Entrustment in physician-patient communication: a modified Delphi study using the EPA approach

Younas et al. BMC Medical Education (2021) 21:497 https://doi.org/10.1186/s12909-021-02931-1 RESEARCH ARTICLE Open Access Entrustment in physician-patient communication: a modified Delphi study using the EPA approach Ayesha Younas1* , Rehan Ahmed Khan2 and Raheela Yasmin3 Abstract Background: Competency based curricula across the globe stress on the importance of effective physician patient communication. A variety of courses have been used to train physicians for this purpose. However, few of them link competencies with practice resulting in confusions in implementation and assessment. This issue can be resolved by treating certain specific patient communication related tasks as acts of entrustment or entrustable professional activities (EPAs). In this study, we aimed to define a competency-based framework for assessing patient physician communication using the language of EPAs. Methods: A modified Delphi study was conducted in three stages. The first stage was an extensive literature review to identify and elaborate communication related tasks which could be treated as EPAs. The second stage was content validation by medical education experts for clarity and representativeness. The third stage was three iterative rounds of modified Delphi with predefined consensus levels. The McNemar test was used to check response stability in the Delphi Rounds. Results: Expert consensus resulted in development of 4 specific EPAs focused on physician-patient communication with their competencies and respective assessment strategies all aiming for level 5 of unsupervised practice. These include Providing information to the patient or their family about diagnosis or prognosis; Breaking Bad news to the patient or their family; Counseling a patient regarding their disease or illness; Resolving conflicts with patients or their families. Conclusions: The EPAs for Physician-patient communication are a step toward an integrative, all-inclusive competency-based assessment framework for patient-centered care. They are meant to improve the quality of physician patient interaction by standardizing communication as a decision of entrustment. The EPAs can be linked to competency frameworks around the world and provide a useful assessment framework for effective training in patient communication. They can be integrated into any post graduate curriculum and can also serve as a selfassessment tool for postgraduate training programs across the globe to improve their patient communication curricula. Keywords: Assessment of communication, Competency based education, communication curriculum, Entrustable professional activities, Postgraduate studies, Modified Delphi study, Physician-patient communication * Correspondence: 1 Department of Medical and Dental Education, Shifa College of Dentistry, Shifa Tameer-e-Millat University, Islamabad, Pakistan 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. Younas et al. BMC Medical Education (2021) 21:497 Background Almost a quarter into the twenty-first century, advances in technology have changed not only the way medicine is taught [1–3] but also, the way it is delivered to patients [4]. It would not be incorrect to say that healthcare education and delivery have been revolutionized in the past few decades [5, 6]. However, one core aspect of healthcare delivery remains traditional and occurs millions of times every day in every physician patient encounter: One conversation at a time. These conversations are actually the most frequently executed medical procedures [7–9] and their results may contribute to a large fraction of healthcare utilization [10]. Training students and residents how to partake in these conversations and effectively communicate with patients is now a necessity required by various accrediting bodies [11, 12]. Expertise in interpersonal and communication skills is expected at all levels of medical education. A review of the literature provides evidence of numerous communication curricula [13–15], which use various pedagogies and assessment modalities to develop and foster physician-patient communication. Nonetheless, all these programs are individual or institutional attempts to assess students and trainees for a skill that is universal, and as yet the medical profession has yet to agree on standard procedures or validated tools that may be used for the teaching and assessment of communication skills of the physician with the patient in any undergraduate or post graduate medical training program [16, 17]. Around the end of the last century, medical education witnessed a swift shift from the outcomes- based approach for medical curricula toward the development of competencies, giving ascent to the Competency Based Medical Education (CBME) movement [18]. The basic philosophy underlying CBME was the formulation of a set of competencies or predefined abilities as the outcomes of curricula [19]. CBME provided a shift in prominence away from time-based curricula in favor of needs-based graduate outcomes which were learner centered. Various competencybased frameworks for under and postgraduate medical students were introduced worldwide and over the span of the last two decades, literature both propagating and criticizing CBME has been published [20]. Of the various criticisms of CBME, one of the most widely discussed was the inability of programs worldwide to transform competencies into daily tasks resulting in confusion around their implementation and assessment. Varied implementations of CBME based programs around the globe failed to link the training of medical professionals to their practice [21]. A student can acquire a set of competencies but may be incapable of incorporating them into explicit tasks essential for adept performance. To counter this claim, the concept of ‘entrustable’ professional activities (EPAs) was proposed by Olle Ten Page 2 o (...truncated)