Milestones, EPAs, and NAS

Internal Medicine End of Training EPAs

Entrustable Professional Activities

At the 2012 APDIM Spring Conference, the AAIM Education Redesign Committee proposed a draft set of entrustable professional activities (EPAs) to help program directors achieve the goals of competency-based medical education. Using feedback provided by members of the AAIM community, the AAIM Education Redesign Committee revised and slightly expanded this list of EPAs to include 16 activities that constitute the core of the profession.

  1. Manage care of patients with acute common diseases across multiple care settings.

  2. Manage care of patients with acute complex diseases across multiple care settings.

  3. Manage care of patients with chronic diseases across multiple care settings.

  4. Provide age-appropriate screening and preventative care.

  5. Resuscitate, stabilize, and care for unstable or critically ill patients.

  6. Provide perioperative assessment and care.

  7. Provide general internal medicine consultation to non-medical specialties.

  8. Manage transitions of care.

  9. Facilitate family meetings.

  10. Lead and work within interprofessional health care teams.

  11. Facilitate the learning of patients, families, and members of the interdisciplinary team.

  12. Enhance patient safety.

  13. Improve the quality of health care at both the individual and systems level.

  14. Advocate for individual patients.

  15. Demonstrate personal habits of lifelong learning.

  16. Demonstrate professional behavior.

These EPAs are written from the perspective of a resident who is ready to enter into unsupervised practice. Accordingly, they are not intended to capture every entrustment decision that occurs over the course of residency training. To present a manageable list and allow flexibility in how programs assess resident competence, some of these EPAs are intentionally broad.

Moving forward, program directors and other groups within and external to AAIM may wish to develop series of discrete EPAs that, in aggregate, inform a more broadly defined end of training EPA. For example, a program may elect to take end of training EPA #8 Manage transitions of care and define component EPAs such as "develop safe discharge plan" or "ensure safe handoffs between caregivers" that inform the broader end of training EPA. Programs may also wish to apply these EPAs to existing developmental assessment frameworks such as reporters, interpreters, managers, and educators (RIME) or learner-manager-teacher (LMT). In summary, these EPAs are intended to act as a starting point or guide for program directors in developing meaningful assessments that inform the evaluation of resident competence and ultimately inform educational milestones reporting in the Next Accreditation System.

To further assist program directors in building meaningful assessments and incorporating the End of Training EPAs into residency training, the AAIM Education Redesign Committee has mapped the curricular milestones directly to these EPAs and provided a three step process for building milestones-based assessments.

Building Assessments for an EPA in Three Steps

One key aspect of competency-based medical education is the ability to capture meaningful and authentic work-based assessments of a trainee’s performance. To assist program directors in developing these work-based assessments, the AAIM Education Redesign Committee has mapped the internal medicine curricular milestones to a set of EPAs that trainees should be expected to demonstrate before entering into unsupervised practice.

When building assessments for a particular EPA, the committee recommends following a three-step process using the EPA mapping document (MS Word).

Step 1

Describe the activity and the tasks required of the resident for a faculty member / program director to entrust this activity to a trainee. This step is crucial at helping faculty and trainees understand the context of what is expected of the trainee. It begins the conversation about expectations and helps all parties to develop a “shared mental model” of the desired performance. Ideally, the description and tasks will be evidence-based and informed by the knowledge, skills, and attitudes required of physicians to meet the outcomes expected of the future health care system. Without this step, faculty may agree upon or state understanding of common words on a page but still have differing ideas of expected performance from a trainee. Examples of step 1 have been provided for EPA #1, EPA #8, and EPA #10.

Step 2

Using the abbreviated list of curricular milestones (i.e. list of 142) provided in the table, the faculty / program director are encouraged to identify those milestones that best inform assessment of the description and tasks identified in step 1. (The mapping document contains agreed-upon abbreviations for the curricular milestones presented at the 2012 APDIM Spring Conference.) Remember, there is typically overlap in many of the curricular milestones, therefore, it is not necessary to choose every potential milestone when building an assessment for an EPA. The milestones chosen should be tailored to a specific residency program based upon the local resources, rotation structure, and existing culture. Choose those milestones that will help faculty assess for competence in a trainee and make a decision regarding entrustment for the chosen activity. While there are not necessarily right or wrong milestones, it remains important to make decisions based upon the knowledge, skills, and attitudes required of physicians to meet the outcomes expected of the future health care system.

Step 3

Apply the curricular milestones identified in step 2 to a particular assessment method or assessment tool. The preferred assessment methods provided by ACGME include direct observation, multi-source feedback, and chart audit. Some program directors will choose to develop and implement new assessment tools while others may choose to overlay the milestones on existing tools and assessment structures. Refer to previous APDIM workshops, posters, and forums for examples on how to develop these assessments. Examples of step 3 have been provided for EPA #1, EPA #8, and EPA #10.