Editor’s Note: This post is the second of two on the topic of competency-based medical education. Read the first post here.
By: Robert Englander, MD, MPH, Terri Cameron, MA, Amy Addams, Jan Bull, MP, and Joshua Jacobs, MD
Dr. Englander is the former senior director of competency-based learning and assessment at the Association of American Medical Colleges (AAMC). Ms. Cameron is director of curriculum programs at the AAMC. Ms. Addams is director of competency-based admissions at the AAMC. Ms. Bull is lead specialist in competency-based learning and assessment at the AAMC. Dr. Jacobs is senior director of electronic portfolios at the AAMC.
Our first blog post focused on outlining the three steps to developing a competency-based medical education (CBME) system. We provided some key definitions and explained Steps 1 and 2.  After defining the desired outcomes (Step 1) and their performance levels (Step 2), the third step in shifting to a competency-based system of education is to develop a framework for assessment. An emerging approach to meaningfully assess a learner’s performance is through entrustable professional activities (EPAs) that place assessment in the context of the workplace. [2,3]
EPAs are the essential day-to-day activities of a specialty or a profession that an individual must be trusted to perform without direct supervision (for the undergraduate to graduate medical education transition) or in unsupervised practice (for the graduate medical education to practice or fellowship transition). These activities are observable and measurable. EPAs require the integration of competencies—usually across domains—and thus can be mapped to those competencies and measured by their milestones that are critical to a supervisor’s decision to entrust a learner. The interrelationship among EPAs, competencies, and milestones is depicted in Figure 1 below. EPAs map to two or more domains of competence (DoC), and to one or more competencies (C) in those domains. Demonstration of the individual competencies can be measured by their milestones (M). However, it is the integration of those competencies and their milestones that ultimately determines a supervisor’s willingness to trust the learner to perform the EPA without supervision.
Figure 1: Relationship between entrustable professional activities (EPAs), domains of competence (DoC), competencies (C), and milestones (M).
While the decision to entrust an individual with an EPA is binary, learners display developmental progression to entrustment that is often described by the level of supervision required for the task (e.g., cannot perform under any circumstances, can only perform under direct supervision, can perform under indirect supervision, or can perform unsupervised). The ability to perform the task without direct supervision has been suggested as the point of entrustment for a medical student transitioning to residency, while the ability to perform the task unsupervised is the point of entrustment for the resident transitioning to practice or fellowship.
EPAs are being adopted as a framework for assessing competence in undergraduate medical education in the United States, at least in part as a result of the recent AAMC publication of the Core EPAs for Entering Residency.  Additionally, EPAs are the framework for graduate medical education assessment and progression decisions for ob/gyn in the Netherlands and for psychiatry in New Zealand and Australia. In the United States, internal medicine and pediatrics have already published their lists of EPAs for the practicing physician, and many other specialties are in the process of doing the same. More information about competency-based medical education and admissions and the core EPAs for entering residency can be found on the AAMC website.
1. Carraccio C, Wolfsthal SD, Englander R, Ferentz K, Martin C. Shifting paradigms: From Flexner to competencies. Acad Med. 2002;77:361-367.
2. ten Cate O. Entrustability of professional activities and competency-based training. Med Educ. 2005;39:1176-1177.
3. ten Cate O, Scheele F. Viewpoint: Competency-based postgraduate training: Can we bridge the gap between theory and clinical practice? Acad Med. 2007;82:542-547.
4. Association of American Medical Colleges. Core Entrustable Professional Activities for Entering Residency (Updated). 2014. https://www.mededportal.org/icollaborative/resource/887. Accessed May 26, 2015.