Concept Of Entrustable Professional Activities Research Articles

Defining a set of teaching EPAs tailored to an undergraduate medical curriculum using a modified Delphi approach

BackgroundThe concept of entrustable professional activities (EPAs) has recently been extended to operationalize professional tasks in teacher training and faculty development in health professions education. The aim of this study is to report on the process and results of defining a set of teaching EPAs (t-EPAs) tailored to the local characteristics of a particular undergraduate medical program.MethodsThe undergraduate medical program at the Charité – Universitätsmedizin Berlin is competency-based, integrates thematic modules and spans 6 years. A writing team identified teaching EPAs based on the program’s study regulations and drafted content descriptions with titles, specifications and knowledge, skills and attitudes. Content validation involved a modified Delphi procedure with a systematic, iterative interaction between a panel of content experts consisting of purposively selected educators and physicians from our faculty (n = 11) and the writing team. The threshold for a consensus was an agreement of 80% of the participants.ResultsAfter two Delphi rounds, a consensus was reached regarding the teaching activities to be included and their content descriptions. The response rate was 100% in both Delphi rounds. The Delphi results include the content descriptions of a total of 13 teaching EPAs, organized into the two overarching EPA domains of classroom-based (n = 10) and workplace-based (n = 3) activities. Tailoring the classroom EPAs to small group teaching and the workplace EPAs to supervising medical students led to several distinct EPAs. Another feature was the development of 2 teaching EPAs for interdisciplinary teaching.ConclusionsIn systematic, Delphi-based process, we defined a set of 13 distinct teaching EPAs tailored to a specific undergraduate medical program that cover the core teaching tasks for faculty in this program. Our report on the principles of the process and the results may guide other medical schools and educators in defining and tailoring teaching EPAs according to their contexts.

Entrustable Professional Activities in Oral and Maxillofacial Surgery Education: A Faculty Development Construct

The formative and summative evaluations of oral and maxillofacial surgery residents have commonly involved the six core competencies of the Accreditation Council for Graduate Medical Education. Unfortunately, the assessment of a resident's competencies in these six core areas is often subjective such that the written feedback might not be supportive of the resident's learning and continuous professional development. Compounding this problem is that faculty are infrequently trained in providing feedback in these core competencies, thereby adding to the inadequacy of this exercise. Entrustable professional activities (EPAs) represent a unit of professional practice, defined as tasks or responsibilities to be entrusted to the unsupervised execution by a trainee once he or she has attained sufficient specific competence. It is the purpose of this article to review the concept of EPAs that represent a hopeful solution to the theoretical and abstract nature of exclusive competency-based training assessments in resident education. EPAs are specifically proposed for oral and maxillofacial surgery resident education while discussing their serving as a faculty development construct.

Clinical supervisors’ experience of a first-time application of entrustable professional activities in clinical supervision of medical students: findings from a Swedish pilot study

BackgroundRecently, all medical universities in Sweden jointly developed a framework for Entrustable Professional Activities (EPAs) for work-based training and assessment. This framework is now being introduced nationally in the new 6-year undergraduate medical programme that directly lead to a licence to practise. When EPAs are introduced, it is of central importance to gain clinical supervisors’ acceptance to apply the framework in their supervision of students. The aim of this study was therefore to investigate how clinical supervisors, not familiar with EPAs, experience clinical supervision using the framework for EPAs.MethodsWe used a purposive sampling to recruit clinical supervisors. They were given written information on EPAs with a selection of suitable EPAs and the Swedish observation rating scale for assessment of autonomy, and they were offered to attend a 30-minute introductory web course. The participants were informed that EPAs were to be tested, and the students were asked to participate. After the study period the clinical supervisors participated in semi-structured interviews. Inductive qualitative content analysis was used to analyse the transcribed interviews.ResultsThree general themes emerged in the qualitative analysis: Promoting Feedback, Trusting Assessments and Engaging Stakeholders. The participants described benefits from using EPAs, but pointed out a need for preparation and adaptation to facilitate implementation. The structure was perceived to provide structured support for feedback, student involvement, entrustment decisions, enabling supervisors to allow the students to do more things independently, although some expressed caution to rely on others’ assessments. Another concern was whether assessments of EPAs would be perceived as a form of examination, steeling focus from formative feedback. To understand the concept of EPA, the short web-based course and written information was regarded as sufficient. However, concern was expressed whether EPA could be applied by all clinical supervisors. Involvement and adaption of the workplace was pointed out as important since more frequent observation and feedback, with documentation requirements, increase the time required for supervision.ConclusionsEPAs were accepted as beneficial, promoting structured feedback and assessments of the students’ autonomy. Preparation of supervisors and students as well as involvement and adaptation of the workplace was pointed out as important.

Establishing Entrustable Professional Activities of Taiwan Radiation Technologist

<p>可信賴專業活動(Entrustable Professional Activities, EPAs)的重要概念，是將核心能力整合成臨床實務專業任務，以信賴等級作為能力進展的依據，供臨床監督授權參考，有助於融合核心概念於臨床照護，應用在職場的教學行為。為進一步推動臺灣醫事放射職類落實勝任能力導向醫學教育(Competency-Based Medical Education, CBME)，本專案活動透過嚴謹共識程序，召集醫事放射職類醫學教育專家完成三大部門之EPAs。活動成果提升了專案對象之EPAs整體概念與五大核心能力理解程度(p<0.001)，問卷調查顯示共識建立法可有效凝聚專家共識（名義團體法4.87分、修正式德菲法4.82分），亦提升EPAs臨床教學助益（4.88分）及醫事放射職類之專業認同（4.87分）。下階段預計號召教學醫院進行場域實踐，以提升整體醫事放射醫學教育水平，促進醫療服務品質。</p> <p> </p><p>Integration of core competencies into professional tasks in clinical practice is the core concept of entrustable professional activities (EPAs). The progression of competencies can be examined using entrustability scales, which are also applied as a reference for clinical supervision and authorization. Through EPAs, core competencies are effectively integrated into clinical care and applied in workplace teaching. To implement competency-based medical education (CBME) in Taiwan for medical radiation technologists, we established the EPAs of the three departments of radiation technology by adopting solid consensus methods. The results revealed that our methods effectively improved the overall understanding of the concept of EPAs and profession-specific core competencies (p<0.001). In addition, the effective consensus methods (4.87 and 4.82 points) improved the applicability of EPAs in clinical teaching (4.88 points) and professional identification in medical radiation technology (4.87 points). In the next step, nationwide teaching hospitals will be invited to implement CBME. Extensive practical experience and feedback will be collected to tailor the program according to local needs.</p> <p> </p>

A mobile application to facilitate implementation of programmatic assessment in anaesthesia training

BackgroundProgrammatic assessment is a concept to support learning through continuously providing information about learner progress to trainees and supervisors. Central to the concept are multiple low-stakes workplace-based assessments and meaningful feedback opportunities. Mobile technology may facilitate frequent and concise workplace-based assessments and trigger meaningful feedback. We designed a mobile application (app) for real-time use at the workplace utilising the concept of entrustable professional activities. As the primary outcome, we analysed completion times and as the secondary outcome the quality of documented learning goals. MethodsThe prEPAred app requests trainees and supervisors to rate level of supervision of a professional activity directly after completion. Subsequently, ratings are compared, and supervisors may provide feedback via the app. We tested the app in five anaesthesiology departments at major teaching hospitals, analysing completion times, agreement on ratings, and quality of documented learning goals. ResultsWe recorded 1518 assessments from 159 trainees and 89 supervisors. Median time for level of supervision rating was 56 (inter-quartile range: 39–85) s for trainees and 17 (11–30) s for supervisors. Learning goals via the app were documented in 767 cases (50.5%). Median feedback time was 2 min, 31 s (confidence interval [CI]: 1 min, 20 s to 5 min, 20 s). In 443 (29%) cases, a specific learning goal was documented. A post hoc analysis revealed that the odds of documenting learning goals increased if trainees rated the level of supervision higher than their supervisors (odds ratio 1.39; CI: 1.03–1.87). ConclusionsThe prEPAred mobile app enabled frequent and concise documentation of workplace-based assessments. Disagreement in level of supervision rating stimulated documentation of specific learning goals indicating more meaningful feedback. Thus, the tool could advance workplace-based assessments towards programmatic assessment.

Bases conceptuales de las actividades profesionales a confiar para la educación de profesionales de la salud en Latinoamérica

The concept of entrustable professional activities emerged as an attempt to overcome some of the criticisms to the competency-based medical education approach; it has had a broad impact in practice and health professions education research. It has been disseminated internationally with its English acronym: EPA. This approach proposes to orient assessment and teaching to specific activities in the profession, which allows the integration of several competencies, and to determine which responsibilities can be entrusted to the trainee, in a gradual and explicit manner. The model assumes the definition of levels of supervision that allow progressive autonomy for each EPA, in students or residents, once they demonstrate the required competencies. Practice, supervision and feedback in real clinical scenarios are key to the development of autonomy in EPA performance. The dissemination of the EPA approach is still limited in Latin America, but it has the potential to create a significant contribution to curriculum design and evaluation, and to assessment practices of health professionals across their careers. It provides a deep review of the assumptions under which healthcare professional practice decisions are made, at under and postgraduate levels.

Rapid Mobilization of Medical Student Volunteers to Administer Vaccines During the COVID-19 Pandemic.

In December 2020, the first COVID-19 vaccines were approved for emergency use by the U.S. Food and Drug Administration, and vaccination efforts rapidly launched across the country. Concurrently, New York City experienced an increase in COVID-19 hospitalizations. This created an immediate need to inoculate frontline workers in a strained health system that lacked sufficient personnel to meet the demand. In response, New York State permitted medical students with appropriate clinical experience to administer vaccinations. Albert Einstein College of Medicine students rapidly stepped in to administer vaccines and serve as clinic navigators.Student leaders at Einstein collaborated with Montefiore Medical Center to rapidly implement a student vaccination initiative. Medical students underwent virtual and on-site training regarding COVID-19 vaccines and their administration. In January 2021, students began to staff vaccine clinics across the Bronx. By July 2021, 291 out of 830 eligible medical and Medical Scientist Training Program (MSTP) students (35.1%) had volunteered >2400 h. Of the 291 volunteers, 77 (26.5%) worked as vaccinators and administered approximately 2929 COVID-19 vaccines from January to May 2021.We demonstrate success using the concept of Entrustable Professional Activities (EPAs) in the context of training medical students in a specific clinical skill. Our framework resulted in the administration of approximately 2929 COVID-19 vaccines from January to May 2021. The authors believe that this framework can be implemented at peer institutions to alleviate the burden on hospital systems and outpatient clinics vaccinating their communities against COVID-19, or to meet future clinical needs.

Development of entrustable professional activities for residents rotating nephrology department in a Japanese university hospital: a Delphi study

ObjectivesTraining strategies regarding entrustable professional activities (EPAs) vary from country to country; one such strategy is for residents. However, there are no reports of EPAs developed for residents who rotate...

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

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

Developing Entrustable Professional Activities for the Training of Translational Scientists: A Modified Delphi Study.

Improved training for translational scientists is important to help address the waste of resources and irreproducibility of research outcomes in current translational medicine. However, there are a lack of training programs that cover the full range of knowledge and skills translational scientists need to develop, and many translational research training programs struggle to develop competency frameworks and assessment tools. Entrustable professional activities (EPAs) have been successfully implemented to link competencies with everyday practice in training health care professionals but have not yet been developed for research training. The purpose of the current study was to develop EPAs for translational scientists that could be used for their training and assessment and help increase the transparency and reproducibility of research outcomes and methods by providing best practices for translational research. In 2019, a modified Delphi technique, preceded by a focus group held in 2018 using a nominal group technique, was used to reach consensus on EPA titles and content among an international panel of 22 translational experts. Mean, standard deviation, and level of agreement were calculated after each round. Consensus was defined as ≥ 80% agreement. Consensus was reached on 89% of the items after the first round and 100% after the second round. The final list of EPAs consists of 17 EPAs divided over 7 sections. The concept of EPAs is new to the field of research training. The 17 EPA titles and their descriptions developed in this study may be used as a framework for improved training for translational scientists with the ultimate goal to contribute to closing the gap between bench and bedside, reducing resource waste in science, and increasing the reproducibility of research outcomes.

Development of entrustable professional activities for a physiotherapy undergraduate programme in Singapore

BackgroundThe concept of entrustable professional activities (EPAs) as an assessment framework is new to undergraduate physiotherapy training in Singapore. The physiotherapy community was tasked to develop EPAs to reflect the core professional activities of an entry-level physiotherapist for its undergraduate programme. MethodsA qualitative participatory approach was used to develop entry-level EPAs for undergraduate physiotherapy students. Four phases occurred; (1) formation and training of the EPA writing workgroup from different sectors of the physiotherapy industry in Singapore; (2) conceptualization of the framework; (3) writing EPAs and; (4) iteration of EPAs through reflection, revision and consensus building. ResultsFive core activities were identified for undergraduate physiotherapy students to perform upon graduation and were developed into entry-level EPAs. These entry-level EPAs were subsequently termed as core EPAs to reflect the core practices expected at entry level across specialties and sectors in Singapore. These EPAs were mapped to five competency domains and 12 competency descriptors. The sources of information to support entrustment decisions were (1) short practice observation, (2) entrustment-based discussion and (3) case notes evaluation. Remote supervision was selected as the level of entrustment that physiotherapy students must attain at graduation. ConclusionThe development of EPAs utilized a ground-up and cross-sector approach to define entry-level EPAs as core physiotherapy activities expected to be performed and assessed during clinical training by undergraduate physiotherapy students. Future research is needed to validate the use of EPAs as an assessment framework for undergraduate physiotherapy education.

E-portfolios and Entrustable Professional Activities to support competency-based education in dietetics.

The concept of Entrustable Professional Activities, recently pioneered in medical education, has emerged to support the implementation of competency-based education. Although competency-based frameworks are widely used in healthcare professional education to develop outcomes-based curricula, assessment of student competency in professional placement settings remains challenging. The novel concept of Entrustable Professional Activities together with established methods of competency assessment, namely e-portfolios and self-assessment, was implemented in the "[La Trobe University Dietetic program in 2015-2016. This study aimed to appraise the e-portfolio and evaluate the use of Entrustable Professional Activities to assess competence. A mixed-methods evaluation, using qualitative and quantitative surveys with follow-up structured consultations, was conducted with final year dietetics students and their supervisors. Dietetics students were comfortable with Entrustable Professional Activities and competency-based assessment, whereas supervisors preferred Entrustable Professional Activity based assessment. All stakeholders valued student self-assessment and the ongoing use of structured e-portfolios to develop and document competency. The use of structured e-portfolios, student self-assessment, and the emerging concept of Entrustable Professional Activities are useful tools to support dietetics student education in professional placement settings.

Development and validation of a postgraduate anaesthesiology core curriculum based on Entrustable Professional Activities: a Delphi study.

Background: Postgraduate training curricula should not be based on time-spans or predefined numbers of performed procedures. One approach to link competencies to clinical tasks is the concept of Entrustable Professional Activities (EPA). The goal of this study was the definition, ranking and validation of EPAs for anaesthesiology postgraduate training and the creation of an anaesthesiologic core curriculum. Methods: Anaesthesiologists of different levels of training participated in the study (single-center, cross-sectional) . First, an expert group defined a preliminary list of EPAs. Then a first Delphi round (n= 47 participants) was applied to identify daily anaesthesiology tasks with the goal to define EPAs. From the first Delphi round a new set of EPAs was defined, using the template and mapping method. Through an alignment process, conducted by the expert group, the preliminary EPAs and the new set of EPAs from the first Delphi round were summarised into a new list of EPAs. This list was presented to the study participants in a second Delphi round (n=80 participants), with the goal to validate and rank each EPA and to define the year of entrustment. For this purpose, participants were asked in the second Delphi round if each EPA should be included into an anaesthesiology core curriculum and in which year of training entrustment should take place. Furthermore, they were asked to rank each EPA on a numeric scale, defining its importance. From this numeric scale, the content validity index (CVI) for each EPA was calculated.Consensus of the results from the second Delphi round was calculated, using the one-way random effects model to calculate Intra-Class-Correlations (ICC). Percentages of agreement among the whole set of EPAs of this study and a previously published set of EPAs were computed.Results: A core-curriculum comprising of 39 EPAs was developed. The EPAs were subdivided into superior/high and inferior/low scoring EPAs, reflecting their importance and were mapped to the year of entrustment. The results reached high consensus among the different participating anaesthesiologist groups (overall agreement was 0.96 for the CVI of each EPA and 0.83 for the year in which the EPAs should be entrusted). Agreement with the previously defined set of EPAs was 73.3%.Conclusion: This study provides a further step in transforming postgraduate anaesthesiology training into a more contemporary approach. Other studies are necessary to complete and amend the presented core curriculum of EPA based postgraduate anaesthesiology training.

Las actividades profesionales confiables: una herramienta para hacer operativo el concepto de competencia

La educación de profesionales de la salud ha evolucionado de un enfoque con énfasis en la adquisición de contenidos a uno vinculado al alcance de resultados predeterminados, constituidos por el desarrollo de competencias por parte de los alumnos. En este contexto, surge el concepto de Actividades profesionales confiables (APROC) como una manera de vincular las competencias a la práctica profesional cotidiana y ofrecer una herramienta que permite operativizarlas facilitando la planificación de la enseñanza. El desarrollo gradual de la competencia implica que los alumnos requieren supervisión decreciente, constituyéndose la evaluación de la práctica en una herramienta fundamental para decidir qué tan apto se encuentra un estudiante para llevar adelante una tarea determinada en un contexto concreto y con qué grado de supervisión. Las APROCs ofrecen un modelo concreto de niveles de supervisión que permiten acompañar a los alumnos en el desarrollo de su autonomía minimizando los riesgos para los pacientes.

Bridging the Gap between Undergraduate Veterinary Training and Veterinary Practice with Entrustable Professional Activities.

The transition from being a veterinary student to becoming a member of the veterinary profession is known to be challenging. Despite being licensed directly after graduation, many veterinarians do not feel fully equipped to practice unsupervised when they graduate. The increasing rate of attrition from veterinary practice, and a relatively high percentage of burnout during the first years in practice, has been suggested to be related to a lack of early career support. Over the past decade, medical education has adopted the concept of entrustable professional activities (EPAs). Recently, EPAs have been proposed to restructure veterinary education to help support the transition from veterinary student to practicing veterinarian. Implementing an EPA-based approach could help to bridge the gap between school and clinical practice, potentially preventing veterinary graduates from dropping out early on from what could have been a promising and exciting professional career.

Implementación de actividades profesionales confiables en la evaluación clínica de prótesis removible

IntroductionCurrent educational paradigms in health science education are oriented towards professional practice. This should be reflected in clinical practice assessment, for which the incorporation of Entrustable Professional Activities (EPAs) seems appropriate. For this reason an analysis was made of the validity, reliability, and student perception of these activities, such as the clinical assessment of removable dental prostheses. Material and methodsA quantitative, correlation, non-experimental and cross-sectional study was carried out. The psychometric properties of the instruments developed under the concept of EPAs were evaluated, and a questionnaire was completed to evaluate student perception of the assessment. ResultsAdequate psychometric properties were observed for one of the assessment tools developed. In addition, there was a favourable perception of this tool by the students, highlighting the acceptability of the evaluation and its effective feedback. DiscussionThis study contributes to the use of EPAs on the assessment of clinical skills in dentistry. Its implementation in this group of students provided evidence of its reliability, validity and positive perception on their part.

Entrustable Professional Activities in final year undergraduate medical training - advancement of the final year training logbook in Germany.

Objective: Training in the final year (FY) of undergraduate medical training currently does not adequately prepare students for the independent performance of medical professional activities after graduation. The concept of Entrustable Professional Activities (EPA) offers the opportunity for a competency-based FY training with the focus on medical professional activities.Methodology: In regular meetings, the FY sub-working group of the German Medical Faculty Association (MFT), which includes representatives with clinical and didactic expertise of the Associations of Internal Medicine, Surgery and General Medicine, developed a concept for the competecy-orientated, EPA-based, FY model logbook 2.0. The selection of the units of practice was made in a cross-disciplinary, consensus-orientated discussion process based on the question which medical professional activities a young professional has to master in the inpatient or outpatient working environment.Results: For the FY electives internal medicine, surgery and general medicine, a blueprint of a total of 18 comprehensive, partially interdisciplinary EPAs relating to inpatient and outpatient care contexts were developed. Each EPA was operationalised by a short description, supervision levels were attributed, and the process of transparent entrustment was determined.Conclusions: The concept for a new FY model logbook 2.0 focuses on the interdisciplinary core medical professional activities in an inpatient and outpatient care context, in order to facilitate transition from undergraduate training to professional practice, and to help avoid overload, thus increasing patient safety.

Implementing a logbook on entrustable professional activities in the final year of undergraduate medical education in Germany - a multicentric pilot study.

Objectives: The final year of undergraduate medical education (practical year) should foster the transition from undergraduate medical education to graduate medical education. Medical students in the practical year should be able to assume professional tasks, and supervisors should assign these tasks to them. In this pilot study, a curriculum based on the concept of entrustable professional activities (EPAs) was implemented and evaluated in the disciplines of internal medicine, surgery and general practice at four university hospitals.Methods: n=37 medical students and n=17 supervising physicians at four German university hospitals participated in the implementation study for one trimester. For evaluation purposes, we conducted focus group discussions and telephone interviews and analyzed them following qualitative content analysis.Results: We identified five different aspects as important for implementing the EPA curriculum in undergraduate medical education in the German context: Implementation process of the EPA curriculum and required resources, Entrustment process, Feedback sessions with supervisors, Students’ and supervisors’ role perceptionOverall impact of EPAs on training conditions in the practical year.Conclusion: The study presents a practical implementation of the EPA curriculum in Germany’s undergraduate medical education. Besides the need for time and resources, the concept shows good feasibility and fosters a competence-oriented undergraduate medical education in the practical year.

Mapping an EPA-based comprehensive curricular proposal for UME.

This article was migrated. The article was marked as recommended. In medical education, there have been three important reforms: science-based curriculum, problem-based learning, and competency-based education. Currently, the concept of Entrustable Professional Activities (EPA) goes a step beyond competencies. The aim of this paper is twofold: first, to present a proposal for an EPA-based curriculum for undergraduate medical education, and second, to describe its curricular framework, educational model and organization. This curricular proposal integrates EPA-based education with the foundations of the interpretive epistemology, the constructivist paradigm and the health care transformations. Using Actividades Profesionales Confiables (APROC) as a curricular guideline helps the educators define knowledge, skills, and attitudes; teachers can plan activities that link theory to practice; evaluators can assess the student's performance and provide him with feedback, and Faculty leaders and collaborators can implement projects to improve educational quality. The curriculum proposal includes a flexible modular system, the integration of biomedical, socio-medical and clinical sciences, and a close link between theory and practice. This curriculum puts medical education at the forefront, it favors the comprehensive education of future physicians, and it constitutes a true educational revolution.

Designing Entrustable Professional Activities for Training Health Professional Educators: a Review of Current Practices

Faculty development substantially contributes to improving the proficiency of health professional educators. However, most training programs are designed around institutional or individual wish lists, from which the assessment of teaching competence is often missing, resulting in the decreased effectiveness of the entire exercise. With an increased call in the literature to introduce structured assessment to faculty development, few initiatives have been taken in which entrustable professional activities are utilized in the teacher training framework. The current article aims to review existing teacher training programs that have incorporated entrustable professional activities (EPAs) in their frameworks and aims to provide further insights into how to adopt the concept of EPAs in faculty development. The literature was searched through the electronic Scopus and PubMed databases using the terms faculty development program, faculty training, teacher training, and entrustable professional activities. The literature search was performed from 2005 to 2018. The search yielded 243 articles in Scopus and 236 articles in PubMed. Studies were excluded that focused on the usage of entrustable professional activities in undergraduate or postgraduate clinical training programs. Of the 479 results, only nine were found to be relevant to EPA-based faculty training programs. Introduction of entrustable professional activities to the domain of faculty training is fairly recent. Only two programs were found in our search that used the concept of EPAs in their training frameworks. One is the Master in Health Professions Education program at the University of Michigan (UM-MHPE), and the other is the Fundamental Teaching Activities (FTA) framework designed for Canadian medical teachers. Current practices reveal fascinating insights into the utilization of EPAs for faculty training. Both the UM-MHPE and FTA frameworks effectively address teaching tasks and competencies. However, despite the multipurpose utility of these frameworks, a few limitations may exist. For instance, these frameworks share limited details about EPAs’ content and their utility in assessment protocols. Moreover, specific teaching domains—such as a problem-based learning (PBL) tutor, mentor, and/or researcher—have not been addressed in the current examples. A need remains for an EPA framework design that can cover missing teaching domains.