Defining the scope of skills for family medicine residencies

Medical school graduates entering one family medicine residency program might receive training that is markedly different than another family medicine residency program. While these new medical school graduates, called residents, will gain the clinical knowledge needed to practice medicine, their scope of skills depend on their specific experiences as residents. A team of healthcare professionals from the Family Medicine Residency Program at Tufts University School of Medicine have published a paper in the Journal of Graduate Medical Education that suggests a way to evaluate family medicine residents based on their level of competency.

"Family medicine resident training is currently determined by the types of patients that the residents treat at their specific hospital or clinic, rather than being determined by the curriculum. We have created a list of entrustable professional activities – or EPAs – to assess clinical competencies that clearly define the breadth of skills required at the completion of residency," said Allen Shaughnessy, Pharm.D., M.Med.Ed., professor at Tufts University School of Medicine and fellowship director of the Tufts University Family Medicine at Cambridge Health Alliance.

Shaughnessy worked with a team of healthcare professionals from Tufts University School of Medicine's Family Medicine Residency Program to develop a list of 76 EPAs around which to structure a competency-based assessment of family medicine residents.

"Competence is defined as the ability to do something successfully. Defining the list of 'somethings' in family medicine residencies has been difficult for both educators and regulators," said Gregory L. Sawin, M.D., M.P.H., assistant professor at Tufts University School of Medicine and program director, Tufts Family Medicine Residency at Cambridge Health Alliance.

Competency-based medical education ensures that acquire a certain set of skills, behaviors, and attitudes in addition to the needed to practice medicine. When these skills, behaviors, and attitudes are integrated and performed in an educational setting, they become known as entrustable professional activities. An activity is "entrustable" when a supervisor deems that a medical resident could have performed a task without supervision; in this case, the resident has demonstrated competency in a given area. As an example, the authors write:

"For example, a competent family medicine physician is expected to provide care for a child with a respiratory illness. This includes eliciting a history, performing a physical examination, arriving at a diagnosis, and implementing a plan of care that is evidence based and takes into account the needs and values of the patient. Although each of these skills can be separately measured and documented in a variety of settings, the overall performance of them in situ constitutes the entrustable activity."

In addition to confirming that family medicine residents know how to treat a specific disease or condition, the EPAs can ensure that residents acquire skills that enable them to effectively interact with medically-diverse patients, uphold ethical principles, use information sources at the point of care, and develop skills relating to running a medical practice.

The leading effort to define competencies is the Outcome Project, from the Accreditation on Graduate Medical Education (ACGME) and the American Board of Medical Specialties. The Outcome Project is shifting medical education from assuring quality through intense training processes to measuring outcomes and specific skill. This shift in medical training was the result of calls for greater accountability in all aspects of the profession.

Shaughnessy notes that the Outcome Project leaves the definition of actual competencies and their assessment to individual residencies. Interpretation may lead to vague competency categories that are not specific enough to provide definitive guidance to residents or faculty members regarding what learning needs to be accomplished and documented. In response, the EPAs provide a detailed, concrete approach to training and evaluating residents in how they provide care.

The initial EPAs presented in the paper were developed at the Tufts University School of Medicine Family Medicine Residency Program, based on the ACGME guidelines, over a two year period. Twenty-one experts were recruited to further determine and refine the EPAs that are most relevant to family medicine education. The experts participated in two rounds of anonymous, internet-based surveys to compile the final list of EPAs. The process began with 91 EPAs that were then narrowed down to 76 based on the feedback.

The EPAs in the paper are intended to be used as a starting point for family medicine residency programs that are interested in moving toward a competency-based educational approach.

"Incorporation of EPA- and competency-based education will challenge traditional residency models that have a 'one size fits all' rotation structure. Family medicine residency programs may need to be more flexible to allow residents to have rotation experiences to meet the EPAs," said Shaughnessy. "Overall, the EPAs will provide family medicine residents with a broad range of clinical experiences and will guide educators when evaluating the skill sets that residents must acquire."

Shaughnessy is also on an expert panel of the family medicine milestones project, a part of the Outcome Project that brings together review committees with specialty medical organizations and boards to develop specific benchmarks of skills and knowledge that residents in every specialty must achieve at certain identified points or stages during their residency education. The panel on which Dr. Shaughnessy serves is in the area of information mastery/evidence-based medicine in the practice-based learning and improvement competency domain, one of six clinical competency areas.

Additional authors of the paper are Jennifer Sparks, M.D., formerly a master teacher fellow at the Tufts Family Medicine Residency Program; Molly Cohen-Osher, M.D., and Kristen H. Goodell, M.D., both lecturers in family medicine at TUSM; and Joseph Gravel, Jr., M.D., former program director at the Tufts University Family Medicine Residency at Cambridge Health Alliance and current residency director of the Lawrence Family Medicine Residency program and associate professor of at TUSM.

More information: Shaughnessy AF, Sparks J, Cohen-Osher M, Goodell KH, Sawin, GL, Gravel J. 2013 (March). Entrustable Professional Activities in Family Medicine. Journal of Graduate Medical Education, 5(1), 112-118. doi: 10.4300/JGME-D-12-00034.1

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