Competency-Based, Time-Variable Education in the Health Professions : Crossroads

Currently, no standard defines the clinical skills that medical students must demonstrate upon graduation. The Liaison Committee on Medical Education bases its standards on required subject matter and student experiences rather than on observable educational outcomes. The absence of such established outcomes for MD graduates contributes to the gap between program directors' expectations and new residents' performance.In response, in 2013, the Association of American Medical Colleges convened a panel of experts from undergraduate and graduate medical education to define the professional activities that every resident should be able to do without direct supervision on day one of residency, regardless of specialty. Using a conceptual framework of entrustable professional activities (EPAs), this Drafting Panel reviewed the literature and sought input from the health professions education community. The result of this process was the publication of 13 core EPAs for entering residency in 2014. Each EPA includes a description, a list of key functions, links to critical competencies and milestones, and narrative descriptions of expected behaviors and clinical vignettes for both novice learners and learners ready for entrustment.The medical education community has already begun to develop the curricula, assessment tools, faculty development resources, and pathways to entrustment for each of the 13 EPAs. Adoption of these core EPAs could significantly narrow the gap between program directors' expectations and new residents' performance, enhancing patient safety and increasing residents', educators', and patients' confidence in the care these learners provide in the first months of their residency training. Show more

To assess the relative importance of criteria used for residency selection in 21 medical specialties given current available data and competitiveness of specialties. In 2006, questionnaires were distributed to 2,528 program directors in university hospital or university-affiliated community hospital residency programs across 21 medical specialties. Responses were recorded using a five-point Likert scale of importance. Mean values for each item were calculated within and across all specialties. Mean scores for item responses were used to create rank orders of selection criteria within the specialties. To facilitate comparisons, specialties were grouped according to the percentages of positions filled with U.S. medical school graduates. The overall response rate was 49%. With the data from all specialties pooled, the top five selection criteria were (1) grades in required clerkships, (2) United States Medical Licensing Examination (USMLE) Step 1 score, (3) grades in senior electives in specialty, (4) number of honors grades, and (5) USMLE Step 2 Clinical Knowledge (CK) score. The top academic selection criteria are based on clinical performance, with the exception of USMLE Step 1 score. Indicators that reflect excellence in clinical performance are valued across the specialties by residency program directors regardless of competitiveness within the specialty. USMLE Step 2 CK ranks higher in the less competitive specialties, whereas research experience is more prominent in the most competitive specialties. The Medical Student Performance Evaluation was ranked lowest of all criteria by the program directors. Show more

Meaningful residency education occurs at the bedside, along with opportunities for situated in-training assessment. A necessary component of workplace-based assessment (WBA) is the clinical supervisor, whose subjective judgments of residents' performance can yield rich and nuanced ratings but may also occasionally reflect bias. How to improve the validity of WBA instruments while simultaneously capturing meaningful subjective judgment is currently not clear. This Perspective outlines how "entrustability scales" may help bridge the gap between the assessment judgments of clinical supervisors and WBA instruments. Entrustment-based assessment evaluates trainees against what they will actually do when independent; thus, "entrustability scales"-defined as behaviorally anchored ordinal scales based on progression to competence-reflect a judgment that has clinical meaning for assessors. Rather than asking raters to assess trainees against abstract scales, entrustability scales provide raters with an assessment measure structured around the way evaluators already make day-to-day clinical entrustment decisions, which results in increased reliability. Entrustability scales help raters make assessments based on narrative descriptors that reflect real-world judgments, drawing attention to a trainee's readiness for independent practice rather than his/her deficiencies. These scales fit into milestone measurement both by allowing an individual resident to strive for independence in entrustable professional activities across the entire training period and by allowing residency directors to identify residents experiencing difficulty. Some WBA tools that have begun to use variations of entrustability scales show potential for allowing raters to produce valid judgments. This type of anchor scale should be brought into wider circulation. Show more