EPA Thinking - Becoming Entrustable

Although efforts to introduce clinical teaching earlier in the curriculum have become common, these efforts focus primarily on supervised procedures as preparation for the clinical curriculum.  However, even these early efforts are tempered by the fact that time devoted to clinical education is time that competes with attention to the basic sciences. Like oil and water; both are messy when they are mixed together. Also, it is assumed that you can’t learn clinical thinking unless a practitioner is teaching it and these same practitioners are heavily committed to clinical service. 

However, the more accurate statement is that you can’t learn to apply clinical thinking unless a practitioner is supervising.  While application of clinical thinking can be delayed to the patient care environment, there is still room for methods that could teach EPA thinking earlier and simultaneously improve learning of the basic sciences.  This has the distinct advantage that EPA Thinking is also Step 1 thinking.

EPA Thinking started with a fundamental question from the metacognitive view that, if the brain is designed to convert input into action and if the EPAs are action, then entrustable behavior would be determined by the way the student’s brain thinks.  This is dramatically evident when both the description for each EPA along with the accompanying vignette are inspected. All thought processes that accompany pre-entrustable behavior are described as robotic and generalized while thought processes for entrustable behavior are described as anticipatory, integrative, and situation oriented. This difference in thinking can be taught.

Is it too early to help students do well on their first exam?  Is it too early for students to become self-aware?  Is it too early for them to increase their internal locus of control?  As you can see, early is a very relative term.  When I am teaching a failing student how to gain control, it is never too early.  

In order to learn EPA Thinking, the students will need to understand themselves as learners and as thinkers. The same metacognitive concepts that help mastery of the EPAs will therefore contribute to learning everything else, especially the basic sciences. Integrative learners have a natural advantage through building associative memory.  Also, their self-awareness of learning weaknesses opens the door for deliberate practice aimed at corrective action. The sooner that students learn about the EPAs, the sooner they will become self-directed learners. It is not unreasonable to assume that this will eventually be seen, not as a way to compete for residency, but as a way to compete for medical school admission itself. Any applicant to medical school who is conversant about the EPAs relative to their own learning will make a stronger impression than those who aren’t.

If students develop EPA Thinking as a normal outcome of clerkship training, then why was it necessary for the AAMC to devote the funding resources to convene an EPA Drafting Panel to specify expectations that were not being met “simply by normal clerkship learning?”  The answer to this question is that the development of EPA Thinking has been, and still is being, left up to chance.  It is just as true in medical ecuation as it is in medical practice that, when you avoid dealing with causes, you cede control over the effects.  The causes are not in the teaching of clinical skills, nor in the teaching of clinical reasoning.  The causes of EPA thinking are found in teaching the individual student an awareness of their own learning and how to make that learning entrustable – we must prioritize self-awareness to produce self-regulation and then self-regulation will produce self-actualization.  The neglect of awareness blocks entrustability.

The assumption that students at matriculation have acquired and developed an understanding of how they learn stands as one of the most profound deficiencies in medical education today.  

The following general questions will serve as a core for each session with additional questions added as relevant:

1. Identify a behavior from the pre-entrustable description for this EPA in the AAMC Faculty and Learners’ Guide.
2. What problems are created by a resident who is pre-entrustable for this EPA?
3. Identify a behavior from the entrustable vignette for this EPA. What type of thinking is associated?
4. What is the corresponding study behavior for this EPA?
5. Give an example of behavior for this EPA in ESPeak Mapping.
6. Give an example of this behavior in the ESP Step 1 QuAGs.
7. How does deliberate practice apply to this situation?
8. How does Jungian type apply to this situation?
9. Where is the information required for this EPA learned in the basic science courses?
10. Where is the thinking required for this EPA learned in the basic science courses??
11. How are the areas of your cortex engaged in this EPA?

The curriculum time needed is two hours per month.  Lecture preparation is zero, and minimal review of the materials will suffice to guide the conversation – the teaching modality is the flipped classroom for 10-12 member groups and all materials are available with free access online.  The materials include a course syllabus, mentor’s notes, student question sets as homework to be presented in class, the materials for the Expert Skills Program at the SuccessTypes website, the AAMC Faculty and Learner’s Guide, and a suggested QI survey to assess both student and mentor experiences.  No training is needed and no special knowledge that is not already in the materials is needed.  Every aspect of this system has been successfully implemented in other venues, e.g. the TTUHSC Family Medicine Clerkship where the flipped classroom was substituted for lectures.  More details are available in the EPA Thinking Course syllabus.

No.  In fact, if you want to conduct your own study on a variation of this project in your own direction, I will still consult with you as colleagues and share materials.  My main purpose in collaboration is to gather enough pilot study experience from different venues to publish the EPA Thinking Course on MedEdPORTAL.  This will disseminate the information needed to encourage widespread adoption.  Once adopted it will be self-perpetuating and not dependent on any one person for its availability.  Innovation is rather pointless if it cannot be sustained.  

I would expect to continue publishing more complete materials here as I get feedback from collaborators over the years.  I also think it is inevitable that studies will branch out in new directions and it would be helpful if there was a formal core, or seminal, publication to use as a reference.  

It is my hope that publication credit to collaborators can help with their careers and open up new directions from new ways of thinking about learning in medical education.

The list of links below should get you where you want to go.

1.  Getting Started Guide (updated 6/2019)

2.  Course syllabus

3.  Course modules (complete through EPA 4)

4.  Sample observation form

5.  Sample survey questions

6.  EPA Thinking Course generic curriculum proposal

7.  EPA Faculty and Learner Guide