Ideally, all medical school graduates should be ready to conduct routine clinical activities upon entering residency. In reality, there are disparities between what activities interns are expected to perform by residency program directors and those they feel ready to perform. Gaps like this could be responsible for what’s known as the “July effect,” an association between the time of year when interns begin their residencies and higher rates of medical complications.
In response, the Association of American Medical Colleges (AAMC) developed a list of 13 core “entrustable professional activities” (EPAs) that new physicians should be able to perform without supervision on their first day of residency. The AAMC then selected 10 medical schools across the country to integrate EPAs into their curricula; the College of Physicians & Surgeons is one such pilot school.
The CUMC Newsroom sat down with Jonathan Amiel, MD, site principal investigator for the P&S pilot, to find out more about the program.
Q: What kind of activities should new residents be able to perform on Day 1?
Amiel: They range from relatively simple things— collecting a history and performing a physical exam, doing common procedures, writing notes, and making oral presentations—to the more sophisticated, like getting involved in quality improvement projects or handing off to other members of the care team.
All of these are clearly important in terms of taking care of patients.
Q: How do the perceptions of medical students and residency directors compare in terms of student readiness, and what are the consequences?
Amiel: When the AAMC polled program directors and graduating students, they found concordance in confidence on certain EPAs—on getting a history and physical, on making presentations.
But for some of them, there were fairly significant gaps. For instance, the program directors had significantly less confidence in students’ ability to do handoffs than the students themselves. Program directors had more confidence in students’ abilities to do common procedures than the students did.
What happens when there’s this kind of gap is that when interns are just starting their graduate medical education, they may be cautious in communicating what they’re not confident in because they want to make a good impression on their supervisors, and if they’re assigned to something that they don’t feel qualified or confident to do, they may try to do it anyway without asking for enough training or supervision, and that could result in pretty significant lapses in patient safety.
Q: Why not just create a “boot camp” at the end of medical school to impart these skills?
Amiel: You can’t learn how to do basic procedures overnight or in the last week of medical school; you have to learn what are the basic principles and then practice them over time with some kind of supervision, some kind of assessment—and opportunities for remediation if you need them. To actually do that, the kind of curriculum that you have to develop is pretty significant.
Over the past 2 1/2 years, we’ve been working with the nine other schools to develop more consistent curricula and assessment methods and, more importantly, an overall structure of coaching. Coaching is meant to help students reflect on what kind of information they’re getting back about their own performance so that they can improve it over time and can request or seek out additional opportunities for enrichment. The hope is that by the end of medical school, every medical student will feel confident to perform the activities that we’re focusing on and be really strong when they start out their internships.
Q: Have any of these changes been implemented at P&S?
Amiel: We started with the class of 2019, and the work begins by orienting the class to the EPAs. We’ve set up a longitudinal coaching program where each student has a coach that teaches them in our Foundations of Clinical Medicine seminar course for first-year students, but also stays with them over the course of the four years. The students meet with the coaches once or twice a semester to go over how medical school is going, what kind of feedback they’re getting—both directly observed by the coach in the Foundations course and, later, on clinical services and in clinical skills assessments. Our aim is to establish a trusting relationship between the coach and the student so that the student can come to the coach over the course of their medical school education with the feedback that they’ve gotten and try to interpret it so that they can create their own short-term and long-term learning plan.
Q: When you finish the pilot, are you expected to provide specific recommendations on how to incorporate these curricular changes—and how does that work given the differences among schools?
Amiel: By the end of the five-year pilot, what we’re hoping to articulate is what’s the promise of EPAs for a medical education program as a whole and what are some tips for implementing this kind of competency-based education curriculum in specific medical settings. The 10 schools in the pilot program are quite different, and the idea was to look at how the EPA framework could be implemented in all these kinds of institutions. So the other schools like P&S can learn from our experience, whereas a school that’s just starting up might look to see what they can draw from ours but also what might be different.