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Letters to the Editor

Narrow Phrasing Is Not Always Best: In Defense of Core EPAs 7, 9, and 13

Brown, David R. MD

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doi: 10.1097/ACM.0000000000003992
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To the Editor:

I agree with Meyer and colleagues 1 that the Association of American Medical Colleges’ Core Entrustable Professional Activities (Core EPAs) for Entering Residency are due for an update. Nonetheless, I am concerned about the potential implications of the authors’ conclusions. The Core EPAs aim to define “the foundation of the MD degree,” 2 but Meyer and colleagues seem to disagree that all of them are foundational. The authors write that Core EPAs 7 (form clinical questions and retrieve evidence to advance patient care), 9 (collaborate as a member of an interprofessional team), and 13 (identity system failures and contribute to a culture of safety and improvement) “may not be entrustable, essential, and important tasks of the practice of medicine.”1 They note that EPA 9 in particular “does not appear to have a clear curricular role.” 1 Although these 3 EPAs are more complex and less straightforward than other EPAs, I cannot imagine a modern MD degree program that does not include a “clear curricular role” for evidence, collaboration, and safety. Efforts to insist on purity of the EPA wording highlight a potential limitation of the EPAs themselves.

The gap in “readiness” of new graduates will not be solved by narrow framing of medicine into a series of brief technical, observable moments or by wordsmithing the Core EPAs to be more discrete. The mismatch in expected roles between student and resident involves numerous larger issues. 3 Meyer and colleagues’ critique of individual EPAs is that they are not specific, discrete, or time limited enough. Nonetheless, EPA 9 (interprofessional collaboration) is central to the practice of modern medicine. If EPAs cannot be used to frame interprofessional collaboration, then EPAs may not be the advance many hoped they would be, and advancing competency-based medical education may require a primary focus on competency milestones rather than EPAs. The more narrowly EPAs are framed, the more there is a need for other forms of assessment. EPA 9 has a general wording that allows it to be applied to many specific interprofessional settings. Arguably, EPAs 7 and 13 are similarly worded for broad application.

After 6 years, an update to the Core EPAs is due. I believe there needs to be more emphasis on patient education and counseling. Nonetheless, if collaboration is not included, it will represent a retreat from the mission of the original Core EPAs to “improve the quality and safety of the care that new residents provide to patients.” 2

Acknowledgments:

The author would like to acknowledge the members of the Core EPA Pilot and the AAMC staff for their inspiration and support.

References

1. Meyer EG, Taylor DR, Uijtdehaage S, Durning SJ. EQual rubric evaluation of the Association of American Medical Colleges’ core entrustable professional activities for entering residency. Acad Med. 2020;95:1755–1762.
2. Englander R, Flynn T, Call S, et al. Toward defining the foundation of the MD degree: Core entrustable professional activities for entering residency. Acad Med. 2016;91:1352–1358.
3. Ellis PM, Wilkinson TJ, Hu WC. Differences between medical school and PGY1 learning outcomes: An explanation for new graduates not being “work ready”? Med Teach. 2020;42:1043–1050.
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