Using EPAs for assessment in the Doctor of Medicine Program

In 2017, the Association of Faculties of Medicine of Canada (AFMC) announced the approval of a national process, creating pan-Canadian Entrustable Professional Activities (EPAs) for Canadian Undergraduate Medical Education (UME) to use in curriculum, guiding assessment of future UME graduates. These EPAs are visioned by national UME educators as the set of core abilities that every graduate should perform before transition to residency.

While in its infancy in Canada, these have been used to guide assessment in a handful of American and European medical schools during the past decade.

In Canada, at present only one school, actively uses them and two others are planning for implementation in the next year – in clerkship.

The strategy of EPAs is that they form the backbone of pan-curricular assessment. At the Schulich School of Medicine & Dentistry UME Program, the

plan is for the AFMC UME EPAs to be rolled out across all four years of the new curriculum over starting with the September 2019 academic Year 1 courses.  

The EPAs for UME students were outlined in the AFMC Report distributed in September 2016.

The twelve EPAs for undergraduate medical education include:

  • Obtain a history and perform a physical examination adapted to the patient’s clinical situation
  • Formulate and justify a prioritized differential diagnosis
  • Formulate an initial plan of investigation based on the diagnostic hypotheses
  • Interpret and communicate results of common diagnostic and screening tests
  • Formulate, communicate and implement management plans
  • Present oral and written reports that document a clinical encounter
  • Provide and receive the handover in transitions of care
  • Recognize a patient requiring urgent or emergent care, provide initial management and seek help Communicate in difficult situations
  • Participate in health quality improvement initiatives
  • Perform general procedures of a physician
  • Educate patients on disease management, health promotion and preventive medicine

While similar to the Association of American Medical College core EPA document, created with a panel of educators including Dr. Jay Rosenfield, Vice Dean, Medical Education, they have been adapted to the Canadian UME context.

As the School and the Doctor of Medicine Program transition the UME curriculum to one with a foundation in competency-based education, it’s important to review how EPAs will be used in learner assessment.

We sat down with Dr. Gary Tithecott, Associate Dean, UME to gather more information.

How will EPAs be used in assessment?

EPA’s are the act of being a physician. They represent tangible activities students and faculty can hold to in assessing progression to competency.

With curriculum revision, Schulich Medicine will be one of the early Canadian schools who use the AFMC EPAs as the foundations of assessment of competency across all four years of the curriculum.

Not all EPAs will be assessed in each year of study. Some are positioned for specific years or stages such as Clerkship. Others can be assessed in an ascending manner across each years. It is important to note that the modalities of assessment for the EPAs could differ as more formative or summative depending on a particular stage or course of curriculum, or depending on the context of learning a student is focused on at any given time.

Are the EPAs the same for undergraduate medical education and postgraduate medical education (PGME)?

No, the UME EPAs are different, and for some educators and learners this has proven confusing. Unlike PGME programs, in which there are many EPA’s across the residency years, there are only 12 EPAs for the UME program in Canada. There are 13 in the USA and less than 10 in European countries.

Why is it important to incorporate the EPAs into the assessment process?

EPAs are the enactment of the actions we do each day as physicians. Assessing where a student is situated across the spectrum in achieving those acts is critical to advancement through the years and into residency.

They serve as a tangible act that the student can understand and relate to in their studies across the curriculum. In order to demonstrate competency of an EPA at a defined stage of medical education, a learner must have factual knowledge and clinical skills that allow them to apply that to a care or society scenario. EPAs offer medical education a new and exciting way to show students and faculty achievements and what further education and support is needed to achieve graduation competency.

Will EPAs be the only source of assessment?

No, EPAs will not be the only source of assessment. Many of the other forms of assessment – both formative and summative will continue. There are a number of excellent assessments in place. The change will be a decrease in number, change in timing and advances into integrating content.

When will the School begin using EPAs as a source of assessment in the Doctor of Medicine Program?

We will get started beginning with a trial in some areas of clerkship in September 2018. This will not be across all rotations and there will be trials to help all understand where we should go for full implementation the next academic year.

We will be building from assessment moments in Clerkship that a study by Drs. Boulton and Shepherd undertook documenting these are already happening. The difference is that we will have a much more formal way to document the assessment. In addition the incoming class in September 2019 will be assessed in EPAs starting in the first semester of medical school with the new curriculum.

How will the School be preparing faculty and students for the use of EPAs in assessment?

At this time, there is work between UME. PGME and Continuing Professional Development to develop tools for faculty. Some faculty have expressed an interest in being involved in developing the assessment tools, and we would welcome further participation.

Moving forward we will be providing more details to faculty and providing learning modules to support this approach to assessment. We believe that a lot of the assessments we need exist and will be integrated into an EPA format. Guidelines will be created to support the assessment of the student, how to apply the assessment to different contexts and how to coach students.

Faculty and students can read more about EPAs, the rationale for implementation and the important role they will play in undergraduate medical education by visiting the AFMC website and reading the AFMC Entrustable Professional Activities for the Transition from Medical School to Residency