Entrustable Professional Activities (EPAs) framework to inform surgical residency training programs in Ethiopia medical education

Background Entrustable Professional Activities (EPAs) are activities that are essential to the discipline and can be delegated to individuals without direct supervision in a specific health care context once they have demonstrated sufficient competence (Amare et al., 2021; Ten Cate et al., 2015; Ten Cate et al., 2017). Since EPAs are believed to have potential benefits, a wide range of specialty programs have proposed them, and they have become popular in medical programs (Amare et al., 2021; Beeson et al., 2014; Haines et al., 2017; McCloskey et al., 2017; Peters et al., 2017; Ten Cate, 2017; van Loon et al., 2014; Young et al., 2018). Even though core EPAs have become available globally (Amare et al., 2021; Touchie & ten Cate, 2016), they cannot automatically be adapted for use in other contexts (Amare et al., 2021; Shorey et al., 2019). With this in mind, the need to develop an EPA framework for surgical residency training in Ethiopia is imperative (Amare et al., 2021). The goal is for graduating surgical residents must be able to carry out these EPAs independently by the time they graduate. However, graduates of general surgery residents have also been criticized for their ability to perform EPAs (Amare et al., 2021; Bucholz EM, 2011 Aug 15; Friedell et al., 2014; Moore et al., 2017; Perone JA, 2017 Apr 1; Wagner JP, 2018 Apr). The present study aimed to develop valid end-of-training EPAs for surgical residency training programs as a framework to inform curriculum design, teaching, and assessing competencies in the local context of Ethiopian medical education” (Amare et al., 2021), as well as to assess how faculty members judge residents' performance in executing EPAs, and how residents rate their own ability to systematically introduce and implement EPAs in the “surgical residency training programs” (Amare et al., 2021). Methods "A three-round Delphi method was used to establish consensus about important surgical EPAs among experts. A total of 136 experts representing all surgical residency training institutions in Ethiopia were invited to participate. Round 1 & 2 consisted of senior expert panelists (n = 8) to identify potential EPAs and determine the content validity. Round 3 consisted of a survey (n = 128) to further validate the identified EPAs by attending surgeons who work with them. Each EPA had to achieve at least 80% or higher agreement among experts to be considered having acceptable content validity" (Amare et al., 2021). In addition, the survey was conducted at “four surgical residency training institutions in Ethiopia” (Amare et al., 2021) to investigate resident and surgical team members judgments of a graduating general surgery residents' competency in carrying out EPAs. Result “In round 1, a total of 272 EPAs were proposed, reduced, and grouped to 39 consented EPAs. In round 2, the same experts rated each EPA’s relevance, resulting in 32 EPAs with a satisfactory item-level content validity index (I- CVI > 0.83). Overall, in the survey in round 3, 29 EPAs met the standard criterion for acceptability (S-CVI/Ave = 0.90) and achieved a high degree of final consensus (ICC =0.998, 95% CI [0.996, 0.999]; (F = 439.2, p < 0.0001)” (Amare et al., 2021). In carrying out EPAs, there was a statistically significant difference in judgments between residents and surgical team members (P =0.03, CI: 0.51-0.95) as well as between surgical faculty members (P =0.001). Conclusion “The framework of 29 validated and accepted EPAs can guide future surgical residency training programs in the Ethiopian medical education context. The framework allows programs to move from a time-dependent to an outcome-based model and transforms traditional assessment into entrustment decisions. Thus, the use of the framework can improve the quality of training and patient care in Ethiopia” (Amare et al., 2021). The perception/judgment gap that exists between residents and surgical teams and among faculty members could pose a problem in education and healthcare systems. Our study emphasizes the need to describe EPAs in sufficient detail and to make performance criteria transparent and understandable before fully implementing an EPA-based assessment.