FAQ: Milestones and EPAs
EPAs are developed by your specialty committee. The EPAs for each discipline can be found in the Royal College ePortfolio. Each resident will see the complete list of all EPAs by stage in their Program Learning Plan.
In Competence by Design (CBD), learners are empowered to initiate observations.
CBD also allows two other groups to initiate observations, the clinical supervisor, and a program director or administrator.
There are a variety of EPAs defined for each stage of training by your national specialty committee. Selecting an EPA depends on what tasks are being done clinically that day. EPAs may be selected by the learner, the clinical supervisor or even the program administrator; but they should be relevant to the current educational experience, clinical environment and the resident’s progress through training.
When a specialty committee defines the EPAs for each stage of competence they also provide guidelines as to the breadth of observations that provide enough information about the resident’s performance to make decisions about competence. This may include specific patient conditions, clinical settings, illness severity or observer roles. The breadth established by the specialty committee is a guideline, not a requirement. Your program or competence committee may be ready to make decisions about the resident’s progress with more or less information. Ultimately the decision as to whether or not there is sufficient data to promote a resident to the next stage of training is determined by the program’s competence committee.
No, even if you observed a resident successfully complete an EPA, you will only comment on the trainee’s ability in that setting, on that day.
Each specialty committee has developed an assessment strategy, which includes a suggested breadth of required successful observations to support the determination of competence. It will be the responsibility of a program’s competence committee to use the EPA feedback you have provided, in addition to feedback from other faculty who have observed the trainee performing these EPAs in a variety of circumstances. Together, this information will allow a competence committee to make a determination of a trainee’s performance in a specific EPA and ultimately to decide on their readiness for promotion.
Some EPAs are quite broad, and may take place in different settings (e.g., part in the ER or a clinic, and part in the OR). As an educator you may frequently observe only a portion of an EPA. Although you may not be able to comment on the entrustment of the entire EPA, you can still provide feedback on the trainee’s performance to facilitate progression or reinforce what they are already doing well.
It is important to keep in mind that feedback is a necessary component of this model of training, which is focused on coaching the resident with a goal of achieving competence. Feedback should always be given regardless of whether or not an entire EPA was observed—the more information that a trainee and the competence committee have the better. The key to both a trainee’s learning and the determination of competence is your feedback.
A common concern raised by busy frontline faculty is finding time for observation. However, you are always observing your resident’s clinical performance as part of your responsibility to provide safe patient care. For the purposes of teaching, learning and assessment there may be times when you choose to do that by direct observation.
In some circumstances, direct observation is most appropriate. For example, to provide appropriate supervision and teaching it may be necessary to directly observe procedural skills, communication skills and physical examination skills.
However, other skills, such as case formulation or clinical decision-making, may be best observed through reviewing a case with the resident and/or reviewing the clinical documentation.
- In the clinic, a trainee independently completes a history and physical and presents the case to you. You can infer their understanding of the patient’s presentation and interpretation of the findings and investigations by their case synthesis and presentation, their ability to answer pertinent probing questions about the case, how the presented information aligns with your review of the results or imaging. As faculty, you can still provide valuable feedback using these indirect observations.
- Nurses on the floor may provide you information with respect to a trainee’s interaction or management of a patient, which may to some degree inform your observation of the EPA. This is extremely useful as we need to know how our trainees perform when we are not there (e.g., do they communicate with the nurse the same way regardless of us watching).
A procedure is a specific discrete action or course of action. A procedure may be a discrete EPA (performing a tonsillectomy) or may be part of a broader EPA (managing patients with tonsillitis).
The Royal College’s ePortfolio system contains national assessment templates. Other systems may have their own proprietary assessment forms. These forms can also be accessed through your PGME office or CBME Lead.
The national assessment templates are integrated into the Royal College’s ePortfolio system. In the ePortfolio, the system will only display the assessment forms defined for each EPA by the specialty committee.
As some schools have opted to use software from an alternate vendor, (not the Royal College’s ePortfolio system) they will use some variation of these templates. In either case, there is a designated assessment template to be used for each and every EPA being observed.
By opening your ePortfolio account you will have access to the EPAs and assessment forms for your program. Filling out the form and clicking on the submit button will make the observation available to you, the trainee, the program director, and the competence committee.
As some schools have opted to use software from an alternate vendor, (not the Royal College’s ePortfolio system) you should check with your vendor or PGME office on how to submit an assessment form.
There are various approaches to ensuring that off-service observers are prepared to support CBD. Some programs are planning to target their peer faculty development efforts on a small specific group of off-services observers who are keen to be involved in CBD. Some programs will target senior residents in the off-service rotations while other programs will be selective about when they choose to observe EPAs (i.e. EPAs may not be observed on certain rotations).
In CBD, the competence committee will exercise judgment in making progress decisions: i.e. they will use specialty defined EPAs and the expected breadth of observations as a guideline to determine that each resident has achieved the appropriate level of performance before being promoted to the next stage. Promotion decisions on EPA achievement are determined within the group decision making process of a competence committee based on the evidence provided by multiple individual teacher-learner interactions. The key is that the committee must feel it has adequate information on the EPAs to make holistic judgments on the progress of the resident.