Entrustable professional activities, emergency medicine and medical education: a systematic review

Abstract

Introduction

Entrustable professional activities (EPAs) are one way to assess competencies, and are designed to bridge the gap between theoretical competencies and real world clinical practice.

Aims

This was a systematic review which aims to answer the question: “Which EPAs related to Emergency Medicine are described for medical schools?”.

Methods

We included original qualitative, interventional and observational studies (cross-sectional, case-control, and cohort studies) that described EPAs relevant to Emergency Medicine for Medical School. The search strategy was created using a combination of keywords and standardized index terms related to EPAs and Emergency Medicine.

Results

The search strategy identified 991 citations. After screening the titles and abstracts, we identified 85 potentially relevant studies. After the full-text review, a total of 11 reports met the criteria for inclusion.

Conclusion

Recognizing a patient requiring urgent or emergent care and initiating evaluation and management is the most common EPA related to Emergency Medicine described at Medical Schools. Use of EPAs is associated with increased student satisfaction and improved competences. However, there is a lack of undergraduate EM specific EPAs being systematically developed and published, and this should be an area to be explored in future studies.

Background

Although Emergency Medicine (EM) has been practiced since ancient times, its recognition has only recently occurred. In this sense, this specialty aims to diagnose and treat patients who require medical care due to an unforeseen condition. In parallel, the Entrustable Professional Activities (EPAs) are a place where knowledge and skills learned during graduation meet professional practice, with the aim to help professors outline the most fundamental pillars to be learned by students and really prepare them for clinical practice post graduation. The creation of EPAs in graduate training has been seen in a lot of specialties, notably in EM; these teaching tools greatly assist in the dissemination of knowledge of an eminently practical specialty. However, a structured EM clerkship to graduate scenarios still remains an area of slow growth internationally, resulting in potential gaps and variations of incoming residents and young physicians. For that, this study aims to identify EPAs described for medical schools that are relevant to EM.

Introduction

For several years, medical education has internationally moved to the use of competence based frameworks (CBME), in order to propose a precision education model aimed at realigning medical education and patients’ needs. [1,2,3] More recent evolution of this direction is the incorporation of entrustable professional activities (EPAs), designed to bridge the gap between the theoretical competencies of CBME and real world clinical practice. [1] EPAs provide a holistic approach to expressing curricular outcomes required to perform specific workplace tasks. [1] This approach of training is theorized to decrease the number of trainees that do not demonstrate clinical competence despite excelling in theoretical and practical exams. [2]

The inclusion of EPAs into graduate medical training programs has been seen in internal medicine, family medicine, anesthesia, and emergency medicine (EM). [3,4,5,6] EM has experienced unprecedented worldwide growth in graduate medical education, and programs are incorporating EM experiences in their curricula. [7, 8] Nonetheless, the addition of mandatory, structured EM clerkships in graduation still remains an area of slow growth internationally. [9] A similar situation could result in gaps in EM learning at the undergraduate level, as newly graduated physicians do not meet the expectations required by their level of capacitation. [9]

At medical school, EPAs can be used by supervisors to contextualize competencies in real world practice, to meaningfully assess the progress and capabilities of new graduates, and provide clearer expectations for students regarding the clinical tasks they will be required to perform after graduation [1]. Further, EPAs also offer curriculum developers and teachers tangible goals for aligning teaching and training with clinical practice, across the continuum from undergraduate to graduate [1]. This study aims to identify EPAs described for medical school that are relevant to EM.

Methods

Study design

This was a systematic review which aims to answer the question: “Which EPAs related to Emergency Medicine are described for medical undergraduate training?” This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. [10]

Eligibility criteria

We included original qualitative, interventional and observational studies (cross-sectional, case-control, and cohort studies) that evaluated, exclusively, EPAs about EM applied to undergraduate scenarios, and with undergraduate medical students. Only complete and published studies were included. Conference abstracts, case reports, narrative reviews, and opinion articles were considered for inclusion, and there was no restriction in terms of language or the year of publication.

Search strategy

A strategy for a literature search was developed and executed by study investigators. The search strategy was created using a combination of keywords and standardized index terms related to EPAs and Emergency Medicine. The search utilized descriptors with boolean operators (EPA OR Entrustable Professional Activities) AND Emergency Medicine. Articles that did not applied EPAs to undergraduate scenarios and/or did not were proposed to undergraduate medical students, were excluded.

The search was run in August 2023 and updated in June 2024 in MEDLINE, Scielo, Web of Science, Scopus databases, and Academic Emergency Medicine: Education and Training. Articles published till 1th July 2024 were evaluated. Reference lists of relevant papers and previous narrative reviews were manually searched in order to identify citations that did not appear in the main searches.

Study selection and data extraction

In phase 1, 4 investigators independently screened all titles and abstracts for eligibility. In phase 2, studies considered potentially relevant were retrieved as full text and independently assessed for eligibility. The investigators were not blinded to the authors, journals, or results of the studies. Any disagreement was resolved by consensus in a discussion between the four review authors with a fifth reviewer. Rayyan was used as a tool to facilitate and organize the review process. [11]

Pertinent data were independently extracted and in duplicate for all the studies using a standardized, predefined extraction form. The extracted data included country, study design, journal, impact factor, inclusion and exclusion criteria.

Results

Study selection

The search strategy identified 991 citations (Fig. 1). After screening the titles and abstracts, we identified 85 potentially relevant studies, which may be found by the spreadsheet link that follows: “https://docs.google.com/spreadsheets/d/1UvSk174yLm6XFov8XcmDebJFOo8ww5tGhme6e2qx0Yg/edit?gid=0#gid=0“. After the full-text review, a total of 11 reports met the criteria for inclusion.

Fig. 1

Study selection flow for the systematic review

Study characteristics

The main characteristics of the included studies are summarized in Table 1. Most studies were published in 2016 and developed in the United States of America (USA). The populations involved a range from 9 to 780 medical students.

Table 1 Title, authors, years of publication, journal, qualis and the impact factor of included articles

EM EPAs for undergraduates

The articles cited from 1 to 46 EPAs during their development. The studies, EPAs and their conclusions are summarized in Table 2.

Table 2 Population, study type, aims, EPAs, mainly results and conclusions

Limitations

Limitations of this review relate mainly to the characteristics of the included studies. First, data availability was heterogeneous, and we included studies of different methodologies, from articles that described the creation of a scenario for the application of one EPA [13, 14, 17], articles that described a course’s curriculum [7, 12, 15, 16, 19, 21] and articles that described the self-assessment for executing EPAs [18, 20]. Additionally, most studies reported medical students in different years of graduation [7, 13,14,15,16,17,18,19, 21], however we chose to include two articles which analyzed newly graduated junior doctors [12,13,14,15,16,17,18,19,20] because we found similarities between the supervised first year of graduated doctors and the final years of medical school in some countries.

EPAs are tools essentially linked to undergraduate teaching; while Emergency medicine, in turn, is a specialty. Therefore, in view of this differentiation, Emergency medicine may not reflect what is learned during undergraduate studies, which limits our study.

A possible methodology for searching and developing the present study could have been to search for the Milestones of the Accreditation Council for Graduate Medical Education and carry out their comparison with each EPA found. As we aim to propose a more comprehensive search, we performed the search according to previously described methods.

Discussion

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.

Conclusion

Although the most commonly EPA assessed was “Recognize a patient in need of urgent or emergent care and initiate assessment and treatment,” other EPAs were also identified. Among them, stand out “to treat adult patients with acute chest pain”, “to treat elderly patients after a fall”, “to recognize and propose initial treatment for patients with vital instability”, “to recommend and interpret diagnoses”, “to monitor exams in common situations”, “to develop a management plan”, as well as many others. This identification reflects the wide variability with which EM teaching scenarios are being created around the world. In this sense, a wide range of different needs emerge, which leads, to the creation of different EPAs that seek to meet a specific teaching-learning demand in each location. This meeting might explain why different EPAs in different locations obtained significant student satisfaction and improved their competencies, which strengthened EPAs employment. That should not be composed by only one EPA. In reality, the communion of several EPAs, adapted to the demands of each location of its implementation, would enable a better teaching of EM in graduation.