EPAs in depth

Entrustable Professional Activities (EPAs) are clearly defined units of professional practice that a trainee can progressively be trusted to perform with an appropriate level of supervision.

In pain medicine, EPAs represent authentic clinical responsibilities that bring together clinical knowledge, practical skills, communication, professional judgement, cultural safety, teamwork and patient-centred care. They can be observed in the workplace, supported through supervision and feedback, and assessed over time across a range of patients, settings and levels of complexity.

EPAs provide an organising framework that connects several elements of training and assessment:

• Competencies describe the knowledge, skills,behavioursand professional attributesrequiredfor effective specialist practice.

• Workplace-based feedback (WBF) forms collect evidence about a trainee’s performance in clinical practice.
• Observation guides and checklists help supervisors focus on relevant aspects of performance and record their observations consistently.

EPAs bring this evidence together around a complete professional activity and support a judgement about the trainee’s readiness for greater autonomy.

Entrustment decisions are specific to the activity, the clinical context and the available evidence. As trainees demonstrate consistent performance across increasingly complex situations, they can progress from close supervision towards greater autonomy and independent specialist practice.

Entrustable Professional Activities (EPAs) are being introduced to provide a clearer and more authentic way of supporting trainees’ progression towards independent specialist practice. This educational reform will better align to the graduate outcomes of the program. Importantly, it also makes explicit, decisions that already being made implicitly i.e. do I trust this trainee to undertake this aspect of professional practice and, with what level of supervision?

EPAs provide a coherent framework for gathering and connecting evidence from across the training program. Drawing on multiple observations, settings and assessment methods will allow trainee progress to be considered over time, rather than relying too heavily on any single examination or assessment event.

The introduction of EPAs forms part of the FPM's longer-term review of its assessment framework.

Recent reforms include:

• Scholar role activities (substituting for the clinical case study).
• Foundations-level multiple-choice question (MCQ) examination (substituting for the single answer question (SAQ) examination.
• Retirement of the long case assessment.

These changes have occurred in response to feedback from trainees and Supervisors of Training and an acknowledgment that assessments should sample the curriculum more broadly and reflect the realities of contemporary clinical practice.

The decision to introduce EPAs draws on contemporary practice in specialist medical education, the emerging evidence base and the expectations of our regulators. It also represents a further step towards a fuller model of programmatic assessment, in which evidence from different parts of the program is deliberately triangulated to build a more complete and defensible picture of each trainee’s development.

Feedback from trainees and supervisors of training (SOTs) will continue to inform how EPAs are introduced and embedded. Supervisors will be supported to provide high-quality narrative feedback in a timely manner, giving trainees specific and actionable guidance about their progress and the next steps in their development. Our aim is to provide a system of assessment that is better connected, more educationally useful and more closely aligned with the capabilities expected of an FPM graduate.

EPA assessment draws on a body of workplace-based evidence gathered over time. A single clinical encounter provides one useful data point; an entrustment decision is based on a broader pattern of performance across different patients, settings, levels of complexity and supervisors.

The aim is to build a portfolio of descriptive evidence, entered into the ePortfolio, that demonstrates a trainee’s development, responsiveness to feedback and readiness for increasing autonomy. 

Evidence may include:

• Direct observation of clinical practice;
• Case-based discussions;
• Reviews of clinical documentation;
• Multi-source feedback;
• Deidentified patient feedback, where appropriate;
• Trainee reflection arising from the workplace-based feedback activities;
• Learning goals and action plans; and
• Relevant assessment evidence aggregated within the ePortfolio.

The value of the evidence depends on its quality, range and context, as well as its quantity. Supervisors will consider factors such as the complexity and risk of the activity, the consistency of the trainee’s performance, the level of support required, the trainee’s clinical reasoning and communication, and how effectively they respond to feedback.

Evidence collection should remain brief, practical and embedded in routine clinical work. Supervisors will record concise narrative feedback that identifies strengths, areas for development, the degree of supervision required and clear next steps. Trainees will use this feedback to reflect on their performance, set goals and demonstrate progress in subsequent encounters.