The Promise and Challenge of Entrustable Professional Activities The competency-based medical education (CBME) framework for training pediatric subspecialists, endorsed by the American Board of Pediatrics Subspecialty Training Task Force, represents a transformative change. 1 Some may ask, “Why do we need to change?” External forces are major drivers, but medicine and the delivery of health care have changed over the past 2 decades, requiring new skills for physicians. 2 MedPAC, the Macy Foundation, and Congress are calling for account- ability for tax dollars invested in Graduate Medical Education. 3,4 CBME has the potential to standardize outcomes to provide accountability by producing physicians who are better prepared to meet 21st century needs. Importantly, CBME has the potential to eliminate the current time-based or “seat-time” model of education, allowing trainees to progress and take on additional responsibilities as soon as they demonstrate competence. Although this may seem like an unattainable Utopia, we believe it is possible. We advocate the use of Entrustable Professional Activities (EPAs) as a framework to help supervisors de- cide when trainees are ready for unsupervised practice. With EPAs, increased entrustment of the trainee to independently perform clinical care occurs as they are assessed to have achieved progressively higher levels of the Milestones associated with the Pediatric Competencies. 5,6 The advantage of the EPA framework is that it places the Pediatric Competencies and the even more granular Milestones into clinical contexts that make practical sense. As their name suggests, EPAs are important, everyday “professional activities” (eg, care of the normal newborn or care of acute illness in an ambulatory setting) that someone can be “entrusted” to perform without supervision. Through the identification of the professional activities of a specialty, EPAs are applicable to both general pediatricians and pediatric subspecialists. Although entrustment is similar to the decisions faculty supervisors make every day about trainees, the formal entrustment decision must be a carefully considered advancement decision based on specific criteria as well as global impressions. Entrustment should not be ca- sual and should not be based solely on number of months of experience. A critical element of entrustment is the concept of trustworthiness for clinical work, which Kennedy et al describe as consisting of 4 dimen- sions: knowledge and skill, discernment of limitations, truthfulness, and conscientiousness. 7 Ultimately the most important consideration with entrustment is the safety of patients in the hands of the person entrusted to perform the clinical activity. In practice, the entrustment decision will only be as good as the data used to make the decision. Entrustment decisions carry significant con- sequences for trainees, training programs, and patients. High-stakes decisions of this type must be made based on data generated from assessment tools with robust validity evidence that withstand scrutiny. 8 AUTHORS: Joseph Gilhooly, MD, a Daniel J. Schumacher, MD, MEd, b Daniel C. West, MD, c and M. Douglas Jones, Jr, MD d a Department of Pediatrics, Oregon Health & Science University, Portland, Oregon; b Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts; c Department of Pediatrics, University of California, San Francisco, California; and d University of Colorado School of Medicine, Denver, Colorado KEY WORDS entrustment, competency, milestones ABBREVIATIONS CBME—Competency-based Medical Education EPA—Entrustable Professional Activity Dr Gilhooly organized the authors and their edits, drafted the introduction and conclusions, and prepared the final commentary; Dr Schumacher contributed the section on the relevance of EPAs to the trainee as this related to his previous publications in this area and helped edit the manuscript; Dr West contributed the section on assessment tools and the need for valid and reliable assessments and helped edit the manuscript; Dr Jones provided the section on the use of EPAs as a framework for competencies and milestones and helped edit the manuscript; and all authors approved the final manuscript as submitted. www.pediatrics.org/cgi/doi/10.1542/peds.2013-3861H doi:10.1542/peds.2013-3861H Accepted for publication Jan 30, 2014 Address correspondence to Joseph Gilhooly, MD, 707 SW Gaines St, Mail Code CDRC-P, Portland OR, 97239. E-mail: gilhooly@ohsu. edu PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2014 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose. S78 GILHOOLY et al by guest on May 25, 2020 www.aappublications.org/news Downloaded from