I'm Heather Baer. Today I'm going to talk to you about EPAs and OPAs. This is a product of the EPA OPA Subcommittee and these materials are meant to help to provide faculty with some basis to start looking at the use of EPAs and OPAs in clinical practice. First, I will review the rationale for untrustable professional activities in medical education. Then I will define observable practice activities, which we call OPAs, and explain their function. I will briefly discuss the concept of mapping. I will discuss the development of PMR-specific EPAs. And then, lastly, provide examples of how EPAs and OPAs might be used in a clinical setting. I have no disclosures to make. The National Library of Medicine defines clinical competence as the capability to perform acceptably those duties directly related to patient care. The ACGME has further delineated this into six core competencies for medical trainees, with which we are all familiar. As part of the next accreditation system, specialties were asked to create milestones that were specific to their training programs. These are defined as competency-based developmental outcomes that can be demonstrated progressively by residents and fellows from the beginning of their education through graduation to unsupervised practice of their specialties. These were written as sub-competencies under the rubric of the core competencies. As we have implemented use of milestones in our residency programs and throughout the specialties, it has become apparent that there are some challenges in adopting these. It turns out that real clinical situations usually involve multiple competencies. Breaking down clinical observations into competencies can sometimes feel artificial, and milestones may not be written in a matter that is readily observable. They can be difficult to use to set expectations for learning, and they were not intended to be used as direct assessment measures. More recently, specialties have started to look at the concept and use of entrustable professional activities as first described by Dr. Tenkate in 2004. This is a conceptual framework that aligns workplace assessment with the realities of the clinical environment. They are described as a unit of professional practice that can be entrusted to a competent learner. For example, from the PMR EPAs, evaluating and managing patients with spinal cord injury and other spinal cord disorders is a central core area of practice that we would expect all of our graduating residents to have been able to develop skills, attitudes, and beliefs that allow them to go into practice and competently manage patients with these issues. When you look at the EPAs, it will become apparent that multiple competencies fall within them, and they cover core or essential work of the profession. EPAs are assessed according to a schema of entrustment. In other words, they're expressed in terms of the degree of supervision that the evaluator feels that the trainee needs in order to perform that task appropriately. How much do I trust this resident? The language of entrustment scales differ somewhat from one to another, but generally they span the gamut from observer to aspirational or mastery. Dr. Tinkott uses the example of teaching a teenager how to drive. So I've given the example of Charlie. Charlie is your teenager who can't wait to get behind the wheel. At first, you might just want Charlie to observe you drive, to read about the rules of the road, and to be able to articulate back to you what he sees you doing. As Charlie gains confidence in driving under different circumstances, you might decide that you trust him even when you're not in the car. Once he's been licensed, he still has a learning curve, and perhaps he's only going to be trustworthy during the day out of rush hour traffic. Once you've watched him do that with competence and consistency, then perhaps you would trust him to drive in rain or sleet or in the dark or in snow. So these are levels of supervision and entrustment that relate to a very important high-stakes activity, which is driving. Similarly, entrustment can be used to look at how well you think a resident or another type of trainee, such as a fellow, has achieved mastery sufficient to require less supervision. As you can see, entrustal professional activities may relate to very large-scale umbrella activities. For example, in PMR, to manage a patient with spasticity, or they could be even broader in scope, such as managing a patient after a stroke. Because these activities have so many different features to them, they may not seem readily observable in and of themselves. To break it down and make it something more practical and useful in a clinical environment, the concept of OPAs, or observable practice activities, emerged. The language that's used around these differs from one medical educator to another and can be confusing. Some medical educators will refer to what we are calling OPAs as rotational EPAs or as granular EPAs. But the main overarching thing to understand about these is that they are more specific activities that may fall under a larger umbrella core content. In terms of spasticity, performing a botulinum toxin injection would be one of the features of a global spasticity management plan. In fact, it may be easier to observe and comment upon than lumping everything together. For another example, an EPA that was described and now is to be published, along with the other PMR EPAs, is evaluating and managing patients with congenital and acquired limb deficiency. That, again, is a pretty broad content area. An OPA that would fall underneath that EPA might be to evaluate an outpatient with a recent lower limb amputation. That in itself includes many different activities, as you can see here, including taking a focal history, an examination, a K-level assessment, a prosthetic prescription, and communicating to the patient and with the patient about their needs and what you observe. As you watch a resident interacting with a patient, it may become clearer as they work through the complex issues how much you need to do to support them. Do you need to provide direct supervision in order to guide them through a K-level assessment or explain it to them? Do you need to put your hands on the patient and show them how to perform an appropriate examination? Or do you think they're capable of doing this with indirect supervision where you might not be in the room? You might be out in the clinic or perhaps you're somewhere else in the hospital and they report to you. These are different levels of supervision that make organic sense to our clinical environment. And do many activities and observations together but into a form that allows us to communicate some aspect of the developmental progress of the resident or other trainee in a way that will bear upon their promotion to another level or to the amount of freedom that you feel that you can give them and responsibility that you feel that they are ready to assume. One of the important things to understand about the EPAs and OPAs is that there are attempts and there's an importance to trying to map these back to the competencies and the milestones. The potential benefits of doing this is that the attending no longer may need to think about and struggle with the language of the competencies and the milestones. You can simply assess the EPAs and OPAs that make sense to their particular area of practice. These assessments ideally would be extracted either manually or better yet electronically according to an a priori map that will go back and inform the competencies and milestones and I'll show you an example of a potential map. Then this abstracted material can be collected in a database and used subsequently for summative assessments and to fulfill the ACGME reporting requirements for the milestones. The challenges that we see at this point are several and particularly the mapping of the EPAs and OPAs to competencies and milestones will take some time and thought. There isn't a one-to-one relationship between the language that will be used in these and how the milestones are articulated but there are ways that have been pioneered to do so. The next question is who does that? Will this be done in a central manner through our committee or another committee as we are considering or will this be something that occurs on a program level. Here is an example of a potential MAP, back again to the OPA that I described related to evaluating an outpatient with a recent lower limb amputation. In looking at the activities that fall within that, one can relate it back to the PMR milestones, including patient care one, patient care five, interpersonal communication and medical knowledge. In this case, one of the medical knowledge milestones that are subcompetencies that are in the appendix in the milestone document. The judgment that has to be made is how the language in the milestones maps along the language or categories in the entrustment scale, but for certain milestones, this is more apparent than others. The concept is that if you decide that this resident needs your direct supervision for this particular activity, that the resident then is automatically credited for all of the milestones that fell within and below or to the left of that assessment. Our committee has been active in reviewing the literature throughout medical education with regard to EPAs and OPAs. Several years ago, we developed through an iterative process PMR specific EPAs by a modified Delphi method. There are 19 of these, as I said, and they are listed in the appendix to this webinar. We also created multiple EPA OPA sets in order to initiate a multicenter pilot. A set, for example, would include the EPA statement, such as electrodiagnosis, and then all the OPAs that might fall underneath that, including performing an electrodiagnostic examination consultation for potential carpal tunnel syndrome. We have made three of these EPA OPA sets and plan to develop a multicenter rigorous pilot once we collect some initial data from a beta test that we'll be starting within several months. Finally, we are busy creating faculty development materials, including this webinar, in order to try to explain to the field why EPAs and OPAs might be considered for use at a program level as part of the observational assessment strategy and to give people a tangible sense of how they might be implemented. Before I get into examples of clinical scenarios in which OPAs might be useful, I did want to give you a sense of some of the EPAs that we have developed. As I said before, evaluating and managing patients with spasticity is one. There's an EPA for managing patients with brain disorders, including traumatic brain injury and sports-related concussion. EPA is related to musculoskeletal syndromes, including the one here, as well as one more specifically devoted towards spinal disorders and axial pain, and an EPA for performing electrodiagnostic consultation and examination. Exercise 1 is meant to make this more understandable on a case-related basis. For example, if the EPA is evaluating and managing patients with spasticity, an OPA that falls within that would include performing a botulinum toxin injection. In this case, you're observing a PMR resident who's performing a botulinum toxin injection to address post-stroke upper limb hypertonia. Prior to the injection, the resident reviews the medical chart, introduces herself, explaining the reason for the visit, performs a focused, pertinent history and physical exam, establishes reasonable goals and expectations in consultation with the patient, but requires verbal guidance in creation of an injection plan in terms of the muscle selection and dosing. Prior to the injection, the resident also executes a complete informed consent and allows time to answer questions from the patient, prepares the botulinum toxin correctly, sets up the procedure appropriately for the chosen method of guidance, and performs a timeout for patient safety. During the injection, the resident talks to the patient through the procedure step-by-step and pauses as necessary to ensure patient comfort. The resident then encounters some difficulty in locating several of the targeted muscles and requires your assistance to redirect the needle. But otherwise, this resident is able to triangulate between the anatomic and instrumented guidance for good needle localization. After the injection, the resident reviews the expectations regarding the time course for the botulinum toxin to kick in, reiterates the signs and symptoms that might suggest an adverse reaction, and explains how to get in contact with the team if side effects are suspected, gives the patient an appropriate follow-up plan, and generates a complete and accurate procedure note. So which competencies were observed? At least three of the competencies could be observed and assessed during that patient-resident interaction. In terms of entrustment, we can step back, look at the entirety of that patient encounter, and determine whether we trust that resident to act only as an observer, whether we had to give direct supervision or the resident requires that, whether the resident requires or would be trusted with indirect supervision, whether we think the resident's now independent or would be, or whether we think the resident is so proficient that perhaps he or she could teach others to do this. Well, let's go back and review. While the resident was quite competent in addressing many of the issues and showing skills needed during this botulinum toxin injection, you still had to give verbal guidance to create the injection plan, and the resident had some difficulty in locating several target muscles. You had to put your hands on and direct that needle. So in this schemata, the resident required direct supervision. You make notes, and there in fact should be room for comments, and comments are extremely important in justifying your assessment, but this singular assessment for this one botulinum toxin injection can help you to direct that resident to the areas that would be most important to target in order to move up in terms of independence and skill acquisition. Here's another example. In this case, the EPA is performing an electrodiagnostic consultation and examination. The OPA is to perform a carpal tunnel screen. So in this case, you're observing a resident performing a carpal tunnel screen. Prior to the study, the resident reviews the medical chart, introduces herself to the patient, defines the reason for the visit, performs a focused, pertinent history and physical examination, creates an appropriate electrodiagnostic plan, executes a complete and informed consent, performs a timeout, sets up the procedure correctly. During the procedure, the resident adjusts the procedure to ensure patient comfort, is able to correctly identify the sites for stimulation and the sites for needle insertion, and is able to troubleshoot for a source of electrical interference. After the injection, the resident checks in with the patient to see if he has any concerns or questions, informs the patient as to how he will receive information regarding the results of the study, is able to identify and interpret no abnormal findings, and composes a comprehensive electrodiagnostic report. So which competencies were observed? And how would you rate this resident on the entrustment scale? Again, multiple competencies could be observed during this resident-patient interaction. So according to this OPA and its entrustment scale, where would you place the resident? In this scenario, I would argue that this resident would be independent. Other people might suggest that indirect supervision would be appropriate. This is an area where programs and faculty specifically invested in the area of evaluation or that particular content area might need to further articulate criteria related to supervision needs. So today was just the first attempt at explaining why many specialties have adopted intrustable professional activities and observable practice activities into their observational assessment strategies for resident and fellow competency evaluations. There's certainly more that our committee will be doing to investigate how these tools may be integrated at a program level, including looking at potential barriers for implementation and thinking further about strategies to allow easy mapping back to the competencies and milestones to alleviate the burden on faculty with regard to assessment and allowing the collection of important data to inform summative decisions, including assessment of milestones to be reported back to the ACGME as we are required to do. Our committee would absolutely love to get feedback from the profession with regard to further development in this area, so if you have any questions or thoughts, please contact me at this email address or any of the members of our committee. And thus I certainly need to acknowledge the remainder of the EPA OPA committee, particularly Dr. Michael Mallow, my co-chair, who was instrumental in developing these materials. And special thanks to Janet Corral at the University of Colorado.

Entrustable Professional Activities

Observable Practice Activities

medical education

clinical practice assessment

supervision levels

accreditation requirements