The question of the month: “What about Competency Based Medical Education (CBME) and Entrustable Professional Activities (EPAs)?”

The question of the month: “What about Competency Based Medical Education (CBME) and Entrustable Professional Activities (EPAs)?”

  • Gamification / Goal setting
  • Case metadata
  • Template media type
  • URL media type
  • User metadata
  • Improving Case Fidelity
  • Competency / Entrustable Professional Activities
  • Case Preview in Web-app
  • Enhanced reporting
  • Learner portal

I have been putting off this discussion of Competency and Entrustable Professional Activities (EPS) for some time. It is not that I don’t have an opinion, but I have to admit that we at MedEdQR don’t have a clear position. I have been following the issues of undergraduate and graduate competency for at least 5 years – since my residency as the Director of the Office of Teaching and Learning at the Joint Medical Program at UC Berkeley. I am not sure it has ever been resolved there and, if one follows the medical press, it is certainly a hot topic.

Has anyone come up with a reasonable solution? From my reviews of the literature, there seems to be as many opinions and attempts at implementation as there are medical education enterprises, both nationally and internationally. For example, one recent comment to an article on competency published on the NEJM Knowledge +* website, states:

“Over the last two decades, competency‐based frameworks have been internationally adopted as the primary educational approach in medicine. Yet competency‐based medical education (CBME) remains contested in the academic literature. We look broadly at the nature of this debate to explore how it may shape scholars’ understanding of CBME, and its implications for medical education research and practice. In doing so, we deconstruct unarticulated discourses and assumptions embedded in the CBME literature.” (Pankaj July 27, 2018 at 3:15 am)

The debate continues as we “deconstruct unarticulated discourses and assumptions embedded in the CBME literature.” Yet work is being done and implementations completed. Where should we start this discussion? Certainly not at the beginning (i.e. “two decades” ago), but maybe by defining the goal and giving some examples of how some medical institutions have tackled the problem.

To define what the goal of implementing a competency based medical education (CBME) curriculum, we borrow from NEJM Knowledge +*

“Think flexible, lifelong learning, with knowledge and/or skills assessed throughout a continuum of learning. In a competency-based educational program, you don’t just acquire knowledge and then spit it back at the time of a final exam. Instead, the method of assessment is formative rather than summative, and you are evaluated on how you apply your knowledge to clinical situations that physicians often face. While summative exams, such as certification exams, play an important role in gauging levels of acquired knowledge, formative assessments are equally important.

Competency-based assessments are used to distinguish between the skills and knowledge that you already have and those for which you need more education and training. In contrast to time-based educational methods, CBME is a learner-centered, active, and lifelong experience that incorporates feedback between the teacher and the learner to fulfill the desired competency outcomes.”

I think we can all agree that that is a pretty good definition. Maybe, for your particular purposes, you might have a broader or more refined definition, but that should be a good starting point.

How have some institutions addressed competency implementations? Rather than trying to paraphrase their discussions, I think it is best to give you a reference where you can read the latest research **. The following highlights some of the approaches (via partial abstracts) to both topic and implementation of competency based medical education (non-EPA approaches) and EPA based implementations. (All contained in the AAMC article referenced below.)

Non-EPA approaches

“…To accomplish the task to ensure competency in human clinical embryology, a 6-month interactive online collaboration was formed. The outcome is a set of competencies in human embryology that should be required of all medical students, with the goals and learning objectives required to achieve these competencies.”

“…In May 2017, milestones were accessed from the Accreditation Council for Graduate Medical Education specialties website. A thematic analysis of the ICS, PBLI, PROF, and SBP milestones was performed to determine unique and common themes across these competencies and across specialties…The thematic analysis provides important insights into how individual specialties interpret and operationalize the ICS, PBLI, PROF, and SBP competency domains and can inform future revisions of milestones to enable harmonization and shared understanding of these competencies across specialties where appropriate.”

“…The present study explored how the Association of Faculties of Pharmacy of Canada’s (AFPC’s) 2010 Educational Outcomes are perceived and taught at the Leslie Dan Faculty of Pharmacy (LDFP). These outcomes were adapted from the CanMeds Physician Competency Framework which describes both medical expert and non-expert roles.”

EPA approaches

“Two dominant themes face medical education: developing integrated curricula and improving the undergraduate medical education (UME) to graduate medical education (GME) transition. An innovative solution to both of these challenges at the Zucker School of Medicine has been the application of the cognitive apprenticeship framework in requiring emergency medical technician (EMT) certification during the first course in medical school as the core on which to build an integrated curriculum and provide entrustable clinical skills…”

“…A national task force employed a three-stage process from May 2014 to February 2017 to develop EPAs for psychiatry…The final EPAs provide a strong foundation for competency-based assessment in psychiatry. Methodological features such as critique by non-psychiatry experts, a national Delphi study with frame-of-reference training, and stringent inclusion criteria strengthen the content validity of the findings and may serve as a model for future efforts in other specialties.”

“As reports of the application of entrustable professional activities (EPAs) increase, not only for postgraduate but also for undergraduate medical education, there is a need for descriptions of what a UME curriculum with EPAs could look like. We provide such a description based on the experiences at University Medical Center Utrecht, the Netherlands, which can be used as an example by other curriculum developers…”

From skimming the research it is clear that there are not only many approaches to implementing CBME, but also many competency frameworks from which to draw. A constant theme did track through the literature – that much work still needs to be done. We at MedEdQR are leaning toward an implementation of EPAs, but are fully aware that it might be too early to take a single tact. As the last of the EPA approaches *** above indicates in the discussion in their abstract,

“The framework of EPAs went through many iterations before it was consolidated. Among the issues that required special attention was the application of a supervision levels scale for sign-off, the necessity to cover all relevant clinical content while not labeling too many small tasks each as a separate EPA, methods of EPA-focused assessment in the workplace and the creation of an e-portfolio model to serve assessment and entrustment.”

I am not trying to be evasive, but there is quite a bit of risk in choosing one methodology over another and we are not sure if there is a middle ground. We will continue to watch the trends in CBME and, depending on client wishes, make a go or no go decision in the future.

John Morris, CEO

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** NEJM Knowledge +:, accessed August 11, 2018.

** Association of American Medical Colleges:, accessed August 11, 2018.

*** Lysanne Graafmans, Indra Posthumas, Lisanne Welink, and Marijke van Dijk., Center for Research and Development of Education, University Medical Center, Utrecht, The Netherlands.

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