Competency-based education, entrustable professional activities, and the power of language.

E diting a journal is all about language. Authors’ thoughts and experiences—their message—must be translated into text, revised, and edited to convey to the readers the concepts intended by the authors. Some concepts are complex and need powerful language to be expressed. A competency-based education movement is dominating graduate medical education reform around the world in the 21st century. This movement can be viewed as a struggle to formulate the values of the medical profession in words that enable a new perspective on curricula, training, and assessment. Without new language, this innovation would not have been possible. The 7 roles of the CanMEDS competency framework (medical expert, communicator, collaborator, health advocate, manager, scholar, and professional), now prevalent around the world, represent powerful language. By comparison, the Accreditation Council for Graduate Medical Education (ACGME) core competencies seem linguistically less powerful but also serve to structure new perspectives about residency training. The word competency has caught on quickly and is now being used ubiquitously. Do all of us, however, give it the same meaning? If asked how the competencies are different from knowledge-skills-attitudes (KSA), many consider the competencies to be ‘‘more integrated’’ than the KSAs are. At the same time, ACGME has called the terms medical knowledge, interpersonal and communication skills, and professionalism each ‘‘core competencies. ’’ Lurie has recently elaborated on how the blurred language around competencies has not contributed to improved assessment practices in medical education and suggests that the idea of ‘‘assessment of competencies’’ should be abandoned. Others disagree and call for enhanced professional development of faculty in this area. The difficulty with the competencies is that the language used to date has been inadequate in facilitating the translation of competency domains into training practices and the monitoring and assessment of trainees. The need to capture these important qualities of physicians in language has led to detailed descriptions that can be too long or too theoretical to be practical. As far back as the 1950s, Miller argued that human working memory is limited and cannot contain more than 7 (62) independent elements at a time. To use an elaborate framework of competencies, subcompetencies, and milestones while observing trainees may cause cognitive overload. If clinical educators cannot comprehend the competency concept and all of its new language, they may not be able to effectively assess trainee competencies. Here, is where the entrustable professional activity (EPA) concept emerges. The EPAs were designed to link competencies to clinical practice and make them feasible. The EPAs—tasks or responsibilities that can be entrusted to a trainee once sufficient, specific competence is reached to allow for unsupervised execution—are now being defined in various health care domains. Because EPAs represent what physicians do in daily practice, the new language can be briefer and less complicated. This issue of the Journal contains 6 articles devoted to EPAs. In addition to this editorial, they include a perspective on the entrustment process, an exploration of the attributes of competence that enable entrustment decisions, and a succinct description in one of this issue’s Rip Outs. Hauer et al and Shaughnessy et al applied the EPA concept to internal medicine and family medicine and identified 30 and 76 EPAs, respectively. Although there is no single correct mode of description and application of EPAs, as long as it serves the purpose of identifying the ‘‘professional activity’’ to be mastered and certified, different views of the nature of EPAs may be applicable. Although the description of EPAs by Shaughnessy et al pertains to the management of specific medical conditions, they do not specify what is done other than ‘‘management. ’’ By staying somewhat closer to the intended definition of EPA, Hauer et al have focused on a more limited number of comprehensive, critical tasks that should apply over multiple patient conditions. The more limited number of EPAs may serve better to formalize entrustment decisions. When put in practice, by applying some of the ‘‘nuts and bolts’’ of this issue’s ‘‘Rip Out,’’ educators may discern which approach is most useful in their own setting. One of the most elaborate applications of EPAs to date is provided by the Royal Australian and New Zealand Olle ten Cate, PhD, is Professor of Medical Education at the Center for Research and Development of Education, University Medical Center, Utrecht, the Netherlands. Corresponding author: Th J (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-12-00381.1 EDITORIAL