Recently Dr. Jonathan Amiel collaborated with MedHub as he presented the findings from a large-scale pilot of the Association of American Medical Colleges (AAMC) Core Entrustable Professional Activities (EPAs). Jonathan Amiel, M.D. is a Professor of Psychiatry and Senior Associate Dean for Innovation in Health Professions Education at Columbia University’s Vagelos College of Physicians & Surgeons. He is also an Attending Psychiatrist at New York Presbyterian and the New York State Psychiatric Institute.
Dr. Amiel obtained his bachelor’s degree in biology from Yale University and his MD from Columbia. He is the past chair of the Association of American Medical Colleges’ (AAMC) Organization of Resident Representatives and Northeast Group on Educational Affairs, which led its Core Entrustable Professional Activities pilot. He serves on the Advisory Committee for the Gold Humanism Honor Society and chairs its Membership Committee. Dr. Amiel’s work focuses on competency-based education and its relationship to developing health professionals’ identities. In his work, he partners with educators across the medical school, medical center, university, and colleagues in national and international professional societies to advance the training of health professionals to optimally meet the evolving needs of the public. The overarching goal is to ensure that training is intentional, just, and aligned with public health needs – including developing our next generation of clinician-scientists, educators, and advocates.
The pilot included thirteen Core Entrustable Professional Activities (EPAs) that medical school graduates are expected to perform without direct supervision on the first day of residency – to shed light on improving the transition from undergraduate to graduate medical education. The presentation highlights the pilot teams, organizational structures, and results of the collaboration to implement within the medical education institutions.
A history of competency-based medical education
Competency-based education draws from decades of experience in K-12 education. It shifted the thinking from what is essential in a particular profession to what purpose the education serves and what medical students can do in authentic clinical environments. Over the past 20-some years, scholars, educators, and practitioners have collaborated to learn systems that employ the principles of competency-based education to train highly successful physicians.
Education trailblazer Elaine Benwell and colleagues distilled the principles of competency-based medical education into five areas:
- Outcome-based competency framework: Graduates of medical programs should function effectively as health professionals at the end of their education. Thus, training outcomes – and aligning them with societal needs – is the primary purpose of our role as medical educators.
- Progressive sequencing of competencies: Competency-based educators think about how learners develop their understanding to progress from novice to master clinician. Educators also help to establish building blocks for future competencies. (Bearing in mind individual progression is not always a smooth or predictable curve.)
- Time is a resource, not a driver of educational programs: Competency-based learning experiences structured to resemble the practice environment, which is sometimes non-linear.
- Teaching tailored to competencies: While many institutions tailor learning experiences to objectives, competency-based education emphasizes learning through experience and application – not solely knowledge acquisition.
- Programmatic assessment: The core of competency-based education is understanding when and how we assess individual learner progress. It recognizes there should be multiple points of student assessment – at low-and high-stake times – to measure performance. And the data is synthesized and applied in a way that aids graduate learners to be ready for the field.
What are the 13 core entrustable professional activities for medical students?
EPAs gather an understanding of learner competency and are highly linked to competency-based education models. The EPAs medical students need to perform with indirect supervision on day one of residency are as follows:
- Gather a history and perform a physical examination
- Prioritize a differential diagnosis following a clinical encounter
- Recommend and interpret common diagnostic and screening tests
- Enter and discuss orders and prescriptions
- Document the clinical encounter in the patient record
- Provide an oral presentation of the clinical encounter
- Form clinical questions and retrieve evidence to enhance patient care
- Give or receive a patient handover to transition care responsively
- Collaborate as a member of an interprofessional team
- Recognize a patient requiring emergent or urgent care and initiate evaluation and management
- Obtain informed consent for tests and/or procedures
- Perform general procedures of a physician
- Identify system failures and contribute to a culture of safety and improvement
Context of the AAMC pilot
Educators across the community started thinking about how well the EPAs are represented in curricula. The questions “What professional abilities can our learners develop and how do we link them?” and “when do educators allow learners to take on the responsibility of direct patient care?” were top of mind for the AAMC and medical educators around the country.
Yet, they still needed to learn the feasibility of implementing an EPA-based program. Thus, the AAMC Commission Department developed a pilot with the vision to optimize safe and effective patient care, ensuring that each graduate from our medical schools is prepared for core, initial duties as an intern. The original vision was to demonstrate the feasibility of implementing the core EPAs for entering residency on the path to graduation of M.D. candidates. The secondary goal was to improve the gap between performance and expectations for students entering residency who have been entrusted with the core EPAs.
The pilot structure and timeline
In the initial call for proposals, the AAMC selected ten schools of heterogeneous makeup (public/private, geographically diverse, number of students). Institutions included:
- Columbia University College of Physicians and Surgeons
- Florida International University Herbert Wertheim College of Medicine
- Michigan State University College of Human Medicine
- New York University School of Medicine
- Oregon Health & Science University School of Medicine
- University of Illinois College of Medicine
- University of Texas Health Science Center at Houston
- Vanderbilt University School of Medicine
- Virginia Commonwealth University School of Medicine
- Yale School of Medicine
The initial term of the pilot was five years, from 2014 to 2019. It was extended until 2021 because the AAMC needed time to wrap its heads around the EPAs and how they fit into the curriculum, better understand the guiding principles for forming the implementation, and amass meaningful qualitative and quantitative data.
There were four phases of the EPA pilot:
2014-2015: The first couple of years focused on theoretical clarification.
2015 to 2017: Clarification of theoretical understanding; teams started implementations by developing toolkits for EPAs that included pre-entrustable descriptions of pre-entrustable behaviors beyond what was initially published.
2017 to 2019: Continuance of implementations. Some schools were ready to make initial entrustment decisions.
2019 to 2021: More and more pilot schools implemented entrustment committees; schools who participated early in the pilot started program evaluation.
AAMC Core EPAs Pilot Outcomes
This post is part of a three-series post. Read the next recap that presents the findings of the study.