‘Entrustable professional activities’

This Invited Commentary accompanies the following original article: Wisman-Zwarter N, van der Schaaf M, ten Cate O, et al. Transforming the learning outcomes of anaesthesiology training into entrustable professional activities. The Delphi study. Eur J Anaesthesiol 2016; 33:559–567 Like any other domain, medical education is stuffed with buzzwords. Some of them last because they represent major advances, whereas others are just ‘fashionable’ and are soon out-dated. In this issue of the journal, Wisman-Zwarter et al.1 provide the first description of learning outcomes for anaesthesiology training in terms of ‘entrustable professional activities’. In medical education, this new concept is often referred to by its acronym ‘EPAs’. A legitimate question arises: to which category of ‘buzzwords’ does ‘EPAs’ belong? Before we provide our own view on a possible answer to this question, it is important to remind nonspecialists of some of the major advances that have taken place in medical education over the last 20 years. To train professionals capable of responding to the numerous challenges of our health care practice many changes have been proposed and implemented: examples are assessment and evaluation tools, learning formats, implementation of interprofessional education, faculty development, etc. Another has been the development of a competency-based educational framework; it has been a prominent approach in Canada, the UK and in the Netherlands over the last 15 years2 but, as seen by the late development of the competency-based postgraduate European Training Guideline in Anaesthesiology,3 only now being accepted in the rest of Europe. We know that simply spending time in rotations in different subsets of the specialty is not enough to make one competent. To address patients’ needs, but also in an effort to provide better tools to educators and tutors, in a competency-based approach competencies describe the abilities of future specialists to possess knowledge, skills, values and attitudes in different professional spheres. However, the acquisition of single competencies does not guarantee that trainees will perform adequately in the clinical environment. Assessing competency has been a ‘fundamental challenge for tutors and frontline teachers’, as stated by Ten Cate et al.,2 who have to evaluate learners daily on clinical problems or tasks to be performed, and not on isolated competencies. Thus, to bridge the gap between competency-based education and the task-specific clinical environment, a new and more comprehensive approach has been proposed: EPAs4 ‘Entrustable Professional Activities’ represent tasks involved in the daily work of a professional. Such tasks usually require several integrated single competencies, as well as underlying knowledge, skills and attitudes; EPAs are a way of setting competency-based education into a more unified clinical practice.5 Once sufficient ability in an EPA has been demonstrated, the trainee can be trusted to perform this specific activity unsupervised. Competency-based education and EPAs, thus, introduce the notion of a more personalised learning experience and reaffirm the key role of clinicians who supervise trainees. Are EPAs really likely to be helpful to clinicians and tutors? Or are they just another possibly irrelevant change or modification by educationalists? EPAs are increasingly integrated in undergraduate medical education6–8 as well as in postgraduate training.9 Although EPAs are definitely a way of describing a curriculum they are not an alternative to competencies: as described by Ten Cate,5 if ‘competencies are descriptors of physicians, EPAs are descriptors of work’, thus, EPAs translate competencies in the clinical practice environment. In their article, Wisman-Zwarter et al.1 provide the first description in Europe of the translation of an existing competency-based national curriculum into an EPA-based one. The challenge was to revisit their national education program in the field of anaesthesia and identify profession-specific activities which all trainees must be able to perform, and which integrate the competencies of the national curriculum. This challenge has been undertaken by a small group of medical experts from one of the Dutch faculties and the subsequent list of EPA's proposed has undergone three Delphi rounds for consensus. What has been achieved by the authors is the very first step toward a more meaningful contemporary curriculum, closely matched to professional practice. Of the 45 EPAs that reached more than 80% consensus, one can find statements such as ‘perioperative anaesthetic care for pulmonary surgery’ or “peripartum pain management’ or even ‘perioperative anaesthetic care for laparoscopic surgery in day care’. These statements identify essential and meaningful profession-specific activities. As stated by the authors themselves, ‘a full description of each EPA will have to be followed by mapping these EPAs to competencies and describing the assessment tools and performance standards’.1 Only then will the clinical tutors be able to assess their trainees, observe them execute these activities under their supervision and, once the trainees have demonstrated their competence, trust them to work competently when unsupervised. Other questions and concerns remain about EPAs: can anaesthesiology training be summarised in only 45 EPAs? How will different institutions provide appropriate exposure to these EPAs? How difficult and expensive will be this personalised learning of EPAs? How will the residents be assessed throughout the curriculum for each particular EPA? What will be the roles of clinicians supervising the residents? What kind of measurement tools should be developed for each EPA? What additional teaching formats should be adopted in the curriculum to facilitate acquisition of some of the EPAs? What faculty development program is required for clinician-educators to use the concept of EPAs during the supervision of residents? While answering these questions, feasibility issues (time and resources) should be kept in mind to overcome operational difficulties that may hamper the implementation of EPAs. These above questions are not trivial and, to prevent ‘EPAs’ becoming a new ‘buzzword’ that will soon be forgotten, need to be answered over the next few years. If the above problems are tackled, and other criticisms that have been made toward competency-based education10 answered, we do believe that EPAs have a real potential to influence future curriculum organisation and residents’ training and assessment in anaesthesiology. Acknowledgements related to this article Assistance with the commentary: none. Financial support and sponsorship: none. Conflicts of interest: none. Comment from the Editor: this Invited Commentary was checked by the editors but was not sent for external peer review.

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