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Scholarly Perspectives

Medical Students’ Views on Implementing the Core EPAs: Recommendations From Student Leaders at the Core EPAs Pilot Institutions

Geraghty, Joseph R.; Ocampo, Raechelle G. MD, MS; Liang, Sherry MD; Ona Ayala, Kimberly E. MD; Hiltz, Kathleen MD; McKissack, Haley; Hyderi, Abbas MD, MPH; Ryan, Michael S. MD, MEHP; for the Core Entrustable Professional Activities for Entering Residency Pilot Program

Author Information
doi: 10.1097/ACM.0000000000003793
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Abstract

The transition from medical student to intern/resident is one of the most important for developing physicians.1–4 Yet, new residents can lack the key skills required to care for patients unsupervised on day 1 of residency,1,3,5 creating the potential for adverse effects for patients and health care systems.6 Given the variability in medical school curricula, there is a need to ensure that all graduates regardless of institution meet minimum basic competencies. To improve the medical school to residency transition and ensure consistency in new residents’ knowledge and skills, the Association of American Medical Colleges (AAMC) convened a group of experts to develop the Core Entrustable Professional Activities for Entering Residency (Core EPAs).7

In 2014, the AAMC recruited 10 institutions to pilot the 13 Core EPAs.8 Doing so required support from key stakeholders at each institution, including educational leaders, faculty, residents, and medical students themselves. The recent literature supports developing the knowledge and skills of faculty and educational leaders in the Core EPAs.9–11 Because medical students and residents offer unique perspectives, engaging them as partners in curricular change can enhance the credibility, energy, and success of reform efforts.12–14 In this Perspective, we as student leaders from 5 of the pilot institutions describe key concepts from the implementation of the Core EPAs based on our experiences and discussions with peers.

First, we describe how the pilot institutions engaged medical students. We then identify 6 key tensions encountered in the Core EPAs implementation process and provide examples illustrating 2 opposing solutions to each tension. Finally, we provide recommendations for other schools considering implementation of a Core EPAs-oriented curriculum. By sharing the student perspective, we aim to inform implementation of Core EPAs-oriented assessment and feedback practices across the United States.

To frame this discussion, we use a polarity management model. This framework was first described in the business literature to indicate how leaders can manage the complex dilemmas they encounter within their organizations. By contrasting 2 opposing options, leaders can make a more informed decision.15 The polarity management framework has been applied to medical education as well,16 as many program implementation considerations require a careful balance of trade-offs. Thus, this model is an effective framework for sharing our collective experience in implementing the Core EPAs.

Student Engagement in the Core EPAs Pilot

Student leadership models at the Core EPAs pilot institutions varied based on the local institution’s culture of student engagement. The most common leadership structure involved student representatives from each year of training. Students attended local meetings, served as liaisons between the EPA committees and the student body, and collected and synthesized feedback on the implementation of the EPAs through surveys, focus groups, and town halls with their peers.

Some students assumed more active roles. At one institution, the Core EPAs leadership team empowered its student leaders to design a pilot program that integrated hand hygiene and patient safety education directly into medical student clinical responsibilities. Another institution tasked fourth-year students with developing orientation materials for rising third-year students.

At the national level, these student leaders participated in biannual Core EPAs consortium meetings and copresented work at national conferences. These active roles advanced student ownership of the EPA curriculum, fostered camaraderie, promoted networking, and provided student leaders with valuable perspectives on key tensions worth considering when developing Core EPAs-oriented curricula.

Key Tensions, Approaches, and Recommendations

We (J.R.G., R.G.O., S.L., K.E.O.A., K.H., H.M.) served as student leaders in implementing Core EPAs-oriented curricula and as recipients of the related educational experiences and assessments. Through direct experiences, engagement with peers at our own and other pilot institutions, and in consultation with faculty members, we identified 6 key tensions in implementing the Core EPAs (see Table 1). Two faculty members (A.H. and M.S.R.) facilitated discussions with us and assisted in articulating these tensions and recommendations.

T1
Table 1:
Summary of Tensions, Opposing Polarities, and Recommendations from Medical Student Leaders at the Core Entrustable Professional Activities for Entering Residency (Core EPAs) Pilot Institutions

Tension 1: How and when should the Core EPAs be introduced?

The first tension we identified relates to the debate between the early or “just-in-time” introduction of the Core EPAs in the curriculum. Most students enter medical school with the notion that assessment occurs through periodic, high-stakes examinations. The EPAs center on the construct of entrustment, which is defined as the decision made by a supervisor to trust a trainee to provide patient care.17 Entrustment decisions may be further characterized as ad hoc or summative. Ad hoc decisions are made in the moment when a supervisor determines what tasks a student is allowed to complete, whereas a summative entrustment decision is grounded in evidence accumulated over time.17 Entrustment thus requires a departure from traditional assessment methods18–20 and a significant shift in the medical student mindset.

On the one hand, the Core EPAs construct could be shared with students immediately upon enrollment, providing them with familiarity with the relevant terminology and a foundation that can be built upon throughout their education. Further, using the Core EPA terminology when referring to EPA-related activities would help students become grounded in the lexicon.

On the other hand, entering medical school is a substantial transition. Students come from diverse backgrounds21–23 and must acclimate to the rigor of the curriculum and a wealth of new terminology. Their perceived value of the EPAs may be limited due to the confluence of other factors during this time. There is also concern that socialization of the term EPAs merely fulfills an administrative purpose without affecting learning.24 Practically, it may seem unnecessary to name an already familiar activity (e.g., gathering a history). This challenge is furthered by recognition that many schools use a large cohort of community-based faculty who may be less engaged with the curriculum and Core EPAs’ lexicon.

Approaches.

Pilot institutions introduced the Core EPAs’ framework to medical students early, using specific EPA terminology, then they provided details on an as-needed basis. The most common concept introduced early was trustworthiness.25 At several institutions, rubrics were used in preclinical doctoring and small group courses to measure trustworthiness. Core EPAs leaders described this early introduction as a valuable component of preclinical education.9 For faculty development, some institutions created video presentations while others provided in-person sessions outlining the EPAs, with an emphasis on developing educational leaders (e.g., clerkship directors or members of the dean’s office) rather than frontline faculty who are involved in direct supervision in the clinical setting.

Recommendations.

Given the significant changes to traditional methods of assessment that are required to implement the Core EPAs, students should be introduced to the framework early, and later attempts to reinforce certain components should be repeated as planned redundancies. First-year students should understand the origin and goals of the Core EPAs, the specific terminology, and how the EPAs fit into the goals of medical education. Institutions could connect the Core EPAs with the oaths many students take at matriculation or graduation and engage students in discussion with questions such as “What key skills do you think are necessary for you to become a successful physician?” This activity would allow students to build their own entrustment frameworks under faculty guidance. Later in medical school, individual EPAs should be discussed and assessed.

The context in which the Core EPAs are introduced is crucial, as it can encourage students to see the value of the EPAs and to view them as more relevant to their later experiences. It is less necessary to use the term “EPA” in day-to-day clinical settings than it is to explain the concept in more practical terms that align with the observed activity. Medical schools could incorporate EPA terminology into workplace-based assessments (WBAs), clerkship assessment forms, and objective structured clinical exams. Lastly, faculty should maximize transparency and provide specific steps toward entrustment to build students’ trust in the system and improve their willingness to engage in the entrustment process.

Tension 2: Who is responsible for driving the assessment process?

The second tension concerns whether students or supervisors should initiate the assessment process. In traditional clerkship curricula, assessments are needed to formulate a final grade. Supervisors receive an assessment request, which is then translated into a grade by a clerkship leadership team. The same may not be true in an EPA-centered curriculum. WBAs associated with Core EPAs performance may serve a dual purpose; they can be both summative and formative. Therefore, it is reasonable that students rather than supervisors drive assessment requests, ensuring that students feel a sense of ownership over their progress. In addition, student-driven assessment may alleviate anticipated difficulties with faculty development related to the Core EPAs, such as having to train large volumes of faculty and orient them to new methods of assessment.

A student-driven assessment process also poses risks. Feedback-seeking behaviors are complex and associated with a variety of factors, including the student’s goal orientation, relationship with the feedback provider, and perception that feedback intended to serve in a formative fashion may be summative anyway.26–28 Therefore, students may select encounters for assessment in which they feel their performance would be optimal, rather than those that facilitate learning.

Approaches.

Among the pilot institutions that developed WBAs, students served as the primary drivers of requests for feedback and assessment. While this method fostered student ownership of their progress, it created unanticipated problems. In some settings, up to 50% of assessors did not complete the assessments. When students encountered a reluctant supervisor, they hesitated to request feedback fearing that a poor WBA or “bothering” the supervisor would result in a poor grade. This concern counteracted the growth mindset that the Core EPAs are meant to instill.

Recommendations.

We recommend a model of shared responsibility, whereby students drive direct observations to receive feedback in real time, with additional faculty-driven assessments to summarize performance. It should be made clear to students that the primary purpose of EPA assessments is to promote continued learning rather than to provide an evaluation of what they have learned. We also encourage faculty to consider where assessments are redundant and to consolidate feedback forms into single documents that have institution-specific, standardized EPA assessments. Beyond feedback forms, we recommend open one-on-one or small group discussions between students and faculty to review performance.

Tension 3: What feedback mechanisms are required?

The third tension we identified focuses on whether new EPA-specific feedback mechanisms are needed. When considering how to incorporate bidirectional feedback between students and supervisors, one option is to integrate EPA-based feedback into existing feedback mechanisms. However, EPAs and the concept of entrustment are very different from traditional feedback. EPAs focus on specific skill acquisition, supervision level needed, and developmental progression, thus feedback should be contextualized to guide students in their longitudinal progression toward independent practice.17,29,30 Meanwhile, traditional methods of assessment are often isolated to a particular clinical rotation.

Approaches.

The pilot institutions uniformly agreed to evaluate the potential of WBAs as a feedback mechanism. WBAs provide an integral method for directly observing students’ EPA performance and help initiate feedback conversations.31 However, WBAs on their own do not ensure high-quality feedback. The Core EPAs require a shift in mindset for supervisors to focus more specifically on students’ readiness to perform basic competencies under indirect supervision at the start of residency. WBAs may facilitate this kind of feedback.

Several pilot institutions developed mobile-friendly applications to collect data from student-driven WBAs. This allowed students to self-identify areas for feedback, administrators to collect longitudinal data, and both parties to note progress over time. These mobile applications were intended to minimize disruptions to supervisors’ workflow. However, some students and supervisors perceived the app as an additional bureaucratic requirement, and supervisors were reluctant to give students opportunities to perform the EPAs for assessment. Thus, students were hesitant to request observation, and feedback opportunities were limited.

Recommendations.

Feedback is best provided in a one-on-one setting, focused on actionable behaviors, and from a credible supervisor who has established a sense of trust with the student. Feedback should address both students’ strengths and their areas for improvement, be provided in real time, and have appropriate follow-up with faculty to ensure growth toward entrustment and accountability.32,33 Although this process may work well in longitudinal models of training,34 the same principles may be applied to other clerkship models. This process of soliciting and providing feedback should not disrupt or overburden students or supervisors. The organization of the feedback mechanisms does not matter, but there should be a designated group of invested faculty who can help students process feedback.

Tension 4: What systems are required for advising, mentoring, or coaching students?

The fourth tension addresses whether entirely new mechanisms of advising, mentoring, or coaching students are needed. Academic advising is an important part of any medical school.35,36 Institutions have adopted a number of advising methods, such as mentoring,37 coaching,37–40 and learning communities.41 Facilitating a longitudinal view of student performance through coaching is a key part of the Core EPAs framework.8 A potential benefit of incorporating EPA-oriented coaching into existing programs is the opportunity to capitalize on current resources and enhance ongoing relationships between students and faculty. Yet, EPA-focused coaching has a different purpose than other models of advising, mentoring, and coaching; therefore, there may be advantages to creating new programs instead of relying on existing models.

Approaches.

The pilot institutions began with a variety of existing advising, coaching, and mentoring programs. At one school, students were assigned a “portfolio coach” with the goal of developing a longitudinal relationship between the students and faculty. Having portfolio coaches allowed for program assessment and student self-reflection over time.42 Other schools developed programs specifically for the pilot, with students assigned an EPA coach. The intended purpose of the coach/student relationship was to facilitate students’ trajectory toward entrustment.

Recommendations.

Longitudinal relationships between students and faculty allow for an optimal assessment process and encourage a stronger sense of community.37,40 However, we also must consider sustainability and resources. Coaching programs often provide salary support for faculty participants.43 Applying that level of support across an institution for the purpose of facilitating EPA-skill development may be a challenge for many schools. Therefore, while we recommend that institutions foster longitudinal coaching relationships, we also recognize that such relationships must account for available resources.

Tension 5: Should EPA performance contribute to students’ grades?

The fifth tension concerns whether EPA performance should be strictly formative or if it should also inform students’ final grades. Grades provide significant stress for students, particularly in the clerkship setting.44,45 Having strong grades is a common criterion for residency selection.46 On the one hand, there may be value to tying EPA performance to grades. A recent study showed that, while many students believed that the clerkship environment supported mastery learning, more than half felt the environment supported a performance orientation instead.45 On the other hand, there are numerous philosophical and practical challenges to integrating EPA performance into grades. First, EPAs are a form of competency-based medical education and, as such, are considered fundamentally developmental.32 Second, faculty would have to decide what weight EPA-based assessments would contribute to a final grade. While some programs have incorporated EPAs into formative assessments,47 none that we know of have incorporated a student’s level of entrustment into a tiered final grade.

Approaches.

None of the pilot institutions incorporated EPA-based assessments into clerkship grades, given the desire to preserve the developmental mindset of progression toward entrustment. While EPA-based assessments have not been explicitly linked to grades, several institutions developed WBAs and permitted supervisors to review them in a limited fashion when making final summative assessments of students. One institution trained a group of assessors to provide more formal and structured feedback; however, this feedback remained formative in nature.

Recommendations.

EPA-based assessments should be strictly formative. However, we recognize that the same individual providing formative feedback may also provide summative grades. Because of this, regardless of the intent of the assessment, students may choose to practice performance-avoidance behaviors,45 whereby they seek to avoid feedback from certain assessors or related to certain EPAs. We found that students perceived EPA-based assessments to be somewhat summative anyway. However, explicitly linking those assessments to grades may provide added risk to the intended focus on developmental progression.

Tension 6: Should entrustment decisions be tied to graduation requirements?

The final tension we identified is whether entrustment decisions should be linked to graduation requirements or provided to students solely for their self-improvement. Without entrustment decisions, the Core EPAs function simply as learning objectives. Entrustment adds a layer of social responsibility by emphasizing students’ accountability to patients.48 Therefore, one may argue that tying entrustment decisions to advancement, promotion, and graduation is foundational to the entrustment concept. This approach would also increase student buy-in. However, given that EPAs are a new concept requiring the development and implementation of related new curricula and assessment methods, there is concern that tying EPAs to graduation at this time may be premature due to schools’ lack of experience in EPA assessment and instruments with insufficient validity and reliability.

Approaches.

Most pilot institutions did not explicitly link entrustment decisions to promotion or graduation. However, some used performance related to constructs, such as trustworthiness, to determine readiness for advancement.25 One institution piloted a requirement for entrustment before graduation for one class; however, they reversed that practice for the cohort and did not try it again. Though this decision demonstrated an institutional commitment to an EPA-oriented curriculum, it also raised concerns over the validity of the measurements used to make the entrustment decisions. Instead, the institution opted to display EPA progress in the Medical Student Performance Evaluation as part of students’ residency applications and to send updated EPA assessments to students’ matched programs before graduation.

Recommendations.

Entrustment decisions should not be tied to high-stakes decisions such as graduation until the process has been fully piloted and sufficient instruments have been developed to conduct valid and reliable assessments. While tying entrustment decisions to promotion and graduation may improve student buy-in, these benefits are currently outweighed by the lack of experience with EPA assessments at this time.

Conclusions

The Core EPAs represent an excellent opportunity to realize the full promise of competency-based medical education. However, challenges remain that may be characterized as tensions between 2 opposing options. We have used the framework of polarity management to describe these tensions and offer recommendations, which often lie somewhere in the middle of the opposing options. We hope our recommendations, which were developed by medical students at the Core EPAs pilot institutions, offer a starting point for further discussion and/or formal research to explore the perspectives of students throughout the process of implementing the Core EPAs.

Acknowledgments:

The authors gratefully acknowledge Sally Santen, MD, PhD, for providing a constructive critique of an earlier version of this manuscript. They are also grateful to all the students, leaders, and participants from the 10 institutions piloting the Association of American Medical Colleges Core Entrustable Professional Activities for Entering Residency.

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