pediatrics
November 2016, VOLUME138 /ISSUE 5

To Trust or Not to Trust? An Introduction to Entrustable Professional Activities

  1. Janice L. Hanson, PhD, EdSa and
  2. Susan L. Bannister, MD, MEdb
  1. aDepartment of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado; and
  2. bDepartment of Pediatrics, University of Calgary, Calgary, Alberta, Canada
  1. Both authors contributed to the conceptualization of this article, drafting of the article, and revising it critically for important intellectual content, and approved the final version and agree to be accountable for all aspects of the work, including accuracy and integrity of all parts of the article.

  • Abbreviation:
    EPAs
    entrustable professional activities
  • As clinical teachers, we look for ways to inspire medical students to reach for excellence in their practice of medicine. Entrustable professional activities, or EPAs, can help us do just this. This article, next in the Council on Medical Student Education in Pediatrics series on clinical teaching, provides an introduction to EPAs. Clinical teachers have always made decisions about which tasks to entrust to medical students and EPAs bring that important experience and judgment into a framework that organizes students’ learning. EPAs have been conceptualized and written for residents, fellows, physician assistants, and, more recently, medical students.

    What Are Entrustable Professional Activities?

    Entrustable professional activities (EPAs) provide a framework for describing what medical students are expected to be able to do before graduation from medical school. They break down the work of a doctor into tasks, such as taking a history, forming a differential diagnosis, or recognizing a sick patient and initiating treatment. The word “entrustable” is part of this framework because most physicians, when working with a learner, have asked themselves, consciously or unconsciously, “Do I trust this learner to do that?” And, only if the answer is “yes” do they allow the learner to do the task. So, although EPAs sound new (and potentially confusing), they are built on a foundation that physicians have intuitively used. After working with a student, for instance, and watching him or her conduct histories and physical examinations, a physician will decide whether to trust the student to conduct future histories and physical examinations on his or her own. This decision will be based on several factors, including the accuracy of the information the student has provided in the past, how well the student recognizes his or her limitations, the complexity of the patient, the circumstances of the family, the nature of the task, and time constraints.1 It really all comes down to whether the physician can affirmatively answer the question, “Do I trust the learner to do this?”

    EPAs help the clinician make this everyday judgment about whether to trust a student with a specific task by stating the task explicitly.2,3 A group of medical educators from across the United States and Canada has agreed on a set of 13 “core EPAs” (see Table 1) that all medical students should be entrusted to do by the time they graduate from medical school, with a supervisor nearby to help when needed.4 These core EPAs include key aspects of patient care and key components of working in a system of care.

    TABLE 1

    Ways to Teach and Assess EPAs

    Entrustment and Supervision

    “Entrustment” is assessed by deciding how much supervision a student needs to perform a particular professional activity when caring for patients. When an aspect of work is new for a student, the clinician may want the student to observe before practicing on his or her own. When students begin to practice on their own, the clinical teacher decides how much supervision they need. The clinician may stay in the room, watching everything they do. As they gain competence, they are trusted to practice with a clinician nearby who later double-checks what the student has done; then, after further practice and teaching, the clinician may double-check only key findings. The amount of supervision needed defines the level of entrustment.10

    How Are Entrustment Decisions Made?

    How does a physician decide to trust a medical student to do something? This decision is often informed by many factors, such as the patient’s acuity, the nature of the task, and the skill of the student. The following 5 factors describe the things that influence a physician’s decision to trust a resident with a task. Physicians most likely consider many of the same things when deciding if a student can be trusted to perform a task.11

    • The learner. Are they reliable? Truthful? Aware of their own limitations? What has been observed about their skill and competence?12

    • The supervisor. The clinical teacher’s own temperament and experience as a preceptor plays a role. Some teachers find it easy to trust each new student, unless the student does something that makes the clinician wary, whereas others wait for each student to prove his or her trustworthiness in each new situation.

    • The context. The clinical environment influences entrustment decisions, too. In a fast-paced clinical environment with few resources and many competing tasks, a student may be allowed less independence than in a less-intense setting.

    • The task. The complexity of the patient’s needs affects the level of supervision a student will need. Does the patient have a complex or unusual diagnosis, a complicated social situation, or many interrelated needs? Or does the patient have an urgent need? If so, a learner may need more supervision than he or she would if the learner was seeing a patient with a common, simple, single issue, or a patient with a common chronic condition that is well-managed.1

    • The relationship between the learner and the supervisor. The relationship between the student and the clinical teacher also influences decisions about trust and supervision. Some learners spend only a few hours or days with a teacher, whereas other teachers and learners work together for several weeks or even longer. If they have developed shared expectations in the context of a working relationship, this can help to facilitate trust.

    Teaching and Assessment Based on EPAs

    Table 1 lists each of the 13 core EPAs4 and provides examples from our experience of how to teach and assess each of these in a busy clinical setting.

    What might a physician be asked to write on a form that uses EPAs to assess medical students? Instead of deciding if a student passes or fails or “meets expectations” (which is often an abstract concept), a clinical teacher will be asked to make a decision that has clinical meaning; that is, can the student be entrusted or not to perform a certain task. The teacher will document what a student can do based on observations, direct supervision, feedback, and teaching. Teachers will be asked to justify their decisions with written examples of what the student did or did not do and how the student responded to feedback and progressed during the clinical experience.

    The observations and assessments that the clinical teacher makes about a student become evidence of the student’s progress. The teacher gathers evidence by observing the student in clinical encounters, coaching the student around presentations, and asking for the student’s self-reflection after clinical encounters. The teacher provides evidence to the clerkship director by writing short examples of the student’s performance that explain the teacher’s judgment13 and by choosing from a list of options that state how much supervision was needed. Although making judgments about students is a familiar task for many preceptors, it is often something that is done intuitively, without deliberate decision-making. Making these judgments deliberate and explicit provides the evidence that the clerkship director needs to reach conclusions about how the student has performed during the clerkship and also provides clear feedback for the student to guide efforts to improve.

    Conclusions

    EPAs provide a framework for describing the work that doctors do and the skills that medical students must acquire before graduation from medical school. This framework assists medical students because it clearly outlines what is expected, it allows students to focus on specific skills, and it demonstrates that one can be doing well in one area and still have room to grow in another. Also, this framework can assist practicing physicians in teaching because it details what medical students need to be able to do. Instead of helping someone become a “good doctor,” clinical teachers can focus their teaching, supervision, and feedback on helping students attain very specific skills, which will, ultimately, help their students become fine physicians.

    Acknowledgments

    The authors thank William V. Razska, Jr, MD, and Meghan Trietz, MD, for their thoughtful reviews of this manuscript.

    Footnotes

      • Accepted July 19, 2016.
    • Address correspondence to Janice Hanson, PhD, EdS, Department of Pediatrics, University of Colorado School of Medicine, 13123 E. 16th Ave, B-158, Aurora CO 80045. E-mail: janice.hanson{at}childrenscolorado.org
    • 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.

    References