We appreciate Dr. Brown’s thoughtful concerns regarding our recent evaluation of the Association of American Medical Colleges’ Core Entrustable Professional Activities (Core EPAs) for Entering Residency. We agree that a medical school curriculum must include instruction on retrieving evidence, collaborating, and prioritizing patient safety. These domains are not, however, what we do (EPAs) as much as they are how we do it (competencies). Although they are important competencies, they are not tasks that can be entrusted. If entrustable tasks and competencies are conflated, the Core EPAs will not live up to their promise of realizing competency-based medical education. Fortunately, reconciling this problem remains feasible.
First, we must acknowledge that EPAs cannot subsume all that is medicine. Medicine requires a wide range of knowledge (e.g., an understanding of glucose metabolism), skills (e.g., the ability to retrieve evidence and to collaborate), and attitudes (e.g., “do no harm”). Even though these competencies are not EPAs, they are all paramount to the art of medicine.
Second, EPAs must map to the competencies that underpin each activity. If a student is told they are only allowed to observe a task, they will reasonably ask, “Why?” The answer will require a reference to the competencies that the student must possess to participate in the activity. This explicit connection will provide context to fundamental competencies that may otherwise appear abstract. The curricular mapping of competencies to each EPA ensures competencies have a clear and meaningful role in day-to-day assessments and, critically, in providing actionable feedback to the learner. Improving the quality and safety of health care will not be achieved by rebranding such competencies as EPAs, but by linking those competencies to the routine and repeated assessment of EPAs.
For example, if Core EPA 13 was redefined as “identifying and reporting patient safety concerns,” it would be an essential task that could be entrusted to a student. Additionally, the enhanced clarity of this task, combined with mapping to related competencies, would better inform curricular development, helping determine where and how students acquire the competencies required to ensure patient safety. Core EPA 9 (collaborate as a member of an interprofessional team), on the other hand, would be difficult to fix, as it describes a skill that is a means to an end. In medicine, we do not collaborate just to collaborate—we do so to deliver health care. Fortunately, most of the other Core EPAs require interprofessional collaboration and should provide ample opportunities to assess this important competency.
The AAMC Core EPAs are a well-informed and thoughtfully crafted first draft of what is needed to start residency. The promise is still there. The time for revision is now.