Essentials of PEM Fellowship Part 2: The Profession in Entrustable Professional Activities Deborah Hsu, MD, MEd,* Michele Nypaver, MD,† Daniel M. Fein, MD,‡ Constance McAneney, MD,§ Sally Santen, MD, PhD,† Joshua Nagler, MD, MHPEd,|| Noel Zuckerbraun, MD, MPH,¶ Cindy Ganis Roskind, MD,# Stacy Reynolds, MD,** Pavan Zaveri, MD, MEd,†† Curt Stankovic, MD,‡‡ Joseph B. House, MD,† Melissa Langhan, MD, MHS,§§ M. Olivia Titus, MD,|||| Deanna Dahl-Grove, MD,¶¶ Ann E. Klasner, MD, MPH,## Jose Ramirez, MD,*** Todd Chang, MD, MAcM,††† Elizabeth Jacobs, MD,‡‡‡ Jennifer Chapman, MD,†† Angela Lumba-Brown, MD,§§§ Tonya Thompson, MD, MA|||||| Matthew Mittiga, MD,§ Charles Eldridge, MD,§§§ Viday Heffner, MD,¶¶¶ Bruce E. Herman, MD,### Christopher Kennedy, MD,**** Manu Madhok, MD, MPH,†††† and Maybelle Kou, MD‡‡‡‡ Abstract: This article is the second in a 7-part series that aims to compre- hensively describe the current state and future directions of pediatric emer- gency medicine (PEM) fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated upon program completion. This arti- cle describes the development of PEM entrustable professional activities (EPAs) and the relationship of these EPAs with existing taxonomies of as- sessment and learning within PEM fellowship. It summarizes the field in concepts that can be taught and assessed, packaging the PEM subspecialty into EPAs. Key Words: pediatric emergency medicine, fellowship training, essentials of fellowship, assessment, entrustable professional activities, domains of competence, competencies, milestones, entrustment, competency (Pediatr Emer Care 2016;32: 410–418) I n the early 2000s, the Accreditation Council for Graduate Med- ical Education (ACGME) defined 6 core competencies (medical knowledge, patient care, practice-based learning and improve- ment, systems-based practice, interpersonal and communication skills, and professionalism) and incorporated them into graduate medical training to be used as a framework for outcomes-based as- sessment. 1,2 Without existing validated assessment tools to align these competencies to training curricula, programs struggled to create processes to meet these requirements. By the mid-2000s, limitations to the core competencies framework were recognized, and planning for the ACGME's Next Accreditation System (NAS) commenced. 3 In 2013, the ACGME implemented the NAS for various spe- cialties including pediatrics and emergency medicine. The aims of the NAS were “to enhance the ability of the peer-review system to prepare physicians for practice in the 21st century, to accelerate the ACGME's movement toward accreditation on the basis of edu- cational outcomes, and to reduce the burden associated with the current structure and process-based approach. ” 3 The ACGME also introduced the Accreditation Data System, a centralized electronic data bank that modernized graduate medical education documenta- tion practices. The initial phases of the NAS implementation consisted of specialty-specific milestones development, updates to the Accreditation Data System, the ACGME Resident-Fellow and Faculty Surveys, case log and clinical experience data, and data re- garding graduates' performances on certifying board examina- tions. 3,4 These changes brought to ACGME-accredited programs the requirement for scheduled reporting of competency and mile- stones data for trainees in graduate medical education. DOMAINS OF COMPETENCE, COMPETENCIES, AND MILESTONES The terminology describing the layers of competency-based assessment has evolved. Within the NAS, the concept of mile- stones was introduced and defined as observable developmental steps that trainees are expected to attain in the course of residency and fellowship. These milestones, organized under competencies (specific areas of performance that can be described and mea- sured) within the domains of competence (previously known as the 6 core competencies), provide descriptions of behaviors that may be observed in physician trainees as they gain necessary knowledge, skills, and attitudes to practice medicine in their fields of expertise 4,5 (see Fig. 1 for a schematic illustrating the relation- ships between domains of competence, competencies, and mile- stones). Competencies and milestones provide a framework for assessing trainees in key elements of expected aptitude within a given specialty. In the context of the NAS, the “benefits of the milestones are that they articulate shared understanding of expec- tations, set aspirational goals of excellence, provide a framework and language for discussions across the continuum, and ultimately From the *Baylor College of Medicine, Texas Children's Hospital, Houston, TX; †University of Michigan, Ann Arbor, MI; ‡Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, NY; §University of Cin- cinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; ||Harvard Medical School, Boston Children's Hospital, Boston, MA; ¶University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA; #Columbia University Medical Center, New York, NY; **Carolinas Medical Center, Levine Children's Hospital, Charlotte, NC; ††Children's National Medical Center, Washington, DC; ‡‡Children's Hospital of Michigan, Detroit, MI; §§Yale University School of Medicine, New Haven, CT; ||||Medical University of South Carolina, Charleston, SC; ¶¶Rainbow Babies and Children's Hospital, UH Case Medical Center, Cleveland, OH; ##University of Alabama, Children's Hospital of Alabama, Birmingham, AL; ***Orlando Health, Arnold Palmer Hospital for Children, Orlando, FL; †††University of Southern California, Children's Hospital of Los Angeles, Los Angeles, CA; ‡‡‡Rhode Island Hospital/Hasbro Children's Hospital, Alpert Medical School of Brown University, Providence, RI; §§§Washington University in St Louis, St Louis Children's Hospital, St Louis, MO; ||||||Univer- sity of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR; ¶¶¶Children's Hospital of Wisconsin, Wauwatosa, WI; ###Univer- sity of Utah, Primary Children's Hospital, Salt Lake City, UT; ****Children's Mercy Hospital, Kansas City, MO; ††††Children's Hospitals and Clinics of Minnesota/Health Partners, Institute of Education and Research, Minneapolis, MN; and ‡‡‡‡Inova Children's Hospital, Falls Church, VA. Disclosure: The authors declare no conflict of interest. Reprints: Deborah Hsu, MD, MEd, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin St, Ste A2210 Houston, TX 77030 (e‐mail: dchsu@texaschildrens.org). This manuscript was written by the authors on behalf of the PEM Fellowship Directors' Writing Group. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0749-5161 ESSENTIALS OF PEM FELLOWSHIP 410 www.pec-online.com Pediatric Emergency Care • Volume 32, Number 6, June 2016 Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.