Entrustable Professional Activities (EPAs)

Conceptualized by Olle ten Cate, "...EPAs are units of professional practice, defined as tasks or responsibilities to be entrusted to the unsupervised execution by a trainee once he or she has attained sufficient specific competence. EPAs are independently executable, observable, and measurable in their process and outcome, and therefore, suitable for entrustment decisions. Sequencing EPAs of increasing difficulty, risk, or sophistication can serve as a backbone for graduate medical education."

EPAs are tasks or actions defined by the specialties of what they expect a graduate of their programs to independently execute with sufficient competence.

EPAs are defined differently across the world. In Canada, the Royal College has a specific definition of what encompasses an EPA. EPAs are also defined at the national level so that all residency programs for a discipline utilize the same set of EPAs.

How were they created?

Each Specialty Committee began a 30-month process before their official implementation of CBD of creating their required CBD Document Suite which includes their discipline's EPAs. Thus, EPAs are standardized across Canada for each specialty and subspecialty. Click here to see the process of the three CBD transition workshops that all Specialty Committees have undergone or will still undergo if they have yet to implement CBD.

Find out more about the educational design process of CBD on the Royal College's CBD Workshops page.

Learn more about EPAs as they pertain to CBD from the Royal College CBD Milestones EPAs and the Competence by Design Cheat Sheet.

Entrustability

This is a key concept that was always inherent in medical training but is now explicitly built into workplace-based assessments in CBME, i.e. EPAs that are assessed on a more frequent basis.

To support growth mindsets, not just for learners but also for teachers, this is a shift in culture and thinking in medical education. The goal is to allow us to think 'how can I do better?' while cognizant of the fact that we need self-compassion as a never-ending sense of 'not good enough' can lead to burnout and the incorrect expectation of perfection.

In CBD, we generally use the O-score which is one type of entrustment supervision scale.

In workplace-based assessments that encompass entrustment decisions like EPAs, it is important to note that these are human interactions and as such there is a rich variation in the individuals involved, the dynamic between the individuals, and the context in which the task or EPA was performed by the resident.

As outlined nicely by ten Cate and Chen, supervisors are consciously or subconsciously making A-RICH decision about a learner's autonomy based on the following qualities of that learner:

  • Agency
  • Reliability
  • Integrity
  • Capability
  • Humility