Trusting graduates to enter residency: what does it take?

T he simple question in the title of this piece reflects the fundamental function of undergraduate medical education (UME). In the past century, the purpose of medical training has moved from readiness for independent medical practice to readiness for postgraduate training. This requires a new benchmark for the transition from UME. The recent emphasis on competency-based postgraduate medical training, with its competency frameworks and Milestones initiative, shows a shift from what abilities physicians in general should possess to what medical specialists should possess. An increasing number of postgraduate programs have now started to link competencies to so-called entrustable professional activities (EPAs), core units of professional work identified as tasks or responsibilities to be entrusted to a trainee once sufficient competence has been reached. If postgraduate training prepares for unsupervised practice from the first day after training, for what does undergraduate training prepare? Much of undergraduate training is workplace-based and it is a logical thought to use the same reasoning: What responsibilities are expected of the physician in the workplace from the first day of residency? That is not the same question as ‘‘What grades must medical students have attained in their theoretical and practical exams? ’’ Trusting residents to work with limited supervision (ie, not checking everything that is being done) is a deliberate decision that affects patient safety. An entrustment decision means taking a calculated risk that chances of future adverse events are minimized. Many documents during the past decades have attempted to describe what qualities or competencies physicians should possess at the end of undergraduate medical training. However, looking at what exactly residents are expected to do safely from the first day of training has not been the general method, although some have used this approach for graduate medical education. The Association of American Medical Colleges has produced a draft document called ‘‘Core Entrustable Professional Activities for Entering Residency’’ (CEPAER), describing 13 EPAs that medical graduates should have attained at a level that permits practice without direct supervision (T A B L E). Medical trainees should be able to carry out these activities without direct supervision from the first day of residency. The authors are to be commended on this initiative for several reasons. The first is its generalized nature. As the EPA concept, defined for postgraduate education, is now emerging in UME, schools may start defining these by themselves. However, a much better strategy is a concerted effort to define generalizable EPAs across schools, as a clear benchmark for any undergraduate and postgraduate program nationally and internationally. It is in fact a redefinition of what a medical physician is, in terms of what he or she should be able and allowed to do with limited supervision, following the meaning of competent in the sense of ability and right to act or judge. Second, the number of EPAs is limited. Long lists of detailed activities tend to transform to checklists and lose power. It is a wise decision to focus on the most important and comprehensive acts medical students should be entitled to do with limited supervision by the end of training. A clear and concise set will be retained in the minds of learners and teachers on both sides of the graduation divide. Third, defining core EPAs implies there is room for elective EPAs. Next to providing space for local differences in curricula, it also very much reflects the flexible competency-based nature of current training initiatives, which are moving from fixed time and flexible standards to fixed standards and flexible time. Trainees who have ambition, interest, and time available to add (speciality-) specific EPAs may be given the opportunity to do so. The draft CEPAER document was presented in November 2013 with the aim to solicit feedback to enable the drafting of a final document in the spring of 2014. In this editorial I present a few specific and general observations that may help to further improve the document. I have witnessed institutions and groups designing EPAs that face similar issues, and hope this contribution can serve to inform a wider public. By the time this editorial is published, the CEPAER consortium may have crafted a next version of the document. Nevertheless, Olle ten Cate, PhD, is Professor of Medical Education at the Center for Research and Development of Education, University Medical Center, Utrecht, the Netherlands. The author would like to thank Dr Robert M. Englander for pointing him to Onora O’Neill’s Ted Talk and for a constructive dialogue that led to adaptations in this editorial. Corresponding author: Olle ten Cate, PhD, PO Box 85500, 3508 GA, Utrecht, the Netherlands, 31.88. 7557010, t.j.tencate@umcutrecht.nl DOI: http://dx.doi. org/10.4300/JGME-D-13-00436.1 EDITORIAL