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Letters to the Editor

In Reply to Lomis et al

Krupat, Edward PhD

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doi: 10.1097/ACM.0000000000002082
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Having written my critique of the Core Entrustable Professional Activities (EPAs) to generate discussion about using the EPA framework in undergraduate medical education, I welcome the comments of Drs. Lomis, Obeso, and Whelan. I have the greatest respect for educators who devote time and effort to making the EPAs work, and I fully share their concerns regarding the advancement of patient safety and welfare and the control of costs. Nonetheless, my views differ substantially from theirs.

First, Lomis and colleagues make no mention of perhaps the most fundamental of my concerns, that the EPAs have a blind spot for those elements of medicine that have at their heart compassion and humanism, communication and trust. We are told that these are not measurable professional activities and therefore are not focused upon, but a quick look at the extensive literature available through organizations such as the Academy on Communication in Healthcare and the Arnold P. Gold Foundation quickly puts this myth to rest.

Next, Lomis et al indicate that I believe “medical educators are too easily distracted to manage the dual frameworks of competencies and EPAs.” Their wording suggests, perhaps unintentionally, that I do not have sufficient faith in medical educators, when in fact I noted that the ability to focus on two perspectives, however complementary, runs counter to long-established, universal principles of human perception. Overseeing assessment at Harvard Medical School for many years, I have reviewed scores of assessment forms, and almost none have contained hybrid ratings. Further, faculty around the world complain about the demands of assessing students using one framework, no less two. While competencies and EPAs are perfectly complementary in principle, they rarely coexist in practice.

Lomis et al acknowledge that they “are acutely aware of the variability in scope among the 13 Core EPAs.” Recognizing this, why have medical educators not gone back to expand, revise, and tweak these EPAs rather than accepting their imperfections? These 13 Core EPAs seem to have been set in concrete very quickly. Although the analogy is imperfect, rather than accept the diagnostic categories of mental illness as if they were handed down at Mt. Sinai, psychiatrists revise the Diagnostic and Statistical Manual (DSM) every so many years, asking trainees and clinicians to break their old mind-set and work within a revised framework. Why can the medical education community not take the DSM approach, especially given the concerns that I—and many others—have expressed about the Core EPAs?

Methodologically, I continue to believe that as clinical educators we should ask ourselves serious questions as to whether assessment via entrustment, however intuitively appealing, is likely to remain subjective and potentially biased, despite heroic efforts by the Association of American Medical Colleges and others. Finally, on the matter of “prematurely abandoning the EPA effort,” as expressed by Lomis et al, I ask us to consider how to tell the difference between abandoning something fundamentally valuable too soon versus staying with something fundamentally flawed too long.

Edward Krupat, PhD
Associate professor, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; e-mail:

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