Entrustment in plastic surgery residents’ informed consent taking for elective surgical procedures: a modified Delphi study

The aim of this study was to develop a competency framework based on entrustable professional activities (EPAs) in oral cancer management by postgraduate trainees in oral and maxillofacial surgery through expert consensus. The study design was based on a modified Delphi technique and involved iterative online surveys with two rounds of data collection and analysis. Initial development of the questionnaire identified five EPAs based on 42 competencies along with supervision level and assessment strategies. The first Delphi round involved administration of the survey questionnaire online to maxillofacial surgeons meeting the inclusion criteria for experts. Consensus was achieved on five EPAs and 36 competencies (≥80% response rate). Six competencies were rephrased and sent again in the Round 2 questionnaire to achieve a consensus. A total of 45 experts participated in Round 1 followed by input from 27 experts in Round 2 of the Delphi panel. Following two iterative rounds of online surveys and feedback, expert consensus was achieved to develop an EPA framework in five EPA domains focused on the management of oral cancer by postgraduate trainees in maxillofacial surgery including 38 specific competencies, supervision level, and assessment strategies. High content validity of the study was established through a comprehensive literature search, and expert feedback was evidenced by an excellent response rate (93.34%, and 64.28%) and a stringent criteria of response agreement amongst experts (≥80%). In conclusion, this study employed expert consensus to identify five EPAs with 38 competencies along with the required supervision level of postgraduate maxillofacial trainees for the management of oral cancer. This EPA framework provides a roadmap for training supervisors to map the learning outcomes in oral oncology for postgraduate trainees in oral and maxillofacial surgery.

Background: A standard undergraduate radiology education is essential to prepare graduates for multidisciplinary clinical practice yet the literature lacks clear guidelines or consensus about the learning objectives of an optimal radiology clerkship.Aim: To define a competency-based framework for undergraduate radiology education by using language of Entrustable Professional Activities (EPAs).Methods: A modified Delphi method with three iterative rounds was used as an expert consensus approach. An online questionnaire with Likert scale was formulated incorporating EPAs and their components (competencies, assessment strategies, and supervision level) and distributed to 45 consultant radiologists following pilot study. Items reaching consensus were accepted and rest were resent in round 2. In round 3, a dichotomous scale was used for final approval and to see response stability.Results: A final set of six EPAs with 87 competencies and respective assessment strategies, all aiming for ‘level 3a’ of supervision was identified. These include recommending cost effective appropriate imaging tests for common pathologies, obtaining informed consent for diagnostic contrast studies, basic interpretation and communication of common pathologies/emergencies on radiographs (chest, abdominal, and skeletal) and on CT brain.Conclusion: This EPA framework for radiology clerkship is a first step towards a competency-based approach to undergraduate radiology training and assessment.

Competency-Based Education, Entrustable Professional Activities, and the Power of Language

It is essential that medical education (MedEd) fellows achieve desired outcomes prior to graduation. Despite the increase in postgraduate MedEd fellowships in emergency medicine (EM), there is no consistently applied competency framework. We sought to develop entrustable professional activities (EPAs) for EM MedEd fellows. From 2021 to 2022, we used a modified Delphi method to achieve consensus for EPAs. EM education experts generated an initial list of 173 EPAs after literature review. In each Delphi round, panelists were asked to make a binary choice of whether to include the EPA. We determined an inclusion threshold of 70% agreement a priori. After the first round, given the large number of EPAs meeting inclusion threshold, panelists were instructed to vote whether each EPA should be included in the "20 most important" EPAs for a MedEd fellowship. Modifications were made between rounds based on expert feedback. We calculated descriptive statistics. Seventeen experts completed four Delphi rounds each with 100% response. After Round 1, 87 EPAs were eliminated and two were combined. Following Round 2, 46 EPAs were eliminated, seven were combined, and three were included in the final list. After the third round, one EPA was eliminated and 13 were included. After the fourth round, 11 EPAs were eliminated. The final list consisted of 16 EPAs in domains of career development, education theory and methods, research and scholarship, and educational program administration. We developed a list of 16 EPAs for EM MedEd fellowships, the first step in implementing competency-based MedEd.

BackgroundCompetency based curricula across the globe stress on the importance of effective physician patient communication. A variety of courses have been used to train physicians for this purpose. However, few of them link competencies with practice resulting in confusions in implementation and assessment. This issue can be resolved by treating certain specific patient communication related tasks as acts of entrustment or entrustable professional activities (EPAs). In this study, we aimed to define a competency-based framework for assessing patient physician communication using the language of EPAs.MethodsA modified Delphi study was conducted in three stages. The first stage was an extensive literature review to identify and elaborate communication related tasks which could be treated as EPAs. The second stage was content validation by medical education experts for clarity and representativeness. The third stage was three iterative rounds of modified Delphi with predefined consensus levels. The McNemar test was used to check response stability in the Delphi Rounds.ResultsExpert consensus resulted in development of 4 specific EPAs focused on physician-patient communication with their competencies and respective assessment strategies all aiming for level 5 of unsupervised practice. These include Providing information to the patient or their family about diagnosis or prognosis; Breaking Bad news to the patient or their family; Counseling a patient regarding their disease or illness; Resolving conflicts with patients or their families.ConclusionsThe EPAs for Physician-patient communication are a step toward an integrative, all-inclusive competency-based assessment framework for patient-centered care. They are meant to improve the quality of physician patient interaction by standardizing communication as a decision of entrustment. The EPAs can be linked to competency frameworks around the world and provide a useful assessment framework for effective training in patient communication. They can be integrated into any post graduate curriculum and can also serve as a self-assessment tool for postgraduate training programs across the globe to improve their patient communication curricula.

BackgroundWhile competency-based education has gained prominence in preparing professionals for practice, clinical microbiology residency programs face a challenge in defining specific, observable tasks that align with Entrustable Professional Activities (EPAs). The current lack of a standardized set of EPAs tailored to clinical microbiology creates a gap in assessing learner proficiency and educational outcomes.ObjectivesThis study aims to develop and validate a set of specific EPAs for clinical microbiology using a multi-step national expert consensus-building process.MethodsThis study was conducted in Egypt, involving experts from various medical schools across the country. As the first step, a thorough literature review was undertaken to identify potential EPAs pertinent to clinical microbiology residency programs. Then, evaluation of EPAs for quality and structure using EQual rubric involved five experts in medical education and clinical microbiology, resulting in the confirmation of relevant EPAs. Subsequently, three rounds of the modified Delphi method were employed, engaging ten clinical microbiology experts from various medical schools. Simultaneously, content validity was assessed based on these ratings. Participants also determined the appropriate year of entrustment for each EPA item, and an 80% Validity index agreement threshold was calculated to ensure consensus among participant groups.ResultsThe use of the literature review and initial expert evaluation using EQual rubric confirmed 39 out of the initially identified 43 EPAs. Following the modified Delphi method rounds, 16 EPAs gained acceptance, signifying their relevance and appropriateness for clinical microbiology residency training. These EPAs were categorized into key areas, including preanalytical testing and quality assurance, microbiological techniques and diagnostics, infection control and safety practices, clinical leadership and teamwork, research and development, and laboratory management and communication.ConclusionsThis study developed 16 EPAs for clinical microbiology residency programs. These EPAs were developed using a robust multi step validation study. This provides a further step towards competency-based postgraduate training in clinical microbiology.Clinical trial numberNot applicable.

Skin conditions affect about two billion people worldwide. Non-dermatologist physicians often struggle to diagnose and manage these conditions effectively. Medical students perceive inadequate dermatology training, hindering competent care delivery. In resource-limited settings like Pakistan, structured Dermatology clerkships are scarce, emphasizing the need to equip physicians with essential skin pathology management skills. This study aimed to develop Entrustable Professional Activities (EPAs) for final-year MBBS students completing dermatology clerkships. Competencies, supervision levels, and assessment strategies associated with these EPAs were also identified. To establish consensus on EPAs for undergraduate Dermatology clerkship, including competencies (Knowledge, skills, attitudes), assessment strategies, and supervision levels. A modified Delphi method with three iterative rounds was employed. Expert opinions were gathered through online questionnaires distributed to 42 dermatology consultants across Pakistan. Consensus was achieved by excluding items not meeting the predefined criteria. Response stability was assessed in the final round. After three rounds, consensus was reached on 6 EPAs, encompassing 42 competencies and assessment strategies. Five EPAs aimed at "level 3a" supervision, addressing key aspects of dermatology practice. The clerkship duration of 4 weeks received majority agreement, and overall stability was high for EPAs and competencies. This study establishes a comprehensive competency-based framework for undergraduate dermatology education, contributing to a competency-based approach for training and assessment. The identified EPAs can align with existing clerkship objectives, enhancing dermatology curriculum effectiveness.

Background:A career in hand surgery in the United States requires a 1-year fellowship after residency training. Different residency specialty programs may vary in case volume. The purpose of this study was to characterize variation in hand surgery training within and between orthopaedic and plastic surgery residents.Methods:Publicly available hand surgery case logs for graduating orthopaedic and plastic surgery residents during the 2010 to 2011 to 2018 to 2019 academic years were obtained through the Accreditation Council of Graduate Medical Education. Student t-tests were used to compare mean case volumes among several categories between plastic surgery (PRS) and orthopaedic surgery (OS) residents. Intraspecialty variation was assessed by comparing the 90th and 10th percentiles in each category.Results:A total of 6,254 orthopaedic and 1,070 plastic surgery graduating residents were included. The mean hand surgery case volume for orthopaedic residents (OS 247.0) was significantly lower than that for plastic surgery residents (PRS 412.0) (P < 0.0001). Orthopaedic residents performed more trauma cases (OS 133.2, PRS 54.5; P < 0.0001) but fewer nerve repairs (OS 3.3, PRS 28.5 P < 0.0001) and amputations (OS 6.4, PRS 15.8; P < 0.0001). Nerve decompression case volumes were similar between the two specialties (OS 50.2, PRS 47.3; P = 0.34). Case volumes among orthopaedic residents varied considerably in amputations and among plastic surgery residents in replantation/revascularization procedures.Conclusions:Orthopaedic surgery residents performed significantly more trauma cases than plastic surgery residents did, but fewer overall cases, nerve repairs, and amputations, while nerve decompression volumes were similar between specialties. This information may help inform residency and fellowship directors regarding areas of potential training deficiency.

Background and objective Entrustable professional activities (EPAs) are tasks that medical professionals can be entrusted to perform in unsupervised settings once they have achieved sufficient specific competencies. Despite their importance, nationally validated neurology EPAs are lacking in Saudi Arabia. This study aimed to develop and validate neurology EPAs in Saudi Arabia. Methods A list of neurology EPAs was developed after an extensive review of existing neurology training program competencies and EPAs. Neurology experts were invited to participate in two rounds of a modified Delphi technique to review the list of EPAs and assess their relevance and representativeness using a 5-point Likert scale. In total, 21 neurologists participated in the study. Descriptive statistics were used to describe participants’ demographic characteristics and group responses to each EPA. Cronbach’s alpha was used to assess the internal consistency of the responses across both Delphi rounds. Results In the first round, 26 EPAs were validated, 10 were excluded owing to a lack of relevance, and one EPA was added as a modification of the existing items. In the second round, one more EPA was excluded because of a lack of relevance, resulting in a final set of 25 neurology EPAs. Conclusion This study developed and content-validated a set of EPAs for neurology residency training in Saudi Arabia. It represents an initial step toward implementing an EPA-based curriculum. Further steps are necessary to ensure adequate integration into training programs.

Entrustable professional activities (EPAs) are an emerging workplace-based, patient-oriented assessment approach with limited empirical evidence. To measure the development of pediatric trainees' clinical skills over time using EPA-based assessment data. Prospective cohort study of categorical pediatric residents over 3 academic years (2015-2016, 2016-2017, and 2017-2018) assessed on 17 American Board of Pediatrics EPAs. Residents in training at 23 pediatric residency programs in the Association of Pediatric Program Directors Longitudinal Educational Assessment Research Network were included. Assessment was conducted by clinical competency committee members, who made summative assessment decisions regarding levels of supervision required for each resident and each EPA. Data were collected from May 2016 to November 2018 and analyzed from November to December 2018. Longitudinal, prospective assessment using EPAs. Trajectories of supervision levels by EPA during residency training and how often graduating residents were deemed ready for unsupervised practice in each EPA. Across the 5 data collection cycles, 1987 residents from all 3 postgraduate years in 23 residency programs were assigned 25 503 supervision level reports for the 17 general pediatrics EPAs. The 4 EPAs that required the most supervision across training were EPA 14 (quality improvement) on the 5-level scale (estimated mean level at graduation, 3.7; 95% CI, 3.6-3.7) and EPAs 8 (transition to adult care; mean, 7.0; 95% CI, 7.0-7.1), 9 (behavioral and mental health; mean, 6.6; 95% CI, 6.5-6.6), and 10 (resuscitate and stabilize; mean, 6.9; 95% CI, 6.8-7.0) on the expanded 5-level scale. At the time of graduation (36 months), the percentage of trainees who were rated at a supervision level corresponding to "unsupervised practice" varied by EPA from 53% to 98%. If performance standards were set to align with 90% of trainees achieving the level of unsupervised practice, this standard would be met for only 8 of the 17 EPAs (although 89% met this standard for EPA 17, performing the common procedures of the general pediatrician). This study presents initial evidence for empirically derived practice readiness and sets the stage for identifying curricular gaps that contribute to discrepancy between observed practice readiness and standards needed to produce physicians able to meet the health needs of the patient populations they serve. Future work should compare these findings with postgraduation outcomes data as a means of seeking validity evidence.

The purpose of this study was to obtain a validated consensus among expert periodontists in Saudi Arabia regarding end-of-periodontics-residency-training entrustable professional activities (EPAs) using a modified Delphi method. The study consisted of two phases. A preliminary phase in which experts met and proposed an initial list of EPAs following an extensive literature review. The second phase consisted of two rounds of the modified Delphi method in which expert periodontists in Saudi Arabia determined the content validity of each EPA. This was determined with a 5-point scale ranging from 1 (not important/relevant) to 5 (very important/relevant), and the mean score for each EPA was calculated. EPAs with a mean value of≤4 or agreement rate among experts of less than 80% were excluded. An initial list of 40 EPAs was proposed. A total of 30 expert periodontists participated in the first round, and 24 participated in the second round of the modified Delphi method ratings. Most of the participants were program directors and represented different programs and cities in Saudi Arabia. Five EPAs were removed, and a final list of EPAs was produced based on the defined criteria. The Cronbach's alpha was 0.920, indicating high reliability. A final list of 35 end-of-periodontics-training EPAs was produced. The findings of this study can serve as a valuable resource for curriculum development, assessments, and evaluation of periodontics training programs in Saudi Arabia.

Entrustable professional activities (EPAs) are professional tasks that can be entrusted to a student under a given level of supervision once he or she has demonstrated competence in these tasks. The EPA construct was conceived to increase transparency in objectives for clinical workplace learning and to help ensure patient safety and the quality of care. A first step in implementing EPAs in a veterinary curriculum is to identify the core EPAs of the profession. The aim of this study was to develop EPAs for farm animal health. An initial set of 36 EPAs for farm animal health was prepared by a team of six veterinarians and curriculum developers and used in a modified Delphi study. In this iterative process, the EPAs were evaluated until higher than 80% agreement was reached. Of 83 veterinarians who participated, 39 (47%) completed the Delphi procedure. After two rounds, the panel reached consensus. A small expert group further refined and reorganized the EPAs for educational purposes into seven core EPAs for farm animal health and 29 sub-EPAs. This study is an important step in optimizing competency-based training in veterinary medicine. Future steps are to implement EPAs in the curriculum and train supervisors to assess students' ability to perform EPAs with increasing levels of independence.

73. ETIOLOGY OF UNABLE TO ASSESS ENTRUSTABLE PROFESSIONAL ACTIVITIES IN A NATIONAL STUDY

Telemedicine entrustable professional activities for nurses in long-term care: A modified Delphi study

Assessing pediatric subspecialty fellows using entrustable professional activities (EPAs) to determine readiness for graduation has not been described. We aimed to determine whether graduating pediatric fellows are meeting the minimum supervision level at graduation previously identified by program directors for the clinical EPAs and the relationship between meeting these levels and initial subspecialty board certification. Pediatric fellows in 14 subspecialties were assessed by clinical competency committees in the spring before graduation in 2019 to 2022 on 3 EPAs common to all subspecialties that involve direct patient care and the subspecialty-specific EPAs. Publicly available board certification data were obtained from the American Board of Pediatrics. EPA supervision levels were collected on 1480 fellows, representing approximately 27% of all graduating fellows. A total of 117 (7.9%) fellows did not meet the minimum supervision level for at least 1 EPA, with some requiring direct supervision. Of fellows who did not achieve the expected level at graduation, 83 (70.9%) were certified. Those who met the minimum level for all clinical EPAs had a higher certification rate compared with those who did not meet the minimum for at least 1 EPA (80.6% vs 70.9%; P = .01). Almost 10% of pediatric fellows are not meeting the expected supervision level for the clinical EPAs at graduation, and yet over 70% of them passed their subspecialty certification examination. This study provides support for using EPAs to determine readiness for graduation and demonstrates that some fellows may need additional training or continued supervision after completion of their fellowship.