Entrustable professional activities, emergency medicine and medical education: a systematic review | International Journal of Emergency Medicine

In this systematic review, we identified EPAs described for medical school that are relevant to Emergency Medicine.

EPAs have been described as units of professional practice, defined as tasks or responsibilities to be entrusted to a trainee once sufficient specific competence is reached to allow for unsupervised practice. [24] They are independently executable within a time frame and observable and measurable in the process and outcome and therefore can be used to make entrustment decisions. [24]

Even though many EPAs have been created for residency programs, as they would be the training stages for highly specialized professionals, the literature has significantly reinforced EPAs’ use in undergraduate scenarios. Indeed, some articles argue that undergraduate EPAs learning improves medical formation, allowing better professional performance, in order to guarantee greater safety for physicians when developing its services, as well as a greater service quality for the population that is receiving care.

Under this view, USA and Canada recently developed or updated EPAs in Emergency Medicine, and adapted them to undergraduate programs. [22, 25] In most of them, EPAs are divided into levels of entrustment. Level 1: The trainee is allowed to be present and observe but not perform the EPA; Level 2: The trainee is allowed to perform EPA under direct and proactive supervision present in the room; Level 3: The trainee is allowed to perform EPA without a supervisor in the room, but readily accessible if necessary, e.g., with indirect and reactive supervision; Level 4: The trainee is allowed to work without supervision, Level 5: The trainee is allowed to supervise novice learners. [1] Some studies assume that level 1 would be attributable to a young doctor who finished Medical School, reinforcing the importance of its application in undergraduate scenarios. [7, 13–14, 16, 17, 18, 19, 21] Nonetheless, the level of entrustment that medical schools should offer their students may vary according to the country. For sure, Brazil includes EM as a terminal competency in the Curriculum Guidelines for medical courses, whereas in this country newly graduated junior doctors can legally work in Emergency Departments without supervision. [8, 26] In parallel, Europe presents a core graduation curriculum in order to highlight the importance of teaching EM on the continent to prepare their physicians to develop their professional activities [27].

AAMC’s EPA 10 was the most cited EPA in our analysis. It is defined as “Recognizing a patient in need of urgent or emergent care and initiating assessment and management”, and is intrinsically aligned with the idea of ​​EM its expansion and greater use in medical education. [28] Although AAMC EPA 10 is relevant to EM, it is actually a generic, and comprehensive EPA that covers a wide range of areas of medical school. So this EPA should be located in almost all, if not in all areas of undergraduate medical education, as each specialty, within its particularities, may present situations that require emergency patient management.

In this sense, the development of EM-related EPAs for undergraduate studies should take into account their adaptation to more specific scenarios are more associated with clearlier EM activities. For example, caring for an elderly patient who has fallen, an adult patient suffering from sudden chest pain, or even recognizing a patient of a critically ill patient and initiating basic cardiac life support, as presented in some of the studies selected in our review, could align more strongly with EM teaching at undergraduate level, in order to prepare students to carry out activities in environments specifically aimed at managing urgencies and emergencies. Thus, student training would be neither shallow, as it not should be reasoned only on a generic EPA; nor overspecialized, as it deals with emergency cases closely linked to certain specialties.

Ten Cate described in detail how to develop an EPA, including a title, justification, description, link to a relevant competency framework, the knowledge, skills, and attitudes required to undertake the task, sources of information to assess progress and the basis for formal entrustment decisions. [1] Some studies, as Kwan et al. [12], describe approaches for developing EPAs. On the other hand, Jonker el al [15] describes a one-year curriculum based in critical care scenarios and EPAs. In general, all the authors cited reinforce the idea that EPAs must be created according to the needs presented by students and according to the resources provided by their creators and evaluators.

Under this bias, the transition from undergraduate medical education (UME) to graduate medical education (GME) training is a difficult period for many new students. This may be derived to a lack of a competency framework that are reasoned in EPAs along undergraduate education. Furthermore, another explanation may be the absence of a link that aims to promote the vertical integration of competencies across the continuum from UME to GME. [29] This could explain the creation of EPAs such as “Manage a patient with transient loss of consciousness, syncope, coma or seizures”, whose authors state that their scope was to fill a graduation gap; as well as “Evaluation of patients with respiratory insufficiency, and Evaluation of patients with circulatory insufficiency”, whose authors argue that the creation of this EPA facilitates the integration of undergraduate students into post-residency [15, 20].

All studies used simulation scenarios to implement and evaluate EPAs, and there was no description of use of EPAs in health services, such as hospitals or primary care. It is interesting to highlight that only study compared medical students with medical professionals. [20] It noted a significantly gap between the evaluated individuals, reinforcing that neither all medicine school duly train their students, in order to train professionals whose performance does not always meet the demands required. [20] Thus, EPAs implementation would reduce this gap and contributes to a best medical training [20].

As proposed by Czeskleba A. et al., 2019 and Hamui-Sutton, A. et al., 2017 the seven articles of this review 1 highlight that the EPAs implementation can improve the patient’s security [7, 13, 16,17,18,19, 21, 30, 31]. In effect, these articles discuss that the use of EPAs not only allows medical professionals responsible for patient care services to delegate only activities consistent with their students’ capabilities, avoiding possible errors due to overloading them; but also, the students themselves, having precisely described what they need to do and having previously trained the performance of certain skills, tend to develop them with greater mastery, increasing their confidence and the safety of the patients they care for.

Furthermore, all studies that objectively evaluated pre- and post-test demonstrated a significant increase in student skills with training using EPAs. In addition, student satisfaction with the teaching method was relevant, considering that students claim that the EPAs teaching model positively requires them to become more effective in performing the skill in question, as they tend to study more about the subject and truly put it into practice, which gives them more confidence and courage in performing their skills. [14, 17, 18, 21]

Our review found some barriers to EPA implementation in EM undergraduate teaching, such as a shortage of supervisors for training and a preference for activities not related to EPAs by the students. [4] Additionally, the studies examined mainly concentrated on clinical skills, neglecting important aspects of EM like resource management, adaptability, resilience, teamwork, leadership, communication, and ongoing education. [32] In fact, this may be a boundary between the competencies of an Emergency Medicine Specialist and the EM skills that a newly graduated junior doctor needs to have.

Despite this, the studies presented in this review showed solid justifications for adapt and implementing EPAs in undergraduate teaching, as they demonstrated how useful EPAs are in learning clinical practice, to the extent that they make learning truly meaningful for students, allowing them to enter the precision education model in which they truly work within competency-based frameworks that are essential for their professional development [33, 34]. The factors previously highlighted may be a focus of improvement for future projects that aspire to the implementation and development of EPAs at medical school, so that this review can be used as a source of stimulation for more projects on the subject, which can strengthen the discussion on the topic and make it increasingly practical and applicable in the daytime undergraduate course.