- CBME —
- Competency-based Medical Education
- EPA —
- Entrustable Professional Activity
The competency-based medical education (CBME) framework for training pediatric subspecialists, endorsed by the American Board of Pediatrics Subspecialty Training Task Force, represents a transformative change.1 Some may ask, “Why do we need to change?” External forces are major drivers, but medicine and the delivery of health care have changed over the past 2 decades, requiring new skills for physicians.2 MedPAC, the Macy Foundation, and Congress are calling for accountability for tax dollars invested in Graduate Medical Education.3,4 CBME has the potential to standardize outcomes to provide accountability by producing physicians who are better prepared to meet 21st century needs. Importantly, CBME has the potential to eliminate the current time-based or “seat-time” model of education, allowing trainees to progress and take on additional responsibilities as soon as they demonstrate competence. Although this may seem like an unattainable Utopia, we believe it is possible. We advocate the use of Entrustable Professional Activities (EPAs) as a framework to help supervisors decide when trainees are ready for unsupervised practice. With EPAs, increased entrustment of the trainee to independently perform clinical care occurs as they are assessed to have achieved progressively higher levels of the Milestones associated with the Pediatric Competencies.5,6
The advantage of the EPA framework is that it places the Pediatric Competencies and the even more granular Milestones into clinical contexts that make practical sense. As their name suggests, EPAs are important, everyday “professional activities” (eg, care of the normal newborn or care of acute illness in an ambulatory setting) that someone can be “entrusted” to perform without supervision. Through the identification of the professional activities of a specialty, EPAs are applicable to both general pediatricians and pediatric subspecialists. Although entrustment is similar to the decisions faculty supervisors make every day about trainees, the formal entrustment decision must be a carefully considered advancement decision based on specific criteria as well as global impressions. Entrustment should not be casual and should not be based solely on number of months of experience. A critical element of entrustment is the concept of trustworthiness for clinical work, which Kennedy et al describe as consisting of 4 dimensions: knowledge and skill, discernment of limitations, truthfulness, and conscientiousness.7 Ultimately the most important consideration with entrustment is the safety of patients in the hands of the person entrusted to perform the clinical activity.
In practice, the entrustment decision will only be as good as the data used to make the decision. Entrustment decisions carry significant consequences for trainees, training programs, and patients. High-stakes decisions of this type must be made based on data generated from assessment tools with robust validity evidence that withstand scrutiny.8 The reality is that currently available assessment tools are, for the most part, not up to this task. This means that we will need to create new assessment methods and generate validity evidence to support high-stakes decisions. Such work will require significant effort and resources. Educational leaders will need to build their skills and have access to experts in the field of assessment. Robust validity studies will require large sample sizes from multi-institutional studies supported by extramural funding. Analysis will require access to and sharing of Milestones data reported to the Accreditation Council for Graduate Medical Education.
This broad-based approach to study EPAs will not only facilitate development of assessment tools but also assist with the determination of normative ranges for each step in physician development. Normative ranges will provide the foundation for learning roadmaps that trainees find valuable. This paradigm shift will allow dialogue about trainee development to move from focusing on where faculty supervisors think trainees should be in the development of clinical skills, to knowing where they are, and ultimately to determining where they should be at critical junctures in their training. Because EPAs are linked to specific Pediatric Competencies and their Milestones, it will be possible to drill back to a discrete set of Milestones to provide trainees with the next steps in their professional development and when achievement might be expected.
The EPA framework for CBME holds enormous promise. EPAs provide clinical context for the Pediatric Competencies and Milestones in a way that makes sense to physicians. But the real power of EPAs is the “E,” the concept of entrustment. Entrustment cannot be simply based on time or postgraduate year completed. Entrustment must be, first and foremost, a matter of patient safety. This notion challenges us to work to overcome shortcomings in assessment to ensure that high-stakes entrustment decisions are valid and defensible to trainees and, most importantly, to patients and families. We believe that we will meet this challenge and that EPAs will help inform the necessary duration of physician training to provide safe and effective care to their patients.
- Accepted January 30, 2014.
- Address correspondence to Joseph Gilhooly, MD, 707 SW Gaines St, Mail Code CDRC-P, Portland OR, 97239. E-mail:
Dr Gilhooly organized the authors and their edits, drafted the introduction and conclusions, and prepared the final commentary; Dr Schumacher contributed the section on the relevance of EPAs to the trainee as this related to his previous publications in this area and helped edit the manuscript; Dr West contributed the section on assessment tools and the need for valid and reliable assessments and helped edit the manuscript; Dr Jones provided the section on the use of EPAs as a framework for competencies and milestones and helped edit the manuscript; and all authors approved the final manuscript as submitted.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
- ↵Stevenson DK, McGuinness GA, Members of Task Force on SCTC. The initiative on subspecialty clinical training and certification (SCTC): Background and recommendations. Pediatrics. 2014;133:S53–S57
- ↵The Josiah Macy Jr Foundation. Reforming graduate medical education to meet the needs of the public. May 2011. Available at: http://macyfoundation.org/events/event/reforming-graduate-medical-education-to-meet-the-needs-of-the-public. Accessed September 24, 2013
- ↵Medicare Payment Advisory Commission. Graduate medical education financing: focusing on educational priorities. June 2010. Available at: www.medpac.gov/chapters/Jun10_Ch04.pdf. Accessed September 24, 2013
- ↵Accreditation Council for Graduate Medical Education and the American Board of Pediatrics. The Pediatrics Milestone Project. January 2012. Available at: www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramResources/320_PedsMilestonesProject.pdf. Accessed September 24, 2013
- ↵Downing SM, Steven M. Validity: on the meaningful interpretation of assessment data. Med Ed. 2003;37:830–837
- Copyright © 2014 by the American Academy of Pediatrics