Working with entrustable professional activities in clinical education in undergraduate medical education: a scoping review

Pinilla et al. BMC Medical Education (2021) 21:172 https://doi.org/10.1186/s12909-021-02608-9 RESEARCH ARTICLE Open Access Working with entrustable professional activities in clinical education in undergraduate medical education: a scoping review Severin Pinilla1,2* , Eric Lenouvel1, Andrea Cantisani3, Stefan Klöppel1, Werner Strik3, Sören Huwendiek2 and Christoph Nissen3 Abstract Background: Entrustable professional activities (EPAs) are increasingly used in undergraduate medical education (UME). We conducted a scoping review to summarize the evidence for the use of EPAs in clinical rotations in UME. Methods: We searched multiple databases for scoping reviews based on the PRISMA guidelines for articles reporting qualitative and quantitative research, as well as conceptual and curriculum development reports, on EPAs in UME clinical rotations. Results: We identified 3309 records by searching through multiple databases. After the removal of duplicates, 1858 reports were screened. A total of 36 articles were used for data extraction. Of these, 47% reported on EPA and EPAbased curriculum development for clerkships, 50% reported on implementation strategies, and 53% reported on assessment methods and tools used in clerkships. Validity frameworks for developing EPAs in the context of clerkships were inconsistent. Several specialties reported feasible implementation strategies for EPA-based clerkship curricula, however, these required additional faculty time and resources. Limited exposure to clinical activities was identified as a barrier to relevant learning experiences. Educators used nationally defined, or specialty-specific EPAs, and a range of entrustability and supervision scales. We found only one study that used an empirical research approach for EPA assessment. One article reported on the earlier advancement of trainees from UME to graduate medical education based on summative entrustment decisions. Conclusions: There is emerging evidence concerning how EPAs can be effectively introduced to clinical training in UME. Specialty-specific, nested EPAs with context-adapted, entrustment-supervision scales might be helpful in better leveraging their formative assessment potential. Keywords: Entrustable professional activities, Undergraduate medical education, Clinical education, Scoping review * Correspondence: 1 University Hospital of Old Age Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland 2 Department for Assessment and Evaluation, Institute for Medical Education, University of Bern, Bern, Switzerland Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Pinilla et al. BMC Medical Education (2021) 21:172 Background Entrustable professional activities (EPAs) have been internationally implemented in graduate medical education (GME) as units of clinical activities that can be entrusted to medical trainees in the clinical workplace [1]. Given that the clinical learning trajectory begins well before entering residency, medical educators have begun to explore how to apply EPAs into undergraduate medical education (UME) as well [2]. Ideally, the intensity of supervision and, inversely, the degree of independence, should change during and with each clinical rotation of medical students. EPAs, as competency-based learning goals, take a central place within competency-based curricula in medical education. However, the rapidly growing literature on EPAs in UME has not been synthesized from the perspective of clinical educators in UME. Globally, clinical rotations represent a foundational element in UME [3]. However, the degree of students’ active participation in both the workplace and curricular design differ considerably across medical education systems [3]. Recently, longitudinally integrated clerkships have been recommended to provide educational continuity [4]. Currently, most medical schools still work with clinical rotations that are limited to a few weeks within given specialties [5]. From an assessment perspective, using summative assessments that are limited to four- to six-week clerkships is not ideal. However, short clinical rotations do provide important formative learning and assessment opportunities for medical students [6]. It is in this context that EPAs could be used to scaffold longitudinal and formative assessment systems, even if clerkship curricula are not longitudinally integrated [7]. Assessment data points collected during these clinical rotations could also inform summative entrustment decisions within overarching assessment programs [8]. Clinical educators represent a key stakeholder group when it comes to working with EPAs in the clinical workplace. In the review by Shorey et al. [9], the authors suggested that educators engaging with competencybased medical education should consider development, implementation, and the assessment of EPAs as discrete steps, and that stakeholder specific recommendations are needed. The review of Meyer et al. [2] addressed the question of assessing EPAs in UME and revealed the inconsistent use of terms and concepts related to EPAs. Furthermore, in general, quality criteria for good assessments have not been sufficiently considered for EPAs in UME. In light of these previous reviews, the rapid growth of literature concerning EPAs, and emerging research on the pre-clerkship use of EPAs as learning goals [10, 11] we searched the literature for articles that provided evidence on how to work with EPAs in workplace-based learning contexts in UME. Specifically, we tried to Page 2 of 10 address the evidence concerning how to develop, implement, and assess EPAs in different specialties and educational systems from a clinical educator’s perspective in UME and to contrast these findings with current best practice recommendations in GME. We also aimed to highlight important research gaps that should be addressed to advance (...truncated)