Formação de competências em saúde da criança nas residências de medicina de família e comunidade

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

Incorporating patient and family voices in the development of entrustable professional activities (EPAs) is not standard practice. Care of children with medical complexity (CMC) is an area of pediatrics that relies on family partnership, and families of CMC are ideal partners in EPA development given their expertise in their child's care and experience interacting with the health care system. The authors describe their model for partnering with families to develop EPAs and reflect on the unique contributions of family leaders to the process. After recruitment of family leaders from a national organization of families and friends of children with special health care needs, the authors used a multistage process for EPA development from June 2019 to February 2021. Family leaders were integrated throughout the process, including creating EPA descriptions, revising content across all EPAs, appraising EPAs through virtual focus groups with other key stakeholders, and finalizing and publishing EPAs. The authors used content analysis to identify recommendations for patient- and family-integrated EPA development. Family leaders and educators partnered in every phase of developing EPAs for the care of CMC, including as content experts, editors, focus group facilitators, and coauthors. Family leaders recommended substantive changes to all EPAs, including revising language, augmenting content, and modifying scope of practice. In addition, content analysis of family leaders' revisions yielded 10 recommendations to ensure that written EPA descriptions are patient- and family-centered. The described process of EPA development for the care of CMC models how families can be integrated into competency framework development and highlights their contributions. Family leader recommendations for embedding patient and family voices in EPA descriptions can serve as a guide for EPA development in other specialties.

Entrustable professional activities (EPAs) is a novel assessment framework in competency-based medical education. While there are published pilot reports about utilization and validation of EPAs within undergraduate medical education (UME), there is a paucity of research within graduate medical education (GME). This study aimed to explore the landscape of EPAs within family medicine GME, particularly related to the understanding of EPAs, extent of utilization, and benefits and challenges of EPAs implementation as an assessment framework within family medicine residency programs (FMRPs) in the United States. A cross-sectional survey, as part of the 2017 Council of Academic Family Medicine (CAFM) Educational Research Alliance (CERA) Family Medicine Residency Program (FMRP) Director omnibus online survey was conducted in fall, 2017. ACGME-accredited FMRP directors were invited by email to participate. The survey response rate was 53.1% (267/503). Overall, 90.1% (237/263) of FMRP directors were aware of EPAs as an assessment framework and 82.8% (197/238) understood the principles of EPAs, but 39.9% (95/238) were not confident in utilizing EPAs. Only 15.1% (36/238) of FMRP directors reported currently employing EPAs as an assessment tool. Identified benefits of EPAs use included increased transparency and congruence of expectations between learners and FRMP as well as facilitation for formative feedback. Identified barriers of EPA incorporation included difficulty integrating EPAs into the current assessment framework and faculty development. While EPAs are well recognized and understood by FMRP directors, there is significant lack of utilization of this assessment framework within FMRP in the United States.

Title: Does one size fit all? Strategy for defining Entrustable Professional Activities for Family Medicine residency in the Brazilian context. Background: In Brazil, health is guaranteed through social and economic policies delivered by the national unified health system focusing on primary health care (PHC). The Family Medicine (FM) specialty delivers most doctors who will work in PHC whose roles are medical care, including local leadership and strategic planning. No description of Entrustable Professional Activities (EPAs) for FM residency in Brazil has been defined. Summary of work: FM specialists and faculty core group analyzed the competence matrices defined by the Brazilian Family Medicine Association and the FM EPAs previously described in other countries. The group formulated EPAs considering the population's healthcare needs, the public health system rules, and the specificities of training in FM in the country. A modified Delphi study was performed to validate the developed EPAs. A panel of twenty-four educators specialists in FM composed Delphi's panel and rated the proposed list of EPAs on a four-point Likert scale. After the first round, the core group analyzed the data and included the panelists' suggestions. The rating data and suggested modifications were opened to the panelists from the second round. The threshold for consensus among panelists was a mean content validity index of at least 80%. Summary of Results: The core group formulated fourteen EPAs. The domains were first contact and longitudinally, health advocacy, equity-oriented health care, interprofessional care, leadership, clinical practice, minor surgery, scholarship, and a specific domain to address population and individual vulnerabilities. Delphi's panel comprised FM residency program directors, teachers, and supervisors. Their mean experience time as educators in FM residency was eleven years. It took two rounds to establish consensus, and the panelists approved all fourteen EPAs. An unprecedented EPA addressing social vulnerabilities and specific population needs was approved with a consensus of ninety percent of the panel. Discussion and Conclusion: Brazil, a developing country, has epidemiological, social, cultural, and economic specificities that differentiate it from developed countries, where EPAs for FM are mainly described. This was evidenced by the need to formulate an EPA to address social vulnerabilities and specific population needs. Take-home message: This work highlights the limitations of transposing EPAs reported in developed countries to low-to-middle-income countries (LMIC). It can support the proposition of EPAs in LMIC residency programs.

South Africa is undergoing a significant shift towards implementing enhanced workplace-based assessment methodologies across various specialist training programmes, including family medicine. This paradigm involves the evaluation of Entrustable Professional Activities (EPAs) through comprehensive portfolios of evidence, which a local and national clinical competency committee then assesses. The initial phase of this transformative journey entails the meticulous development of EPAs rooted in discrete units of work. Each EPA delineates the registrar’s level of entrustment for autonomous practice, along with the specific supervision requirements. This concise report details the collaborative effort within the discipline of family medicine in South Africa, culminating in the consensus formation of 22 meticulously crafted EPAs for postgraduate family medicine training. The article intricately outlines the systematic structuring and rationale behind the EPAs, elucidating the iterative process employed in their development. Notably, this marks a groundbreaking milestone as the first comprehensive documentation of EPAs nationally for family medicine training in Africa.

BackgroundThere is a growing need for Entrustable Professional Activities (EPAs) specifically tailored to health professions educators including dental educators, whose responsibilities extend well beyond clinical expertise. Despite the breadth and complexity of these responsibilities, the current literature lacks EPA frameworks that are explicitly designed to reflect the unique and multifaceted scope of practice of dental educators.ObjectiveThe objective of this Modified Delphi study was to develop a validated and consensus-based set of EPAs for dental educators.MethodsA three-stage consensus-building approach was employed in this study: (1) identification of existing EPAs in the literature through a systematic scoping review; (2) two rounds of a Modified Delphi exercise conducted via online questionnaires; and (3) a final in-person consensus focus group discussion to refine and finalise the list of EPAs.A total of 40 EPAs were systematically identified through a scoping review of the literature. These EPAs were subsequently evaluated by a panel of 10 experts using a three-stage modified Delphi technique. Consensus was quantitatively define as median rating of ≥3 on a 4-point Likert scale, with an item-level Content Validity Index (i-CVI) of ≥0.8. Open ended responses were thematically analysed.ResultsIn the first round, consensus was reached to eliminate 6 EPAs, 7 EPAs further consolidated to 2 EPAs, 12 EPAs were revised and 15 EPAs were accepted without revision. In the second round, a total of 81 EPAs, comprising 29 retained from the first round and 52 newly suggested EPAs, were reviewed. Consensus was reached to exclude 1 EPA. By the end of Round 2, 80 EPAs were brought forward to the third round, which was conducted as in-person focus group meeting. The final round resulted in the elimination of 6 EPAs and the consolidation of 9 EPAs into 3, culminating in the endorsement of 68 EPAs, which were systematically organized into 12 distinct domains.ConclusionsThis study successfully developed a validated and consensus-based set of 68 EPAs tailored for dental educators, addressing a critical gap in the current literature. This set provides a foundational tool to guide professional development, performance assessment, and role definition of dental educator.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12909-025-08119-1.

Competency-Based Medical Training in Anesthesiology: Has It Delivered on the Promise of Better Education?

The Alliance for Academic Internal Medicine charged its Education Redesign Committee with the task of assisting internal medicine residency program directors in meeting the challenges of competency-based assessment that were part of the Accreditation Council for Graduate Medical Education's (ACGME's) Next Accreditation System. Recognizing the limitations of the ACGME general competencies as an organizing framework for assessment and the inability of the milestones to provide the needed context for faculty to assess residents' competence, the Education Redesign Committee in 2011 adopted the work-based assessment framework of entrustable professional activities (EPAs). The committee selected the EPA framework after reviewing the literature on competency-based education and EPAs and consulting with experts in evaluation and assessment. The committee used an iterative approach with broad-based feedback from multiple sources, including program directors, training institutions, medical organizations, and specialty societies, to develop a set of EPAs that together define the core of the internal medicine profession. The resulting 16 EPAs are those activities expected of a resident who is ready to enter unsupervised practice, and they provide a starting point from which training programs could develop assessments and curricula. The committee also provided a strategy for the use of these EPAs in competency-based evaluation. These EPAs are intended to serve as a starting point or guide for program directors to begin developing meaningful, work-based assessments that inform the evaluation of residents' competence.

First-year residents begin clinical practice in settings in which attending staff and senior residents are available to supervise their work. There is an expectation that, while being supervised and as they become more experienced, residents will gradually take on more responsibilities and function independently. This study was conducted to define 'entrustable professional activities' (EPAs) and determine the extent of agreement between the level of supervision expected by clinical supervisors (CSs) and the level of supervision reported by first-year residents. Using a nominal group technique, subject matter experts (SMEs) from multiple specialties defined EPAs for incoming residents; these represented a set of activities to be performed independently by residents by the end of the first year of residency, regardless of specialty. We then surveyed CSs and first-year residents from one institution in order to compare the levels of supervision expected and received during the day and night for each EPA. The SMEs defined 10 EPAs (e.g. completing admission orders, obtaining informed consent) that were ratified by a national panel. A total of 113 CSs and 48 residents completed the survey. Clinical supervisors had the same expectations regardless of time of day. For three EPAs (managing i.v. fluids, obtaining informed consent, obtaining advanced directives) the level of supervision reported by first-year residents was lower than that expected by CSs (p<0.001) regardless of time of day (i.e. day or night). For four more EPAs (initiating the management of a critically ill patient, handing over the care of a patient to colleagues, writing a discharge prescription, coordinating a patient discharge) differences applied only to night-time work (p≤0.001). First-year residents reported performing EPAs with less supervision than expected by CSs, especially during the night. Using EPAs to guide the content of the undergraduate curriculum and during examinations could help better align CSs' and residents' expectations about early residency supervision.

Entrustable Professional Activities: Reflecting on Where We Are to Define a Path for the Next Decade.

Entrustable professional activities (EPAs), as a focus of learner assessment, are supported by validity evidence. An EPA is a unit of professional practice requiring proficiency in multiple competencies simultaneously, that can be entrusted to a sufficiently competent learner. Taken collectively, a set of EPAs define and inform the curriculum of a specialty training. The goal of this study was to develop a set of EPAs for Dutch PICU fellows. A multistage methodology was employed incorporating sequential input from task force members, a medical education expert, PICU fellowship program directors, and PICU physicians and fellows via a modified three-round Delphi study. In the first modified Delphi round, experts rated indispensability and clarity of preliminary EPAs. In the subsequent rounds, aggregated scores for each EPA and group comments were provided. In round two, respondents rated indispensability and clarity of revised EPAs. Round three was used to gain explicit confirmation of suitability to implement these EPAs. Based on median ratings and content validity index (CVI) analysis for indispensability in the first two rounds, all nine preliminary EPAs covered activities that were deemed essential to the clinical practice of PICU physicians. Based on median ratings and CVI analysis for clarity however, four EPAs needed revision. With an agreement percentage of 93–100% for all individual EPAs as well as the set as a whole, a high degree of consensus among experts was reached in the third round. The resulting nine PICU EPAs provide a succinct overview of the core tasks of Dutch PICU physicians. These EPAs were created as an essential first step towards developing an assessment system for PICU fellows, grounded in core professional activities. The robust methodology used, may have broad applicability for other (sub)specialty training programs aiming to develop specialty specific EPAs.

Since publication of the 2 Institute of Medicine reports, To Err is Human1 and Crossing the Quality Chasm,2 the public and government expect and demand higher quality and safer patient care. To accomplish its mission of improving health care by assessing and advancing the quality of resident physicians’ education,3 the Accreditation Council for Graduate Medical Education (ACGME) encouraged competency-based education with the creation of 6 core competencies. Recently, the ACGME created the milestones, which emphasize competency-based developmental outcomes. The family medicine milestones, to become effective July 1, 2014, consist of 22 outcomes based on the 6 core competencies. A mandate for family medicine residency programs is to ensure their graduates are able to provide safe health care to their patients. As programs begin to implement the milestones, an emerging complimentary theme is the entrustable professional activity (EPA), which is a way to translate competencies into clinical practice.4 Collectively, a set of EPAs for family medicine constitute the core clinical activities of a family physician,5 ie, what does a family physician do in practice and how do we know a graduate is competent to independently and safely practice those activities? Going beyond a checklist of behaviors, EPAs define the “knowledge, skills, and attitudes” integrated across the competency domains and the work that a family physician does.4 As family medicine is such a rigorous and diverse specialty, constructing a comprehensive list of EPAs is indeed a daunting task. One educator recommends a graduate medical education program have no more than 20 to 30 EPAs that are clear but not too detailed.6 An initial attempt at defining EPAs in family medicine included a list of 76 items that mostly focused on the ambulatory setting.6 Ideally, EPAs should be independently executable within a given time frame as well as observable and measurable.4 Ultimately, the EPAs should be a list of what the public can expect from their family physicians. Currently, a committee of family medicine leaders is drafting a list of EPAs for our specialty. They are expected to release the list this fall–intentionally coinciding with the anticipated Family Medicine for America’s Health report. The emergence of EPAs in family medicine is intended to support the milestones, and it is important to note their differences. Milestones follow each competency along a developmental continuum. While milestones detail individual competencies, real care delivery requires integration of these abilities in a more complex manner.5 For example, an EPA on care for the underserved/vulnerable patient would require a resident (on multiple occasions) to demonstrate knowledge of population health, advocacy, and cost awareness, and to employ team-based care, utilize IT resources, etc. Proficiency in an EPA requires mastery of several competencies, and goes well beyond ACGME program requirements, time spent on rotations, or patient numbers. The EPA assessments are based on specific observable activities throughout residency and not just a general impression. EPAs can also be used to drive curriculum development at the residency level. Program directors should use EPAs as they are intended to strengthen professional standards, improve patient safety, and enhance outcomes. The implementation of EPAs is not meant to be burdensome; rather, they should help programs bridge the gap between initial competency-based assessments and real-world practice. EPAs will be particularly helpful for family medicine faculty who struggle with Likert scale numerical ratings. We are in an exciting time in family medicine education as we look to incorporating milestones and EPAs into our residency programs. Implementation should produce higher quality graduates who will provide safe, quality care to their patients and communities.

Development of entrustable professional activities for competency-based prosthodontic specialty training programmes.

Development of Entrustable Professional Activities for Training of Hospice and Palliative Care Pharmacists (SCI961)

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.