Since 2010, medical education organizations have been collaborating to carve a new pathway for students interested in pediatrics. Instead of the traditional “time in place” model that demands four years of medical school plus three years of residency training, the Association of American Medical Colleges’ Education in Pediatrics Across the Continuum (EPAC) project is exploring a competency-based training program where a student advances based on whether or not they’ve mastered a set of specific skills. With support from the Macy Foundation, the AAMC is now piloting the program at four sites (University of California, San Francisco; University of Colorado-Denver; University of Minnesota; and University of Utah). The program grew out of a partnership between AAMC, the American Board of Pediatrics, and the Accreditation Council for Graduate Medical Education and a group of senior educators eager to develop a new training model that would ensure all health professionals entering practice today have the necessary skills to deliver the best quality of care.
“The goal is to optimize education to create better doctors,” explained Robert Englander, MD, MPH, former Senior Director, Competency-Based Learning and Assessment at AAMC, and former Co-PI on the project. “The best way to do this is to be very clear with students about what good outcomes look like and what skills are needed to deliver those outcomes. Today, there is universality in the amount of time it takes to become a doctor, but there is not universality in each student’s level of competency. Our hope with EPAC is to show that if students advance based on their level of competency rather than time, we’ll create a system where all health professionals deliver the highest quality of care,” he said.
Converting to a model of education that is based on competency skills instead of simply the amount of time spent in training requires a lot of collaboration, coordination, and planning. Dr. Englander identified four key steps to getting to a competency-based system of medical education:
- Step 1: Identify your desired outcomes. The desired outcomes, or the competencies, have been defined for a physician. They include 58 competencies in eight domains. The domains range from patient care and professionalism, to interprofessional collaboration and interpersonal communication skills (1). Each of these activities require the integration of 4-8 of the 58 competencies in 8 domains that in the aggregate define a physician (1). The ability of the learners to integrate these competencies into the entrustable professional activities will be measured along the way to ensure the outcome of well-rounded and capable doctors.
- Step 2: Identify what the competency looks like at various levels of performance. Set milestones to measure performance levels and be explicit about the desired outcomes.
- Step 3: Develop a framework to assess the competencies. For the EPAC program, assessment is rooted in a framework of Entrustable Professional Activities (EPAs) One set of EPAs are the Core EPAs for entering residency published by the AAMC last year. These are activities that a medical student must be able to do without direct supervision to move on to residency. Once in residency, the pediatrics community has defined a second set of EPAs that residents must be entrusted to do unsupervised to move from residency into practice. Only through entrustment on these activities will medical students and residents be able to make the transitions from medical school to residency and residency to practice, respectively.
- Step 4: Measure outcomes. It is critical to see if the model is leading to better care. Measuring outcomes needs to be a core part of the process.
The EPAC Steering Committee and the pilot sites spent four years developing EPAC and they have just selected (or are about to select) the first cohort of four students from each institution to pilot the model. All students in the program have made a commitment to the pediatrics field and to remain at their respective institution for residency.
Garnering that kind of commitment isn’t easy, admits Dr. Englander, but it’s critical for this pilot to work since they are testing competencies over time.
Four students from each institution were chosen to make the program logistically manageable. Dr. Englander says they plan to start small and eventually scale it up as it matures, both to other programs and to other specialties. Students from each of the schools will meet with the project teams twice a year, sharing what’s working well and what’s not. They’ll then provide real-time feedback. “We really want the students to create a learning community amongst themselves, and be a part of the decision-making process,” he says.
Although the program is competency-based, the pilot sites cannot guarantee EPAC students will necessarily finish their training faster (a common misperception of the program). “What we can say,” Dr. Englander explained, “is that when you are clear about the desired outcomes and the path to get there, on average, training should take less time. If you look outside of medicine (K-12) where this is happening, you see that when you move from time-based to competency-based, you almost always see a decline in the time it takes to get to the next level,” he said.
What the EPAC program can promise students though, is the opportunity to develop lasting, longitudinal relationships with peers, faculty, and patients. This perk is the one that Dr. Englander says most excites prospective applicants. Because students are placed in clinical clerkships during medical school and remain there through residency, many of them will be working with the same staff for several years. During this time they’ll also be building relationships with senior faculty and students in the program. “It is a win-win for everyone,” he said.
In the future, AAMC hopes to expand EPAC to other pediatric programs in the country, and involve more students. After the program has piloted for a few years, they’d then like to look at bringing other specialties on board.
To learn more about EPAC, visit: https://www.aamc.org/initiatives/epac/.
1.Englander R, Cameron T, Ballard AJ, Dodge J, Bull J, Aschenbrener CA. Toward a Common Taxonomy of Competency Domains for the Health Professions and Competencies for Physicians. Academic Medicine. 2013;88(8):1088-1094.