reasons beyond actual resident readiness that may contribute, this study highlights a gap in readiness for unsupervised practice at the time of graduation.
Competency-based medical education is a journey that FM residencies have traveled for more than two decades, largely without using that specific term. We are on the precipice of a daunting new phase of CBME: the implementation of the ABFM Core Outcomes, which define specific targets for all FM residency graduates. In this chapter, we detail the history of CBME and explain the key terminology that can obscure this topic. We describe the foundational principles of education that underlie the value of CMBE. We detail the key pieces of residency program design that facilitate the development of a system of assessment to track residents’ progress on the journey to competency. We provide examples of processes that can be a part of such a system of assessment. Finally, we explore the future of CBME in FM, considering several crucial factors that will influence the development of our discipline in the next decade.
Proficiency in clinical skills is foundational to medical education, yet many students report feeling unprepared and anxious about performing physical examinations. This chapter reviews the efficacy of multimedia-based approaches to enhance learning and achieve these medical educational gaps. We review the potential, advantages and challenges associated with video-based learning, interactive computer simulations, virtual, augmented and mixed reality. The integration of Entrustable Professional Activities (EPAs) with multimedia-assisted training tools effectively bridges the gap between theory and clinical practice. By defining clear tasks and enhancing with immersive learning tools, this approach strengthens key competencies and supports better learning outcomes, reducing student anxiety during patient interactions. This chapter highlights the potential of multimedia-based learning in fostering more competent and confident medical professionals.
3 I-Introduction-problématique 5 II-La compétence, approche par compétences, philosophie des compétences : précisons ces termes ! II.1-Qu'est-ce que l'approche par compétences ? 8 II.2-Qu'est-ce qu'une compétence ? 10 II.3-Qu'est-ce qu'être compétent ? 13 II.4-… et la compétence professionnel ? 15 III-La médecine familiale et les compétences requises des futurs généralistes III.1-C'est quoi le référentiel de compétences ? 20 III.2-A quoi sert un référentiel de compétences ? 21 III.3-Le référentiel de compétences du médecin de famille 23 III.3.1-L'OMS présente le concept de « médecin 5 étoiles » 23 III.3.2-Le cadre des compétences des médecins CanMEDS 26 III.3.3-Le Collège des médecins de famille canadien 28 III.3.4-EURACT : La définition Européenne de la médecine générale_médecine familiale, WONCA EUROPE 2002 28 III.4-Le référentiel de compétences du médecin de famille enseignant 30 III.5-Comment se construit un référentiel de compétences 39 III.5.1-Les étapes de l'élaboration du référentiel 40 III.5.2-Un exemple en construction : « Référentiel de compétences du médecin généraliste tunisien » 42 III.5.3-Référentiel de compétences : Une étape stratégique dans la construction de la médecine générale 47 IV-Réflexions et recommandations générales 50 Références bibliographiques 54
Aims:
This study aimed to identify and synthesise the evidence on factors influencing the incorporation of Entrustable Professional Activities into assessment in nutrition and dietetics education.
Methods:
A systematic review was conducted with a narrative synthesis and was undertaken and reported in accordance with the PRISMA guidelines. Six electronic databases were searched (MEDLINE, CINAHL, SCOPUS, PsycINFO, Web of Science, and EMBASE) on 9 September 2024. Methodological quality was assessed using the Critical Appraisal Skills Program checklists. Key patterns identified from the narrative synthesis of the included manuscripts were labelled as themes and represented in a figure.
Results:
Across the international literature, six articles were identified revealing six main and interconnected themes related to factors influencing the incorporation of Entrustable Professional Activities in nutrition and dietetics. In summary, development and review processes for Entrustable Professional Activities require key stakeholder engagement in addition to ensuring they are linked to assessment structures and existing frameworks. Furthermore, technology platforms and applications appeared to support Entrustable Professional Activity incorporation, and training is an important part of integration.
Conclusions:
Further research on factors influencing incorporation is occurring and is suggested to continue, especially given Entrustable Professional Activities seemingly offer a tangible option to simplify the intricacy of competency-based assessment in work-based practice. However, further research to enhance understanding of whether Entrustable Professional Activities support nutrition and dietetics learners and assessors in undertaking high-quality assessment with utility is warranted.
Zusammenfassung
Anvertraubare professionelle Aktivitäten (APT) sind ein Konzept aus der kompetenz-basierten Lehre, das Studierenden und Lehrenden eine Orientierung für die schrittweise Übergabe von Verantwortung für die Ausführung einer Tätigkeit bietet. Im September 2024 haben wir mit Vertreter:innen aus den Gesundheitsämtern in Dresden, Chemnitz, Bautzen, Leipzig und Pirna sowie der TU Dresden und der DGÖG begonnen, APTs für das Praktische Jahr der Medizinstudierenden im Öffentlichen Gesundheitswesen zu entwickeln.
Entrustable professional activities (EPAs) are increasingly being adopted as an assessment tool by medicine and other health professions in a bid to enhance competency-based health professional education. EPAs are well-defined professional activities that can be entrusted to students to perform with varying levels of supervision. They were introduced to overcome some of the limitations of traditional assessment methods of competency such as individual skills assessment or Direct Observation of Procedures and Objective Structured Clinical Examinations. Could EPAs be beneficial in Australian and New Zealand optometric clinical education for advanced skills training and accreditation including the credentialing assessment of overseas educated practitioners? This paper discusses the historical context of how competencies were introduced and assessed in Australian optometry, the evolution of the concept of EPAs in medicine and other health professions, their design and implementation worldwide and whether EPAs could be adopted into optometric training and assessment in Australia and New Zealand.
Entrustable professional activities (EPAs) are advancing medical education across the globe, with growing interest in India. Hands on training has always been the cornerstone for postgraduate (PG) training in India. While competency-based education practices are embedded in our system, the specific framework and its terminologies are less widely recognized. For those new to these concepts, competency-based medical education is an educational approach focussed on achieving competencies (abilities) during medical training. Entrustable Professional activities are structured tasks within this framework, representing units of professional work that learners are entrusted to perform once they have demonstrated sufficient competence. Introduction to EPAs can formalise the existing approach to post-graduate education, by defining clear expectations that focus on outcome-based progression, that benefits all stakeholders. This article, titled ‘Not Just for Mavericks’, aims to introduce EPAs, to teachers within the pathology post-graduate programme in India, while offering international readers insight into India’s unique context and the transformative role EPAs could play in streamlining medical training. The article aims to answer the queries on EPAs from the perspectives of medical educators, teachers, the learners, administrators and the policymakers with an intent to explore the application of this concept in their own contexts. Furthermore, it introduces the concept of EPAs as a practical tool for implementing the National Medical Commission’s guidelines on competency-based post-graduate education in pathology. Relevant studies were identified using PubMed, Google Scholar and cross-referencing, with selected data synthesised to support the review’s objectives.
Zusammenfassung
Die Etablierung der Professuren für Öffentliche Gesundheit bietet die Möglichkeit, langfristig ÖGD-relevante Forschungsprojekte und -infrastruktur aufzubauen. Sie erlauben die Entwicklung von gemeinsamen Forschungsprojekten mit Themen aus der Praxis des ÖGDs. Die Professuren bilden den Ausgangspunkt, um eine neue Generation von Gestalter:innen im ÖGD in der Entwicklung von Forschungsprojekten zu unterstützen sowie die wissenschaftliche Kapazität im ÖGD zu stärken im Sinne eines zukunftsfähigen ÖGDs.
Purpose
To evaluate the implementation of a longitudinal assessment framework utilizing entrustable professional activities (EPAs) in dental education during the initial 2‐year implementation.
Method
The Consolidated Framework for Implementation Research was utilized to evaluate contextual factors influencing implementation across the following domains: innovation, outer setting, inner setting, individuals, and process. Purposive sampling was used to ascertain a diverse pool of participants and various perspectives. Inclusion criteria required engagement for >12 months at the time of the study. A semi‐structured interview guide was developed. Two focus groups of faculty and staff and four individual leadership interviews were conducted via Microsoft Teams, transcribed, and thematic analyses were performed using MAXQDA.
Results
Fifteen participants described innovation design details, adaptability, complexity, and relative advantage. The contextual fabric of the setting was evaluated, highlighting the influence of the pandemic, institutional culture, structural shifts, and the pivotal role played by champions. The implementation process was investigated with a focus on training, engagement, access to information, faculty capability, motivation, learner experience, and continual assessment of implementation processes. Data suggests the framework was multi‐dimensional, evolving, and learner‐centered. It facilitated early identification of learners requiring support, provided comprehensive information guiding entrustment and practice readiness decisions and demonstrated preliminary evidence of effectiveness of the innovation.
Conclusion
Engaging in longitudinal assessment using EPAs is multifaceted and influenced by implementation context and intrinsic motivation prevalent among faculty members. The study identifies areas for refinement in support of continuous quality improvement and implementation of this innovative assessment framework in dental education, including technological support, training, and ongoing alignment.
Background
A holistic architectural education is the culmination of learning knowledge, skills, attitudes, and values, which eventually reflects in the quality of graduates. Even though different schools of thought have made various kinds of qualitative contributions towards the evolution of architectural education in India, it has largely been dominated by the quantitative and technical aspects of its regulating framework. Architects engage with the demanding contradictions between responsibilities of an ethical nature, the dynamic challenges of practice, and the intricacies of architectural imagination. The aesthetical and imaginative foundations of the field make it incumbent upon the architects to possess a balance of ecumenical proficiencies for accountability and personalization. The purpose of the study is to identify relevant attributes of Competency Based Education (CBE) that can be adopted for architectural education in India.
Methods
This research follows a narrative review approach and a descriptive-analytic method to broadly understand the attributes of CBE and its potential relevance to architectural education in India. 323 articles were searched on various search strings based on their relevance to the inquiry. 76 documents written in English language were included and appraised through the Scale of the Assessment for Narrative Review Articles (SANRA) tool to avoid any risk of bias. The PRISMA 2020 checklist and flow diagram has been used to report the findings of this narrative review.
Result
The study identifies eight critical parameters of CBE with respect to its definitions, origins, transitions, regulatory environment, characteristics, approaches and implications on teaching-learning, frameworks and models of assessment; and challenges, which makes a case for the relevance of CBE for architectural education in India, which hasn’t been explored yet.
Conclusion
The broader expectations of ‘being competent’ can be addressed through a conscious adoption of strategies of relevant attributes of CBE which can encourage building attitudes and temperament for life-long learning.
To standardize preparation for residency, the AAMC created 13 generalized Entrustable Professional Activities (EPA). To improve student preparedness for surgical residency, we developed surgery-specific EPAs by comparing attending surgeon and resident opinions regarding what EPAs should be addressed during the fourth year of medical school.
A focus group of attending surgeons developed 29 surgery-specific EPAs based on the AAMC’s core EPAs. We then surveyed attending surgeons and current surgery residents. Data were collected using the Chen Scale for determining activity entrustability and then evaluated for agreement and discordance.
Of those queried, 12 of 12 (100%) attending surgeons and 42 of 106 (40%) residents completed the survey. Those surveyed agreed that of the proposed EPAs 18 were entrustable, 6 were not, and there was discordance for 5 of the EPAs.
Specialty-specific EPAs demonstrate the potential to bridge performance gaps between medical school and residency.
Purpose
This study examines the feasibility and psychometric results of an assessment of entrustable professional activities (EPAs) as a core component of the clinical program of assessment in undergraduate medical education, assesses the learning curves for each EPA, explores the time to entrustment, and investigates the dependability of the EPA data based on generalizability theory (G theory) analysis.
Method
Third-year medical students from the University of Minnesota Medical School in 7 required clerkships from May 2022 through April 2023 were assessed. Students were required to obtain at least 4 EPA assessments per week on average from clinical faculty, residents supervising the students, or assessment and coaching experts. Student ratings were depicted as curves describing their performance over time; regression models were used to fit the curves.
Results
The complete class of 240 (138 women [58.0%] and 102 men [42.0%]) third-year medical students at the University of Minnesota Medical School (mean [SD] age at matriculation, 24.2 [2.7] years) participated. There were 32,614 EPA-based assessments (mean [SD], 136 [29.6] assessments per student). Reliability analysis using G theory found that an overall score dependability of 0.75 (range, 0-1) was achieved with 4 assessors on 4 occasions. The desired level of entrustment by academic year end was met by all 240 students (100%) for EPAs 1, 6, and 7, 237 (98.8%), 236 (98.3%), and 218 (90.8%) students for EPAs 2, 5, and 9, respectively, 197 students (82.1%) for EPA 3, 178 students (74.2%) for EPA 4, and 145 students (60.4%) for EPA 12. The most rapid growth was for EPA 2 (β 0 = .286), followed by EPA 1 (β 0 = .240), EPA 4 (β 0 = .236), and EPA 10 (β 0 = .230).
Conclusions
The study findings suggest that EPA ratings provide reliable and dependable data to make entrustment decisions about students’ performance.
This book discusses the ins and outs of a new approach to competency-based education in the education and training of health professionals, including doctors and medical specialists, but also nurses, dentists, pharmacists, veterinarians, physiotherapists and others. Embedded in a conceptual discussion of what competence in health professionals means, the book discusses theoretical foundations of trust and entrustment of trainees with the practice of patient care tasks. It elaborates the implications for identifying the objectives of training, formulated as entrustable professional activities (EPAs), for the associated curriculum development, for assessment of trainees in the clinical workplace, for faculty development and for the management of large scale change in health professions education. In the past decade, EPAs have been proposed, piloted or implemented in all sectors of health professions education and in countries across all continents. Yet, there is a widely felt desire for a better understanding of all related concepts. This text was written with teachers, educational managers, educational scholars, and health profession trainees in mind. The book is the result of a collaboration of fifty highly engaged authors, all actively involved in their own projects and studies around EPAs and workplace-based assessment, as teachers, developers and managers. All chapters have been critically read and commented on by internal and external reviewers, making this work a state of the art document about the topic.
This book discusses the ins and outs of a new approach to competency-based education in the education and training of health professionals, including doctors and medical specialists, but also nurses, dentists, pharmacists, veterinarians, physiotherapists and others. Embedded in a conceptual discussion of what competence in health professionals means, the book discusses theoretical foundations of trust and entrustment of trainees with the practice of patient care tasks. It elaborates the implications for identifying the objectives of training, formulated as entrustable professional activities (EPAs), for the associated curriculum development, for assessment of trainees in the clinical workplace, for faculty development and for the management of large scale change in health professions education. In the past decade, EPAs have been proposed, piloted or implemented in all sectors of health professions education and in countries across all continents. Yet, there is a widely felt desire for a better understanding of all related concepts. This text was written with teachers, educational managers, educational scholars, and health profession trainees in mind. The book is the result of a collaboration of fifty highly engaged authors, all actively involved in their own projects and studies around EPAs and workplace-based assessment, as teachers, developers and managers. All chapters have been critically read and commented on by internal and external reviewers, making this work a state of the art document about the topic.
This book discusses the ins and outs of a new approach to competency-based education in the education and training of health professionals, including doctors and medical specialists, but also nurses, dentists, pharmacists, veterinarians, physiotherapists and others. Embedded in a conceptual discussion of what competence in health professionals means, the book discusses theoretical foundations of trust and entrustment of trainees with the practice of patient care tasks. It elaborates the implications for identifying the objectives of training, formulated as entrustable professional activities (EPAs), for the associated curriculum development, for assessment of trainees in the clinical workplace, for faculty development and for the management of large scale change in health professions education. In the past decade, EPAs have been proposed, piloted or implemented in all sectors of health professions education and in countries across all continents. Yet, there is a widely felt desire for a better understanding of all related concepts. This text was written with teachers, educational managers, educational scholars, and health profession trainees in mind. The book is the result of a collaboration of fifty highly engaged authors, all actively involved in their own projects and studies around EPAs and workplace-based assessment, as teachers, developers and managers. All chapters have been critically read and commented on by internal and external reviewers, making this work a state of the art document about the topic.
This book discusses the ins and outs of a new approach to competency-based education in the education and training of health professionals, including doctors and medical specialists, but also nurses, dentists, pharmacists, veterinarians, physiotherapists and others. Embedded in a conceptual discussion of what competence in health professionals means, the book discusses theoretical foundations of trust and entrustment of trainees with the practice of patient care tasks. It elaborates the implications for identifying the objectives of training, formulated as entrustable professional activities (EPAs), for the associated curriculum development, for assessment of trainees in the clinical workplace, for faculty development and for the management of large scale change in health professions education. In the past decade, EPAs have been proposed, piloted or implemented in all sectors of health professions education and in countries across all continents. Yet, there is a widely felt desire for a better understanding of all related concepts. This text was written with teachers, educational managers, educational scholars, and health profession trainees in mind. The book is the result of a collaboration of fifty highly engaged authors, all actively involved in their own projects and studies around EPAs and workplace-based assessment, as teachers, developers and managers. All chapters have been critically read and commented on by internal and external reviewers, making this work a state of the art document about the topic.
This book discusses the ins and outs of a new approach to competency-based education in the education and training of health professionals, including doctors and medical specialists, but also nurses, dentists, pharmacists, veterinarians, physiotherapists and others. Embedded in a conceptual discussion of what competence in health professionals means, the book discusses theoretical foundations of trust and entrustment of trainees with the practice of patient care tasks. It elaborates the implications for identifying the objectives of training, formulated as entrustable professional activities (EPAs), for the associated curriculum development, for assessment of trainees in the clinical workplace, for faculty development and for the management of large scale change in health professions education. In the past decade, EPAs have been proposed, piloted or implemented in all sectors of health professions education and in countries across all continents. Yet, there is a widely felt desire for a better understanding of all related concepts. This text was written with teachers, educational managers, educational scholars, and health profession trainees in mind. The book is the result of a collaboration of fifty highly engaged authors, all actively involved in their own projects and studies around EPAs and workplace-based assessment, as teachers, developers and managers. All chapters have been critically read and commented on by internal and external reviewers, making this work a state of the art document about the topic.
This book discusses the ins and outs of a new approach to competency-based education in the education and training of health professionals, including doctors and medical specialists, but also nurses, dentists, pharmacists, veterinarians, physiotherapists and others. Embedded in a conceptual discussion of what competence in health professionals means, the book discusses theoretical foundations of trust and entrustment of trainees with the practice of patient care tasks. It elaborates the implications for identifying the objectives of training, formulated as entrustable professional activities (EPAs), for the associated curriculum development, for assessment of trainees in the clinical workplace, for faculty development and for the management of large scale change in health professions education. In the past decade, EPAs have been proposed, piloted or implemented in all sectors of health professions education and in countries across all continents. Yet, there is a widely felt desire for a better understanding of all related concepts. This text was written with teachers, educational managers, educational scholars, and health profession trainees in mind. The book is the result of a collaboration of fifty highly engaged authors, all actively involved in their own projects and studies around EPAs and workplace-based assessment, as teachers, developers and managers. All chapters have been critically read and commented on by internal and external reviewers, making this work a state of the art document about the topic.
Correct performance of invasive skills is essential, but residents often undertake such procedures after no or minimal instruction.
We instructed eight postgraduate year 1 (PGY1) residents in the cadaver laboratory using a competency-based approach (CBI). Each resident had been evaluated before the laboratory during patient encounters. Group instruction in endotracheal tube insertion (ET), venous cutdown (VC), and chest tube insertion (CT) was followed by individual pretesting and hands-on teaching, with 100% competency the goal. Failure was considered an inability to perform the task correctly or within 120 seconds. After the laboratory, residents were evaluated for correctness and rapidity of performance.
Prelaboratory failures consisted of ET, 7; CT, 5; VC, 7. Postlaboratory failures were 0 for all. Prelaboratory complications consisted of ET, 3.3 +/- 1.1; CT, 1.9 +/- 1.0; VC, 3 +/- 1.0. Postlaboratory complications were 0 for all. Prelaboratory times (seconds) were ET, 66.5 +/- 30.8; CT, 104 +/- 4.1; VC, 116.3 +/- 0.7. Postlaboratory times were ET, 25 +/- 7; CT, 65.5 +/- 10.7; VC, 81.3 +/- 2.5. Changes were statistically significant for all (P < .03, nonparametric). Residents performed 20 CTs with 1 pneumothorax, 80 ETs with 2 failures, and 20 VCs with no complications. Initial trauma resuscitation time decreased from 25 to 10 minutes.
(1) Residents' skills rapidly improve with CBI; (2) skills learned through CBI in the laboratory can be translated to and sustained in the clinical setting; (3) CBI produces competent residents who perform skills rapidly and with minimal complications.
The Script Concordance (SC) test is a new assessment tool. It is designed to probe whether knowledge of examinees is efficiently organized for clinical actions. That kind of organization of knowledge is named a script. The SC test places examinees in written, but authentic, clinical situations in which they must interpret data to make decisions.
The SC test is designed to measure the degree of concordance that exists between examinees' scripts and scripts of a panel of experts. The objective of this article is to provide interested educators with the practical "how to" information needed to build and use an SC test.
The theoretical background of the SC test is described. The principles of construction of an SC test are presented, including the writing of clinical cases, the choice of item format, the validation of the test, and the elaboration of the scoring system.
A series of studies have shown that the SC test has interesting psychometric properties, in terms of reliability, face validity, and construct validity. Results from these studies are succinctly presented and commented.
The SC test is a simple and direct approach to testing organization and use of knowledge. It has the strong advantage for a testing method of being relatively easy to construct and use and to be machine-scorable. It can be either paper- or computer-based and can be used in undergraduate, postgraduate, or continuing medical education.
Realizing medical education is on the brink of a major paradigm shift from structure- and process-based to competency-based education and measurement of outcomes, the authors reviewed the existing medical literature to provide practical insight into how to accomplish full implementation and evaluation of this new paradigm. They searched Medline and the Educational Resource Information Clearinghouse from the 1960s until the present, reviewed the titles and abstracts of the 469 articles the search produced, and chose 68 relevant articles for full review. The authors found that in the 1970s and 1980s much attention was given to the need for and the development of professional competencies for many medical disciplines. Little attention, however, was devoted to defining the benchmarks of specific competencies, how to attain them, or the evaluation of competence. Lack of evaluation strategies was likely one of the forces responsible for the three-decade lag between initiation of the movement and wide-spread adoption. Lessons learned from past experiences include the importance of strategic planning and faculty and learner buy-in for defining competencies. In addition, the benchmarks for defining competency and the thresholds for attaining competence must be clearly delineated. The development of appropriate assessment tools to measure competence remains the challenge of this decade, and educators must be responsible for studying the impact of this paradigm shift to determine whether its ultimate effect is the production of more competent physicians.
IntroductionToday we are talking about competence-based approaches to education and train-ing. Two or three years ago, it would have been audit or, on the other side ofthe Atlantic, the impact of Health Maintenance Organizations on education. Morerecently, the debate has raged about the relevance of evidence-based medicine.Ten years ago, we might all have been extolling the management of education byobjectives. For years, we have watched the exponents of problem-based learningvery successfully setting out their pitch. We have believed in horizontal integration,vertical integration, adult learning principles, small groups, authentic assessment,....who knows? Some of us might even be prepared to defend lectures and rotelearning. Which one of us has not made up for the child-centred education ourchildren receive by making them chant tables in the car on the way to school?So, what are we to make of this history of changing educational fashion andpractice? Does the truth change so frequently? Does educational research move sofast? Does the problem change so quickly that we constantly need to find new solu-tions? Probably not. Are we seeking the holy grail of education, unable to convinceourselves that there really is not one? Possibly. But there are other explanationstoo for our constant hurtle through a Kafka-esque landscape of metamorphosingeducational entities which we grasp and believe in until they shrink back into theshadows and become memories of another beautiful outfit that the Emperor wore.And here we are. This month’s panacea is competence-based education [if thatis not a contradiction in terms]. And I am here to represent the anti-panacea schoolof educational development. I am also here to represent the profession of medicine– because someone has to defend it against imported and inappropriate ways ofthinking that are quite possibly threatening to the profession itself, and strangely,often the worst enemy of the profession is the professionals themselves.If it is any compensation, most other professions are being attacked by the samedisorder. Law, social work, education – all are displaying signs of narrowing to sets
Editor—Hutchinson presents a one sided, simplistic, and politically correct view of medical education.1 Many of her statements were generalisations unsupported by evidence, with the result that her article irritated rather than informed the reader. It focused on a patient led service and changing roles as the challenges to training.
I challenge the assumption that every patient and every situation requires information and choice, otherwise the doctor is not doing things the way he or she should, or that doctors see devolving care to other professionals as a threat. However, I do agree with her question at the end of the article, whether curriculums and assessments truly reflect the type of doctor the public will expect in future years. The answer is no.
Patients expect that after five years at medical school, new doctors would have taken a rigorous examination in medicines and prescribing, know how to recognise and basically manage an emergency, and have been trained in the diagnostic process (clinical reasoning and the interpretation of tests included), for example. Whenever I ask, patients prefer easy access and competence over choice and “niceness” (which is effectively what our medical students are trained in) but everyone wants information. The real challenges are how to produce expert professionals in a shorter time, with poor infrastructure, in a culture that emphasises competency rather than expertise. This article seemed to miss the point.
The decision to trust a trainee to manage a critically ill patient is based on much more than tests of competence. How can these judgments be incorporated into assessments?
Competency based postgraduate medical programmes are spreading fairly rapidly in response to the new demands of health care. In the past 10 years, Canada, the United States, the Netherlands, and the United Kingdom have introduced competency models and other countries are following.1–5 These frameworks are valuable, as they renew our thinking about the qualities of doctors that really matter.
Paramount in these developments is the view that quality of training should be reflected in the quality of the outcome—that is, the performance of its graduates. As postgraduate training almost fully focuses on learning in practice, training and assessment moves around the top two levels of Miller's hierarchical framework for clinical assessment (figure).6 Knowledge and applied knowledge of residents may be interesting, but performance in practice is the real thing. The question is: How can we assess it?
Miller's pyramid for clinical assessment
Competency based training suggests that competence and competencies are what we want trainees to attain. But is this the same as performance? If a doctor is competent, what happens if she does not perform according to her assessed competence? Most authors agree that performance involves more than competence.7 It clearly includes something that cannot easily be caught with traditional assessment methods. One component is willingness to apply your competence.8 But there is more.
Consider two residents, 1 and 2. Resident 1 scored A on the knowledge, applied knowledge, and objective skills examinations whereas resident 2 scored B. Both serve in a night shift in the hospital, and you are on call that week. Each of them faces a critical acute care problem. Resident …
Most of the changes proposed by Modernising Medical Careers depend on moving to a competency based system for training and assessment. But does everyone agree that this is the way forward? Career Focus asked for various views
Increased attention is being paid to the specification of learning outcomes. This paper provides a framework based on the three-circle model: what the doctor should be able to do ('doing the right thing'), the approaches to doing it ('doing the thing right') and the development of the individual as a professional ('the right person doing it'). Twelve learning outcomes are specified, and these are further subdivided. The different outcomes have been defined at an appropriate level of generality to allow adaptability to the phases of the curriculum, to the subject-matter, to the instructional methodology and to the students' learning needs. Outcomes in each of the three areas have distinct underlying characteristics. They move from technical competences or intelligences to meta-competences including academic, emotional, analytical, creative and personal intelligences. The Dundee outcome model offers an intuitive, user-friendly and transparent approach to communicating learning outcomes. It encourages a holistic and integrated approach to medical education and helps to avoid tension between vocational and academic perspectives. The framework can be easily adapted to local needs. It emphasizes the relevance and validity of outcomes to medical practice. The model is relevant to all phases of education and can facilitate the continuum between the different phases. It has the potential of facilitating a comparison between different training programmes in medicine and between different professions engaged in health care delivery.
Realizing medical education is on the brink of a major paradigm shift from structure- and process-based to competency-based education and measurement of outcomes, the authors reviewed the existing medical literature to provide practical insight into how to accomplish full implementation and evaluation of this new paradigm. They searched Medline and the Educational Resource Information Clearinghouse from the 1960s until the present, reviewed the titles and abstracts of the 469 articles the search produced, and chose 68 relevant articles for full review. The authors found that in the 1970s and 1980s much attention was given to the need for and the development of professional competencies for many medical disciplines. Little attention, however, was devoted to defining the benchmarks of specific competencies, how to attain them, or the evaluation of competence. Lack of evaluation strategies was likely one of the forces responsible for the three-decade lag between initiation of the movement and wide-spread adoption. Lessons learned from past experiences include the importance of strategic planning and faculty and learner buy-in for defining competencies. In addition, the benchmarks for defining competency and the thresholds for attaining competence must be clearly delineated. The development of appropriate assessment tools to measure competence remains the challenge of this decade, and educators must be responsible for studying the impact of this paradigm shift to determine whether its ultimate effect is the production of more competent physicians.
Outcome-based education, a performance-based approach at the cutting edge of curriculum development, offers a powerful and appealing way of reforming and managing medical education.The emphasis is on the product-what sort of doctor will be produced-rather than on the educational process. In outcome-based education the educational outcomes are clearly and unambiguously specified. These determine the curriculum content and its organisation, the teaching methods and strategies, the courses offered, the assessment process, the educational environment and the curriculum timetable.They also provide a framework for curriculum evaluation. A doctor is a unique combination of different kinds of abilities. A three-circle model can be used to present the learning outcomes in medical education, with the tasks to be performed by the doctor in the inner core, the approaches to the performance of the tasks in the middle area, and the growth of the individual and his or her role in the practice of medicine in the outer area. Medical schools need to prepare young doctors to practise in an increasingly complex healthcare scene with changing patient and public expectations, and increasing demands from employing authorities. Outcome-based education offers many advantages as a way of achieving this. It emphasises relevance in the curriculum and accountability, and can provide a clear and unambiguous framework for curriculum planning which has an intuitive appeal. It encourages the teacher and the student to share responsibility for learning and it can guide student assessment and course evaluation. What sort of outcomes should be covered in a curriculum, how should they be assessed and how should outcome-based education be implemented are issues that need to be addressed.
The controversy centred on the notion of competence involves epistemological, ethical, and political considerations. Progress with analysing these objections entails classifying such criticisms into those which are integral to the concept of competence, and those which are not. Problems and their resolution can then be conducted within an appropriate framework. Ethical and political considerations concern the appropriateness or otherwise of competence-based schemes within the values of a democratic society. Objections on these grounds, though serious, are not considered fatal to competence-based schemes and they can be met by including more traditional courses within a person's total educational experience. However, analysis reveals that epistemological problems are the most serious difficulties facing competence-based schemes. Competence-based schemes appear to be committed to two different theories of knowledge and meaning. On the one hand, behavioural performances presume that knowing means behaving in a required fashion, and on the other hand, underpinning knowledge presumes that knowing means possessing the causal mental concepts which produce the required behaviour. Such a position is fundamentally incoherent, with the result that such schemes need reformulating with one coherent theory of meaning and one agreed epistemology.
The competency approach has become prominent at most stages of undergraduate and postgraduate medical training in many countries. In the United Kingdom, for example, it forms part of the performance procedures of the General Medical Council (GMC),1 underpins objectively structured clinical examinations (OSCEs) and records of in-training assessment (RITA), and has been advocated for the selection of registrars in general practice and interviews. 2 3 It has become central to the professional lives of all doctors and is treated as if it were a panacea—but there is little consensus among trainees, trainers, and committees on what this approach entails.
I aim to explore the origins and development of the competency approach, evaluate its current role in medical training, and discuss its strengths and limitations.
Summary points
The competency based approach consists of functional analysis of occupational roles, translation of these roles into outcomes, and assessment of trainees' progress on the basis of their demonstrated performance of these outcomesIt has become dominant at most stages of medical trainingPotential advantages include individualised flexible training, transparent standards, and increased public accountabilityIf applied inappropriately, it can result in demotivation, a focus on minimum acceptable standards, increased administrative burden and a reduction in the educational contentWe should be cautious of applying the competency based approach universally unless robustly defined higher order competencies are available
The birth of the competency movement
The competency approach did not result directly from recent scandals of incompetent doctors. It originated from parallel developments in vocational training in many countries, such as the national qualifications framework in New Zealand, the national training board in Australia, the national skills standards initiative in the United States, and the national vocational qualifications (NVQs) in the United Kingdom.4 This movement was driven largely by the political perceived need to make the national workforce more competitive in the global economy. For example, in Britain, the national vocational qualifications were developed as a set of standards each broken down into elements by which performance in the workplace can be assessed. This approach has since been adopted for training across other areas, particularly the technical and vocational fields.
How does competency based training work? The basic essential elements consist of functional analysis of the occupational roles, translation of these roles (“competencies”) into outcomes, and assessment of trainees' progress in these outcomes on the basis of demonstrated performance. Progress is defined solely by the competencies achieved and not the underlying processes or time served in formal educational settings.5 Assessments are based on a set of clearly defined outcomes so that all parties concerned, including assessors and trainees, can make reasonably objective judgments about whether or not each trainee has achieved them.6 Potential benefits of this approach include individualised flexible training and transparent standards.
This approach has attracted several criticisms. Firstly, functional analysis of occupational roles is problematic. It is difficult to identify a range of competencies that truly cover work roles in their broadest sense and to represent adequately the types of knowledge relevant to the competency identified. 7 8 Secondly, the assessment of competencies is by no means value free, and people who use it shape its meaning. Thirdly, the competency approach is based primarily on the behaviourist framework, which attempts to break down work roles into small discrete tasks. It ignores the connections between individual tasks and the meaning underlying each task. It therefore cannot represent the complex nature of situations in the real world. The danger is that these narrowly defined competencies will dominate the curriculum, which would not be suitable for learning in higher education.9 The approach using checklists and passing or failing candidates is superficial and often proves demotivating, as it encourages trainees to do the right thing to pass rather than to think critically and excel. The parties concerned—trainees, employers, professional bodies, and the government—may have different views about which aspect of the occupation is regarded as the most important.10 The process of developing competencies is at least partly political because it allows the government to influence what are included as important competencies and to allocate resources based on outcomes of performance. 11 12 A recent review of published evaluative studies of competency based training found an increase in administrative burden but no convincing beneficial effects on motivating students, work performance, or relevance to the needs of industry.11
The rise of “holistic” varieties
As this behaviourist approach to learning would be even less appropriate for professions requiring complex skills, a range of broader competency approaches flourished. In 1991, the general national vocational qualifications, which include core skills such as numeracy, communication, and problem solving, were developed to supplement the NVQ framework, although doubts exist about whether such generic skills transferable to all context actually exist.9 An integrated approach acknowledges competency as a complex combination of knowledge, attitudes, skills, and personal values.13 A holistic approach takes into account the cultural and social context in assessing competence and focuses on how personal attributes are used to achieve outcomes in real life scenarios.14 A competency of a higher order—meta-competency—has been used to describe the general ability to learn and apply competencies effectively in many different aspects of a person's activities.15 These approaches attempt to make the competency based model less reductionist in nature.
Current scene in medical training
Traditionally, the framework of medical training was time based, and students were assessed periodically to determine their grades. Equal weight was given to both process and outcome of learning. Emphasis was given to the understanding of basic concepts and principles, and skills were evaluated globally. Recently, competency based approaches have gradually taken over. Although the behaviourist approach may occasionally be used for training in areas where rigid protocols exist, such as the advanced life support course, holistic varieties of the competency based approach are used more widely. In Australia, criterion referenced procedures to set standards have been used to define and measure competency for the graduate entry medical programme.16 In the United Kingdom, the Royal College of General Practitioners distinguishes between clinical competence (what doctors can do) and clinical performance (what doctors do do) and defines competencies as a combination of knowledge, skills, and attitudes which, when applied to a particular situation, lead to a given outcome. Competency based medical training is usually developed in four steps: determine what the appropriate competencies are, devise training programmes, devise appropriate assessment methods, and set minimum pass standards.
Appropriate competencies can be determined in several ways, such as the GMC's Good Medical Practice for its performance procedures, postal questionnaire surveys of examiners and the committee of trainee members for the part 2 of the examination for membership of the Faculty of Public Health Medicine.17 Competencies for general practitioners have been defined by using triangulation of results from focus groups with general practitioners, behavioural coding of general practitioners' consultations with patients, and interviews with patients.18 There is little evidence, however, that addressing each of these competencies separately is a more effective form of training and assessments than the traditional global approach.
Competency based medical training is prominent in undergraduate medical education
(Credit: GEOFF TOMPKINSON/SPL)
Based on the competency approach, the objective structured clinical examination using checklists and standardised patients was initially thought to be more reliable and objective and gradually replaced the traditional long case. A recent review has found, however, that, for equal testing time, it is slightly less reliable than the long case.19 Several possible reasons for this surprising finding were given: standardisation of what happens within a case does not eliminate the variability of performance across clinical problems, and the use of ratings in long cases may achieve higher reliability than checklists. Perhaps another reason is that checklists including attributes such as attitudes and personal values may achieve lower reliability than behavioural outcomes. If this were the case, the exclusive focus on outputs that is often perceived to be the key advantage of the competency based approach does not necessarily result in objective and reliable assessments. In their summary assessments, general practice registrars need to submit a video of seven consultations to demonstrate each prescribed competency at least four times. Some candidates find such an exercise exceedingly time consuming and think that it might hinder other educational opportunities and enjoyment of general practice.20
Leading royal colleges set criterion referenced minimum pass standards by a panel agreeing on the probable scores of borderline candidates for both the written examinations and the objective structured clinical examination. 21 22 Although these procedures can be used to set standards for excellence, they currently tend to focus on the minimum acceptable standards. In other examinations and assessments, the pass standards may be more arbitrary.
Other issues are important. Firstly, a key advantage of the competency approach is its focus on competencies achieved rather than time served, so that trainees can progress at their own pace. But the training period for undergraduate and postgraduate medical training is currently fixed. Secondly, the competency approach ignores the learning process, although the process is important for lifelong learning. Thirdly, with the focus of the competency approach on skills and attitudes rather than a solid understanding of the basic concepts and principles, the risk is that “medical education” may give way to “medical training.”
An evaluation
Compared with the traditional approach, the competency based approach potentially leads to individualised flexible training, transparent standards, and increased public accountability. If applied inappropriately, it can also result in demotivation, focus on minimum acceptable standards, increased administrative burden, and a reduction in the educational content. Higher order competencies need to be defined and developed more robustly. We should be cautious of adopting the competency based approach universally across stages of medical training for which well defined and validated competencies are unavailable. After all, it is just one of many potentially useful approaches that may have a role at various stages of the educational progress.
AcknowledgmentsContributors: WCL is the sole author and guarantor of the paper.Footnotes
Conflict of interest None declared.References1.↵Southgate L, Campbell M, Cox J, Foulkes J, Jolly B, McCrorie P, et al.The General Medical Council's performance procedures: the development and implementation of tests of competence with examples from general practice.Med Educ 2001; 35(suppl 1): 20–28.2.↵Patterson F, Lane O, Ferguson E, Norfolk T.Competency based selection system for general practitioner registrars.BMJ 2001; 323(suppl): S2.http://bmj.com/cgi/content/full/323/7311/S2-7311 (accessed 28 Jun 202).OpenUrl3.↵Wood LEP, O'Donnell E.Assessment of competence and performance at interview.BMJ 2000; 320(suppl): S2.http://bmj.com/cgi/content/full/320/7231/S2-7231 (accessed 28 Jun 2002).OpenUrl4.↵Department of Education.Working together: education and training. London:HMSO,1986.5.↵Grant G.On competence: a critical analysis of competence-based reforms in higher education. San Francisco:Jossey-Bass,1975.6.↵Wolf A.Competence-based assessment. Buckingham:Open University Press,1995.7.↵Burke JWMansfield B.Competence and standards. In: Burke JW, ed. Competency based education and training. Lewes:Falmer Press,1989.8.↵Fennel EMitchell L, Wolf A.Understanding the place of knowledge and understanding in a competence based approach. In: Fennel E, ed. Development of assemble standards for national certification. Sheffield:Employment Department,1991:25–29.9.↵Hyland T.Competence, education and NVQs: dissenting perspectives. London:Cassell,1994.10.↵Marshall K.NVQs: An assessment of the “outcomes” approach in education and training.J Further Higher Educ 1991; 15:56–64.OpenUrl11.↵Flude M, Sieminski SBates I.The competence and outcomes movement. In: Flude M, Sieminski S, eds. Education, training and the future of work II. London:Routledge,1999:98–123.12.↵Leung WC.Managers and professionals: competing ideologies.BMJ 2000; 321(suppl): S2.http://bmj.com/cgi/content/full/321/7266/S2-7266 (accessed 28 Jun 2002).OpenUrl13.↵Gonczi A.Future directions for vocational education in Australian secondary schools.Austral N Z J Vocational Educ Res 1997; 5:77–108.14.↵Toohey S, Ryan G, Mclean J, Hughes C.Assessing competency-based education and training.Austral N Z J Vocational Educ Res 1995; 3:86–117.OpenUrl15.↵Fleming D.The concept of meta-competence.Competence Assessment 1993; 22:6–9.16.↵Searle J.Defining competency—the role of standard setting.Med Educ 2000; 34:363–366.OpenUrlCrossRefMedlineWeb of Science17.↵Kisely SR, Donnan SP.Competencies for part 2 of the examination for membership of the Faculty of Public Health Medicine.J Public Health Med 1997; 19:11–17.OpenUrlFREE Full Text18.↵Patterson F, Ferguson E, Lane P, Farrell K, Martlew J, Wells A.A competency model for general practice: implications for selection, training, and development.Br J Gen Pract 2000; 50:188–193.OpenUrlMedlineWeb of Science19.↵Norman G.The long case versus objective structured examinations.BMJ 2002; 324:748–749.OpenUrlFREE Full Text20.↵Bahrami J.The lost video.BMJ 2001; 323:581.OpenUrlFREE Full Text21.↵Thorndike RLAngoff WH.Scales, norms and equivalent scores. In: Thorndike RL, ed. Educational measurement. Washington DC:American Council on Education,1971.22.↵Rothman AI, Cohen R.A comparison of empirically—defined standards for clinical skills checklists.Acad Med 1996; 71(suppl): S1–S3.OpenUrlCrossRef
Commentary: The baby is thrown out with the bathwater
Vin Diwakar (vinod.diwakar{at}bhamchildrens.wmids.nhs.uk), consultant in general paediatrics and medical education.Medicine, Health Policy and Practice, University of East Anglia, Norwich NR4 7TJThe Education Centre, Birmingham Children's Hospital, Birmingham B4 6NH
Controversy over the competency based approach to professional education centres on a lack of consensus over what the term means.1
Leung casts doubt on the value of the competency based approach. He takes a narrow view, dismissing work which develops the concept to reflect the complexity of professional practice. Leung ignores evidence and consensus that knowledge driven traditional models of professional training fail to meet the demands of daily practice. 2 3
“Competency” describes what a doctor should be capable of doing, and Leung is correct that education focused entirely on narrow definitions of competencies has limitations for professionals. Reflective practice is ignored by reducing professional practice to an exhaustive list of competencies.4
Both traditional medical teaching and the reductionist approach to competence assume that medical education is only about teaching doctors to solve predictable problems. Professional practice requires an education which recognises that patients are treated as individuals. Clinical problems are personal and unique. To solve them, we make informed, but ultimately value based, judgments that are founded on intelligent reflection on previous experience (expertise).
Analysis of the ability of professionals to choose, develop, and adapt abilities for different situations bridges the gap between traditional or reductionist approaches and the realities of practice. Leung dismisses a significant body of work on assessment of these “higher order competencies” or “meta-competencies.”
Miller described a four stage hierarchy of competencies, starting with “knowledge,” progressing through “know how” and “show how” (competence), and culminating in “does” (performance).5 Performance depends on the context in which a doctor works as well as his or her abilities.
Unlike Leung, I think that most professional bodies recognise this hierarchy of professional competence. Methods of assessment change as doctors progress. Certification of medical students and junior trainees is like a driving licence. The minimum that a doctor must be able to do before he or she can move on to the next stage of professional practice and training is specified. Knowledge and competencies are emphasised, but flexibility in thought and action is required.2Certification of senior trainees and reaccreditation of established practitioners focuses on performance. Attempts to define competencies and meta-competencies across the scope of professional practice are likely to be impossible. Thus, assessment makes use of portfolios, peer and self assessment, and clinical outcomes.6
Leung's misgivings about competency based education represent one end of a spectrum of views about the extent to which the term includes concepts of competency, meta-competency, and performance. Some argue that the constructivist nature of meta-competency cannot be reconciled to the reductionist industrial origins of the term “competency.”1 Others argue that competency based approaches include elements of all these concepts. It is not surprising that evidence for benefits of the “competency based approach” is hard to find, and disagreement exists over what the terms actually mean. Even so, a recent systematic review found studies showing improved performance by doctors and safety of patients from residents who had attended courses based on competencies. 7 8
In practice, terms are less important than what we do with the concepts that they represent. Several issues are clear. Traditional models of medical education have been found wanting. A sophisticated model of professional education is required that recognises both basic standards and continuing professional development. The best methods of teaching and assessing these components of daily clinical practice need to be established. A fruitless debate about the meaning of “competency based education” is likely to detract from these, the real challenges of the next decade.
Footnotes
Competing interests Competing interests: VD holds grants from the Royal College of Paediatrics and Child Health and West Midlands Postgraduate Deanery to develop a competency based curriculum for senior house officers in paediatrics.References1.↵Tarrant J.What is wrong with competence?J Further Higher Educ 2000; 24:77–83.OpenUrlCrossRef2.↵General Medical Council.Tomorrow's doctors: recommendations on undergraduate medical education. London:GMC,1993.3.↵Hutchinson L, Aitken P, Hayes T.Are medical postgraduate certification processes valid? A systematic review of published evidence.Med Educ 2002; 36:73–91.OpenUrlCrossRefMedlineWeb of Science4.↵Barnett R.The limits of competence: knowledge, higher education and society. Buckingham:Society for Research into Education,1994.5.↵Miller GE.The assessment of clinical skills/competence/performance.Acad Med 1990; 65:563–567.OpenUrl6.↵Southgate L, Hays RB, Norcini J, Mulholland H, Ayers B, Woolliscroft J, et al.Setting performance standards for medical practice: a theoretical framework.Med Educ 2001; 35:474–481.OpenUrlCrossRefMedlineWeb of Science7.↵Caraccio C, Wolfsthal SD, Englander R, Ferentz K, Martin C.Shifting paradigms: from Flexner to competencies.Acad Med 2002; 77:361–367.OpenUrlMedlineWeb of Science8.↵Martin M, Vashisht B, Frezza E.Competency based instruction in critical invasive skills improves both resident performance and patient safety.Surgery 1998; 124:313–317.OpenUrlMedlineWeb of Science
The goal of all graduate medical education is to ensure that the graduating physician is competent to practice in his or her chosen field of medicine. The evaluation of a resident's competency to practice, however, has never been clearly defined, nor has the fixed period of time given for residency training in each specialty been shown to be the right amount of time for each individual resident to achieve competency. To better ensure that new physicians have the competencies they need, the author proposes the replacement of the current approach to residents' education, which specifies a fixed number of years in training, with competency-based training, in which each resident remains in training until he or she has been shown to have the required knowledge and skills and can apply them independently. Such programs, in addition to tailoring the training time to each individual, would make it possible to devise and test schemes to evaluate competency more surely than is now possible. The author reviews the basis of traditional residency training and the problems with the current training approach, both its fixed amount of time for training and the uncertainty of the methods of evaluation used. He then explains competency-based residency education, notes that it is possible, indeed probable, that some trainees will become competent considerably sooner than they would in the current required years of training, quotes a study in which this was the case, and explains the implications. He describes the encouraging experience of his neurosurgery department, which has used competency-based training for its residents since 1994. He then discusses issues of demonstrating competency in procedural and nonprocedural fields, as well as the evaluation of competency in traditional and competency-based training, emphasizing that the latter approach offers hope for better ways of assessing competency.
This paper presents findings from a multimethod evaluation of an interprofessional training ward placement for medical, nursing, occupational therapy and physiotherapy students.
Unique in the UK, and following the pioneering work at Linköping, the training ward allowed senior pre-qualification students, under the supervision of practitioners, to plan and deliver interprofessional care for a group of orthopaedic and rheumatology patients. This responsibility enabled students to develop profession-specific skills and competencies in dealing with patients. It also allowed them to enhance their teamworking skills in an interprofessional environment. Student teams were supported by facilitators who ensured medical care was optimal, led reflective sessions and facilitated students' problem solving.
Data were collected from all groups of participants involved in the ward: students, facilitators and patients. Methods included questionnaires, interviews and observations.
Findings are presented from each participating group, with a particular emphasis placed on the perspective of medicine. The study found that students valued highly the experiential learning they received on the ward and felt the ward prepared them more effectively for future practice. However, many encountered difficulties adopting an autonomous learning style during their placement. Despite enjoying their work on the ward, facilitators were concerned that the demands of their role could result in 'burn-out'. Patients enjoyed their ward experience and scored higher on a range of satisfaction indicators than a comparative group of patients.
Participants were generally positive about the training ward. All considered that it was a worthwhile experience and felt the ward should recommence in the near future.
This paper aims to describe current views of the relationship between competence and performance and to delineate some of the implications of the distinctions between the two areas for the purpose of assessing doctors in practice.
During a 2-day closed session, the authors, using their wide experiences in this domain, defined the problem and the context, discussed the content and set up a new model. This was developed further by e-mail correspondence over a 6-month period.
Competency-based assessments were defined as measures of what doctors do in testing situations, while performance-based assessments were defined as measures of what doctors do in practice. The distinction between competency-based and performance-based methods leads to a three-stage model for assessing doctors in practice. The first component of the model proposed is a screening test that would identify doctors at risk. Practitioners who 'pass' the screen would move on to a continuous quality improvement process aimed at raising the general level of performance. Practitioners deemed to be at risk would undergo a more detailed assessment process focused on rigorous testing, with poor performers targeted for remediation or removal from practice.
We propose a new model, designated the Cambridge Model, which extends and refines Miller's pyramid. It inverts his pyramid, focuses exclusively on the top two tiers, and identifies performance as a product of competence, the influences of the individual (e.g. health, relationships), and the influences of the system (e.g. facilities, practice time). The model provides a basis for understanding and designing assessments of practice performance.
Through the use of the critical incident technique one may collect specific and significant behavioral facts, providing " a sound basis for making inferences as to requirements " for measures of typical performance (criteria), measures of proficiency (standard samples), training, selection and classification, job design and purification, operating procedures, equipment design, motivation and leadership (attitudes), and counseling and psychotherapy. The development, fundamental principles, present status, and uses of the critical incident technique are discussed, along with a review of studies employing the technique and suggestions for further applications. 74-item bibliography.
Background Graduate medical education in the UK is in danger of being subsumed in a minimalist discourse of competency.
Argument While accepting that competence in a doctor is a sine qua non, the author criticises the construction of a graduate and specialist medical education based solely upon a competency model. Many competency models follow the concepts of either academic competence or operational competence, both of which have lately been subject to criticism.
Conclusion The author discusses the need for replacing such criterion-referenced models in favour of a model that engages the higher order competence, performance and understanding which represent professional practice at its best.
Based on developments in educational psychology from the late 1980s, the authors present a model of an approach to teaching. Students' learning processes were analyzed to determine teacher functions. The learning-oriented teaching (LOT) model aims at following and guiding the learning process. The main characteristics of the model are (1) the components of learning: cognition (what to learn), affect (why learn), and metacognition (how to learn); and (2) the amount of guidance students need. If education aims at fostering one's ability to function independently in society, an important general objective should be that one learns how to fully and independently regulate his or her own learning; i.e., the ability to pursue one's professional life independently. This implies a transition from external guidance (from the teacher) through shared guidance (by the student together with the teacher) to internal guidance (by the student alone). This transition pertains not only to the cognitive component of learning (content) but also to the affective component (motives) and the metacognitive component (learning strategies). This model reflects a philosophy of internalization of the teacher's functions in a way that allows optimal independent learning after graduation. The model can be shown as a two-dimensional chart of learning components versus levels of guidance. It is further elaborated from learners' and teachers' perspectives. Examples of curriculum structure and teachers' activities are given to illustrate the model. Implications for curriculum development, course development, individual teaching moments, and educational research are discussed.
Skills for the new millennium: report of the societal needs working group Available at: (http
- Canmeds
3 CanMEDS. Skills for the new millennium:
report of the societal needs working group.
Available at: (http://www.healthcare.ubc.ca/
residency/CanMEDS_2005_Framework.pdf).
General competencies of the future medical specialist
- O P Bleker
- Cate Thj
- Rsg Holdrinet
Bleker OP, ten Cate ThJ, Holdrinet RSG.
General competencies of the future medical
specialist [in Dutch].
Is competencybased training and assessment the way forward? Available at: (http://careerfocus.bmjjournals.com/ cgi/reprint Accessed
- R Macdonald
- G Easton
13 MacDonald R, Easton G. Is competencybased training and assessment the way
forward? BMJ Careers 2004;(7477):220-221.
Available at:
(http://careerfocus.bmjjournals.com/
cgi/reprint/329/7477/220). Accessed February
14, 2007.
Principles of good medical education and training. Available at: (www.gmc-uk.org/education/publications/ gui_principles_final_1.0.pdf)
General Medical Council. Principles of good
medical education and training. Available at:
(www.gmc-uk.org/education/publications/
gui_principles_final_1.0.pdf). Accessed
February 14, 2007.
AMA position statement prevocational medical education and training
Australian Medical Association. AMA
position statement prevocational medical
education and training. Available at: (http://
www.ama.com.au/web.nsf/doc/WEEN-6JVTW2). Accessed February 14, 2007.
ten Cate O. Trust, competence and the supervisor's role in postgraduate training
ten Cate O. Trust, competence and the
supervisor's role in postgraduate training.
BMJ. 2006;333:748-751.
Curriculum Obstetrics and Gynaecology. Netherlands Association for Obstetrics and Gynaecology NVOG
- F Scheele
- M F Schutte
Scheele F, Schutte MF, eds. Curriculum
Obstetrics and Gynaecology. Netherlands
Association for Obstetrics and Gynaecology
NVOG. [in Dutch]. Utrecht: Het Centrum-Utrecht BV, 2005.
- Martin