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Letters to the Editor

Building Trust in Entrustment: Pursuing Evidence-Based Progress in the Core Entrustable Professional Activities for Entering Residency

Lomis, Kimberly D. MD; Obeso, Vivian T. MD; Whelan, Alison J. MD

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doi: 10.1097/ACM.0000000000002061
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To the Editor:

The Core Entrustable Professional Activity (EPA) pilot group appreciated Dr. Krupat’s thoughtful discussion of the Core EPAs for Entering Residency.1 Krupat reiterates several key points raised in our 2017 article.2

We in the pilot, joined by peers across the United States, are working diligently to study the Core EPAs to determine applicability of this framework in undergraduate medical education (UME). The Core EPA initiative aligns with efforts across the continuum of medical education to address the triple aim—lowering health care costs, improving population health, and improving patient safety.

We disagree that medical educators are too easily distracted to manage the dual frameworks of competencies and EPAs. These are complementary approaches designed to provide learners with the clinical experiences, feedback, and coaching necessary to support their development.

Faced with the real work of implementation, we are acutely aware of the variability in scope among the 13 Core EPAs. To promote a shared mental model, our group recently published one-page schematics for each of the EPAs. These summarize the detailed content of the Curriculum Developers’ Guide3 and provide behavioral anchors that describe developmental progression bridging UME and graduate medical education (GME).

We believe the added layer of entrustment is a critical aspect of this framework. Although we acknowledge the need to monitor confounders that could influence the global judgment of “frontline” clinical supervisors, we support ten Cate’s4 premise that we should bring patient welfare to the forefront during assessment. Our pilot EPA colleagues who work primarily in GME are enthusiastic about framing assessment in terms of the learner’s advancing responsibility, and they support explicit attention to trustworthiness. Pilot members share concerns about the quality of new assessment tools and are analyzing data to track the performance of these. We are exploring newer approaches to validity that embrace the challenges of complex systems.5

The pilot group advocates a full exploration of the potential of the Core EPAs. Prematurely abandoning the EPA effort will reduce our ability to establish consistent standards supporting the transition of MD graduates to GME training. Pilot schools have devoted significant resources to this effort, so we certainly agree with the need to study whether learner outcomes warrant that investment. We strive to enable evidence-based decisions regarding the future of the Core EPA framework.

Kimberly D. Lomis, MD
Associate dean, Undergraduate Medical Education, and professor of surgery, Vanderbilt University School of Medicine, Nashville, Tennessee;

Vivian T. Obeso, MD
Assistant dean, Curriculum and Medical Education, and associate professor of medicine, Florida International University Herbert Wertheim College of Medicine, Miami, Florida.

Alison J. Whelan, MD
Chief medical education officer, Association of American Medical Colleges, Washington, DC; e-mail: [email protected]


1. Krupat E. Critical thoughts about the core entrustable professional activities in undergraduate medical education. Acad Med. 2018;93:371–376.
2. Lomis K, Amiel JM, Ryan MS, et al. Implementing an entrustable professional activities framework in undergraduate medical education: Early lessons from the AAMC Core Entrustable Professional Activities for Entering Residency pilot. Acad Med. 2017;92:765–770.
3. Association of American Medical Colleges. Core Entrustable Professional Activities for Entering Residency: Curriculum Developers’ Guide. 2014. Washington, DC: Association of American Medical Colleges; Accessed October 26, 2017.
4. Ten Cate O. Entrustment decisions: Bringing the patient into the assessment equation. Acad Med. 2017;92:736–738.
5. Hodges B. Assessment in the post-psychometric era: Learning to love the subjective and collective. Med Teach. 2013;35:564–568.
Copyright © 2018 by the Association of American Medical Colleges