Longitudinal Assessment of Resident Performance Using Entrustable Professional Activities

Abstract

Importance: Entrustable professional activities (EPAs) are an emerging workplace-based, patient-oriented assessment approach with limited empirical evidence.

Objective: To measure the development of pediatric trainees' clinical skills over time using EPA-based assessment data.

Design, setting, and participants: Prospective cohort study of categorical pediatric residents over 3 academic years (2015-2016, 2016-2017, and 2017-2018) assessed on 17 American Board of Pediatrics EPAs. Residents in training at 23 pediatric residency programs in the Association of Pediatric Program Directors Longitudinal Educational Assessment Research Network were included. Assessment was conducted by clinical competency committee members, who made summative assessment decisions regarding levels of supervision required for each resident and each EPA. Data were collected from May 2016 to November 2018 and analyzed from November to December 2018.

Interventions: Longitudinal, prospective assessment using EPAs.

Main outcomes and measures: Trajectories of supervision levels by EPA during residency training and how often graduating residents were deemed ready for unsupervised practice in each EPA.

Results: Across the 5 data collection cycles, 1987 residents from all 3 postgraduate years in 23 residency programs were assigned 25 503 supervision level reports for the 17 general pediatrics EPAs. The 4 EPAs that required the most supervision across training were EPA 14 (quality improvement) on the 5-level scale (estimated mean level at graduation, 3.7; 95% CI, 3.6-3.7) and EPAs 8 (transition to adult care; mean, 7.0; 95% CI, 7.0-7.1), 9 (behavioral and mental health; mean, 6.6; 95% CI, 6.5-6.6), and 10 (resuscitate and stabilize; mean, 6.9; 95% CI, 6.8-7.0) on the expanded 5-level scale. At the time of graduation (36 months), the percentage of trainees who were rated at a supervision level corresponding to "unsupervised practice" varied by EPA from 53% to 98%. If performance standards were set to align with 90% of trainees achieving the level of unsupervised practice, this standard would be met for only 8 of the 17 EPAs (although 89% met this standard for EPA 17, performing the common procedures of the general pediatrician).

Conclusions and relevance: This study presents initial evidence for empirically derived practice readiness and sets the stage for identifying curricular gaps that contribute to discrepancy between observed practice readiness and standards needed to produce physicians able to meet the health needs of the patient populations they serve. Future work should compare these findings with postgraduation outcomes data as a means of seeking validity evidence.

Figure 1.. Growth Curves Across Residency for 17 General Pediatrics Entrustable Professional Activities (EPAs)

See Table 1 for full description of EPAs and supervision level scales. dx indicates diagnosis; PGY, postgraduate year.

Figure 2.. Developmental Progression Scales for General Pediatrics Entrustable Professional Activities (EPAs) 1 to 9

The beginning of the white bar (left side) indicates the point at which 25% of residents achieved a given supervision level, with the end of the white bar (right side) indicating the point at which 75% achieved the level. The end of the blue bar (right side) indicates where 90% of residents achieved the supervision level. See Table 1 for full description of EPAs and supervision level scales.

Figure 3.. Developmental Progression Scales for General Pediatrics Entrustable Professional Activities (EPAs) 10 to 17

The beginning of the white bar (left side) indicates the point at which 25% of residents achieved a given supervision level, with the end of the white bar (right side) indicating the point at which 75% achieved the level. The end of the blue bar (right side) indicates where 90% of residents achieved the supervision level. See Table 1 for full description of EPAs and supervision level scales.