EPA Thinking - Becoming Entrustable
Learning lessons does not end. There is no part of life that does not contain its
lessons. If you are alive, there are lessons to be learned.
From the book, “If Life is a Game, These are the Rules” by Cherie Carter-Scott, Ph.D.
Course Materials for "EPA Thinking - Becoming Entrustable"
Everything is provided here with free access for a medical school to introduce students to the type of thinking needed to perform the Core Entrustable Professional Activities for Entering Residency (EPAs). Residency programs consider all thirteen EPAs to be essential on day 1 of their postgraduate education. They are derived from a previously determined set of clincal competencies that are required by the ACGME to evaluate progress of resident physicians in the acquisition of clinical skills.
- The current goal is to invite all interested institutions to use the materials for conducting trial courses in EPA Thinking and, where the interest permits, to collaborate with me by pooling Quality Improvement survey data to support a publication.
- At the point of publication, appropriate updates will be made to make the contents here consitent with published information.
- Prior experience with each part of this teaching approach has already worked well in comparable settings here at Texas Tech and at other schools where I have consulted. There are significant increases in both degree of integration and degree of engagement of student participants over time.
Long term goal:
- The long term goal is to facilitate the general awareness that EPA Thinking is simply the outcome of skilled thinking producing skilled learning.
- EPA Thinking can prepare a student to achieve success even prior to medical school because it does not depend on performance of actual clinical activities. Rather, it depicts a way of thinking that is both a practice and a goal.
- In an ideal world, the students in undergraduate medical education will know more about themselves as learners and about the opportunities for EPA Thinking than those who are evaluating them.
- John Pelley
Awareness of the process by which students think and learn is the most important and yet least understood contributor to the acquisition of clinical skill. It is not generally well understood, for example, that people have different preferences for taking in information, for organizing information, for retrieving learned information, for generating alternative hypotheses about a problem, and for prioritizing the likelihood of the most logical hypothesis. As a result, educators tend to have an erroneous belief that students are limited to their current way of thinking and that this limitation can only be addressed through improved teaching and hard work by the students.
- There is ample evidence that students can both strengthen and diversify their thinking skills by teaching themselves through self-regulated deliberate practice. The evidence from brain research has produced several prominent national reports with findings that knowledge of metacognition is the primary means to accomplish this.
- This course in EPA Thinking will guide students in acquiring an awareness that learning results from a specific thinking process, namely the Experiential Learning Cycle (ELC), and that the ELC itself is processed by specialized areas in the brain cortex.
- Knowledge of this learning process is systematically explored throughout the course, and applied to the current curriculum, so that both the students and their teachers can identify individualized strategies designed to build the skills needed for EPA Thinking.
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; it takes a lot of effort to mix them together. Also, it is assumed that you can’t learn clinical thinking unless a practitioner is teaching it and, yet, 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 (including simulation teaching), 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.
In 2005, Dr. Olle ten Cate introduced the neologism, ‘entrustability.’ He viewed entrustability as a property of a professional activity. While the rest of the story can be found here, there are some key concepts to highlight. First, entrustability itself is a designation intended to describe activity carried out in health care, not a description of the person doing the work. It therefore does not describe a level of competence or degree of proficiency. Dr. ten Cate suggests instead the use of ‘readiness’ when describing the learner. His purpose is to avoid conflating entrustability with competency, the latter of which can be measured on a scale of the proficiency of the learner. Entrustability is not measured but is used to describe how the activity is conducted. When the AAMC EPA Drafting Committee provided a description of both pre-entrustable activities and entrustable activities, it became obvious that the thinking for how each is conducted is dramatically different. This led to my concept of entrustable 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 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 (or resident) 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 also 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 already develop EPA Thinking anyway, 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 education 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:
- Identify a behavior from the pre-entrustable description for this EPA in the AAMC Faculty and Learners’ Guide.
- What type of thinking is associated - novice/robotic or integrative/anticipatory?
- Where do you think the information for this EPA is addressed in the preclinical curriculum?
- Identify a behavior from the entrustable vignette for this EPA. What type of thinking is associated?
- What is the corresponding study behavior for this EPA?
- Show how ESPeak Mapping helps to develop the skills needed for this EPA.
- How does deliberate practice apply to this situation?
- How does Jungian type apply to this situation?
- Where is the information required for this EPA learned in the basic science courses?
- Where is the thinking required for this EPA learned in the basic science courses?
The curriculum time needed is between one and 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 at this location. 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.