Implementing EPAs in undergraduate osteopathic medical education has distinct challenges. Workplace-based assessment in patient care settings is essential to making entrustment decisions. However, valid and reliable assessment tools are sparse, and standards of reliability cannot easily be met.
17 Because the construct of entrustment is the synthesis of multiple complex factors, entrustment decisions require the use of a variety of instruments across time, in different contexts, and by different evaluators.
18 The capacity of a school to meet these expectations depend on available resources, an alignment of the school's clinical curriculum, adequate patient volume, and access to a range of care settings and trained preceptors.
18 As trainees move from one rotation or clinical setting to another, additional observations are often required to reconfirm the trainee's competency, especially given that skills can diminish over time if not practiced.
2 The volume of assessments may increase because EPAs and CBME, in general, focus not only on units of work, but also the work process itself. This focus can pose potential challenges, such as defining work that does not easily fit into the EPA framework, introducing additional assessments to better understand the process of work, and creating assessment methods that do not overcomplicate the evaluation process or overburden faculty. This increase in assessments required for entrustment can add stress to an already burdened system and requires a process for tracking over time.
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Assessment of entrustment establishes an even greater layer of complexity. Within the notion of entrustment reside behaviors such as conscientiousness, honesty, and recognition of one's limitations.
20,21 Ultimately, a decision regarding student readiness to perform a given activity under appropriate supervision must be made. For students entering residency, the level of supervision required may vary by EPA. It may range from co-activity (performance with the aid of a trainer) to independent performance with immediate supervision.
22 These types of decisions are multifactorial and depend on complex interpersonal interactions and workplace-based factors. Residency-level entrustment and supervision scales are readily available for use.
23 However, in UME, much work is needed to create scales and tools for these types of assessments.
Entrustment decision making is most successful in an environment that allows for individualized learning trajectories and practice opportunities in the context of longitudinal relationships with preceptors.
24 Many institutions cannot fulfill these ideals given health care delivery constraints, patient-safety concerns, and competing demands to meet increasing resident training requirements, which often limit student opportunity to gain hands-on experience and receive valued feedback from mentors.
24 Moreover, osteopathic medical schools rely heavily on decentralized clinical education, rather than the more traditional academic health center model, which requires the engagement and trust of community-based preceptors to understand and reliably make entrustment decisions.
25 This concept of assumed responsibility for faculty can be daunting, and levels of comfort with this responsibility are still evolving.
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Portfolios are a viable tool for collecting, organizing, and managing assessment data on learners and can be used to keep learners engaged in assessment, foster lifelong learning, and promote professional identity formation across time.
27 However, effective use of portfolios also requires a sustained mentoring capacity and the necessary time and resources for the implementation process, as well as for the mentor.
24 In addition, feedback mechanisms must be in place to enable improvement in abilities.
28 Mentors must be well trained to assess students, to serve in the mentoring role, and to provide feedback that will facilitate student progress. The purpose of the portfolio and the embedded assignments must be explicit to all stakeholders. Learners must understand the benefits of the portfolio to prevent them from perceiving learning as “busy work.”
24 For true progress over time, all stakeholders, including faculty, medical students, residents, and national licensure boards, must be invested in conversations regarding evidence supporting learner assessment and mechanisms to document achievement of agreed-upon competence. Without adequate resources, time, training for mentors and assessors, recognized purpose, and communication among all stakeholders, it will be hard to collect and complete a longitudinal snapshot of learner achievement toward EPAs across time and contexts. These conversations must occur at a national level if handoffs of learners from UME to GME are expected to succeed and progress toward entrustment.