Anyone who’s struggled through high school or university language courses will have observed, perhaps with exasperation, how young children learn to speak those languages quite effectively without the benefit of formal instruction. Growing children blissfully bypass linguistic theory and grammatical rules, and simply start speaking the language, employing a combination of imitation and trial-and-error to find what sounds and phrases produce desired effects. In fact, they may not even be aware that any linguistic conventions or grammatical structures exist. In my high school experience, French-speaking classmates had difficulty passing high school French courses because, as our non-Franchophone French teacher explained, the course was about the French language, not about speaking French. This distinction, lost on myself and the other peri-pubescent males of our rural Ontario community, caused many to abandon all hope for the educational system. There was a gap, it seemed, between formal “book learnin’” and real world skills that would allow people to function effectively and earn a living.
Every discipline, occupation or societal role can be regarded as requiring both theoretical underpinnings and practical application.
The theoretical components consist of the relevant knowledge base and a deeper understanding of the principles on which that knowledge base is established. This may involve learning scientific or abstract disciplines that might seem quite removed from the practical application. Such learning usually resides formally within our educational institutions and is recognized through the granting of diplomas or degrees.
Practical application, in contrast, is pragmatic, workplace-based and performance driven. Knowledge acquisition is more directly related intended purposes, and the ultimate goal is mastery of the specific skills, acts or functions understood to be requisite to the role.
The history of medical education is a story of struggle to balance theory and practice. Initially, medical education was purely a workplace, apprenticeship-based experience. Aspiring doctors worked with established practitioners and at some point, usually established by mutual agreement, were deemed ready to practice independently. The emergence of professional societies provided some external scrutiny and certification of competence. It was the rather profound intervention of the Carnegie Foundation and its sponsorship of the Flexner enquiry and subsequent report released in 1911 that moved medical education firmly into the university setting and established the requirement for fundamental education in the scientific foundations of medical practice.
Today, medical schools continue to struggle with establishing the appropriate balance between theory and practice. Educators ponder the degree to which fundamental science should be provided, the methods in which it should be taught, when and how patient-based experiences should be introduced. Students struggle to find “relevance” in their educational experience, particularly in the early years. A degree of mutual trust is essential to the process.
The emergence of “competency- based” education over the past decade or so is a valiant attempt to bridge the theory/practice gap. The “competencies” are based on the “roles” considered essential to (and characteristic of) the effective, practicing physician. In addition to expertise in clinical medicine and its scientific foundations, communication, collaboration, scholarship, advocacy, leadership and professionalism have been widely and rightfully accepted as attributes of the effective practitioner. Utilizing those attributes as a basis for development and design of a medical educational program may seem logical and appealing. However, on closer inspection, this extrapolation makes two key assumptions that are fundamentally flawed and have resulted in considerable challenges to our programs:
The first flawed assumption is that all competencies can (and should) be taught and learned. Many of the competencies relate to personal attributes, values or qualities. Examples drawn from our own competency framework include:
- The graduate is able to identify honesty, integrity, commitment, compassion, respect and altruism
- The graduate demonstrates respect for patient confidentiality, privacy and autonomy
- The graduate demonstrates respect for diversity, regardless of social, cultural or ethnic background
- The graduate demonstrates engagement in effective and shared decision making
Such objectives can be identified, characterized, used for purposes of selection and even required as a behavioural expectation. However, they are, for the most part, inherent characteristics that can’t truly be “taught”. It’s no more reasonable to expect that any individual can be taught to be a doctor than it is to expect than anyone can be taught to be a star athlete. Certainly good education can characterize the key expectations, contextualize their role and refine their application, but they cannot be developed de novo, regardless of good intentions, diligence and excellent teaching methods. Nonetheless, medical education programs devote precious curricular time and resources in attempts to ensure students possess attributes that, many would argue, should be substantially in place on admission.
The second flawed assumption is that all competencies can be reliably assessed. The medical education community has developed impressive expertise in the assessment of knowledge, skills and even complex tasks. However, the assessment of personal qualities such as interpersonal collaboration, compassion and integrity has not progressed much past the “know it when I see it” stage.
All this has led to a strong sense among both teaching faculty and students that there continues to be a “missing link”, essentially a theory/practice gap between the stated objectives of our program, and the fundamental goal of producing graduates able to excel as postgraduate program trainees and as young physicians.
To address these concerns, the medical education community is beginning to embrace an approach originally proposed by Dr. Olle ten Cate (ten Cate O. Entrustability of professional activities and competency-based training. Med Educ. 2005: 39(12); 1176, and ten Cate O. Trust, competence and the supervisors role in postrgraduate training. BMJ 2006; 333(7571);748).
“Entrustable Professional Activities” have been defined as units of professional practice. As such, they are tasks or responsibilities that trainees are to be able to perform independently by the time they complete their educational program. Importantly, EPAs are independently executable, observable, and measurable. In short, they go beyond what our students should know and be, and articulate in specific terms the things we expect our graduates to be able to do, and form the criteria by which they can be objectively and reliably assessed. The various competencies are necessary components required in order to achieve that EPA. However, demonstration of ability to perform the EPA, not the components, is the necessary final step to qualification.
To illustrate, let’s consider the simple and familiar example of driving a car, which can be considered a societal EPA. In order to achieve that EPA, candidates must master certain competencies, such as understanding the rules of the road, good vision, trustworthiness. Those attributes must be demonstrated or mastered in order to qualify to drive, but the ultimate “test” is the driving test itself.
An example of what might constitute a EPA for medical education might be the ability to perform a history and physical examination appropriate to patients presenting with certain key clinical presentations. That particular activity requires a number of requisite competencies including, for example:
- An understanding of the structure of the normal human body
- An understanding of structural changes that occur in various disease states
- An understanding of the symptoms and signs expected that are relevant to various presentations
- An understanding of the pathophysiologic mechanisms of clinical signs and symptoms
- An ability to communicate effectively with patients from various backgrounds
- The ability to maintain patient confidentiality
- The ability to interact effectively and respectfully with patients and their families
- The ability to understand the clinical utility and predictive value of various physical examination findings
- The ability to manage an interview effectively and efficiently
It becomes apparent from this list that medical expert, communicator, professional and scholar competencies are all required in order to carry out this particular, key EPA. They must all be learned and mastered individually, to be sure. However, individual achievement of each component is insufficient unless they “come together” to enable the learner to perform the fully formed professional activity.
Importantly, EPAs can be developed relevant to the fully qualified physician, and then described relevant to various stages of development. They therefore have the potential to unify the medical education continuum from entry to independent practice readiness.
A number of key organizations either have developed, or are in the process of developing EPAs. The American Academy of Medical Colleges sponsored an international consensus panel that produced a particularly attractive set of 13 EPAs currently being piloted at selected sites. The Association of Faculties of Medicine of Canada, at the suggestion of the Undergraduate Deans, has recently established a committee under the leadership of Dr. Claire Touche that is exploring the development of a common set of EPAs that could be utilized by all Canadian medical schools. The Royal College of Physicians and Surgeons of Canada, is incorporating EPAs as foundational component of it’s Competency by Design approach to postgraduate and continuing medical education.
In the meantime, our schools are likely to engage EPAs more actively as they endeavor to ensure their curricula are relevant to their students, and reliably address the real needs of postgraduate programs and society.
EPAs are the bridge that will take us from theory to practice.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education