# data[].attributes.body
WHO
Singapore medical education system will also be gradually adopting EPAs into our medical education assessment. We (faculty and trainees) will need to embark on this EPA journey. It will be rolled out in phases to all the medical related training programmes, inclusive of nursing and allied health.

WHAT
EPAs are professional tasks of a specialty that a trainee can be entrusted to perform in a given healthcare context, once sufficient competence has been demonstrated.

WHEN
Internal Medicine Residency Programme has officially started on this EPA journey from Jul 2023.

WHERE
The whole of Singapore. All 3 SIs will be involved. It will be rolled out in phases for all other residency programmes in the coming years.

WHY
A trainee with good medical knowledge, professionalism, communication skill scores from faculty [competencies] does not always translate to being competent enough to be trusted to run an inpatient general medical ward [EPA], with distant supervision.

Inclusion of EPA allows a more accurate assessment of the trainee's ability to carry out these professional tasks with or without closer supervision. This will also be more useful when it comes to whether a resident can be trusted to progress to a senior resident / associate consultant, when the supervision required reduces significantly.

When we round with a junior doctor, we consciously or subconsciously assess if the junior doctor can be trusted to deliver the patient information accurately and ensures that the tasks are followed through. You react to the junior doctor's entrustability by deciding how obsessive you want to be. E.g. clicking through all the results and seeing the patients multiple times a day vs letting the junior doctor have more autonomy and checking on them less often.

This is essentially how we assess EPAs. The faculty makes a decision about how much a trainee can be trusted to perform the task and at what level of supervision. This is not new and is something that we have been doing for a long time, but never formally included in our assessments.

# data[].attributes.body
Nuts and Bolts of EPA
Prof Olle ten Cate

# data[].attributes.attachment_link.title
Nuts and Bolts of EPA Olle ten Cate 2013

# data[].attributes.body
1. Managing patients in the medical inpatient ward

2. Performing medical bedside procedures

3. Managing acutely ill patients

4. Managing patients in the ambulatory care setting:

Clinic, ambulatory centre e.g. MAC, ED

Refer to below for specifications and limitations for each EPA.

# data[].attributes.attachment_link.title
Entrustable professional activities versus competencies and skills Exploring why different concepts are often conflated

# data[].attributes.body
Transitioning from CBME to EPAs
Adj Associate Professor Mabel Yap

Part 1
https://icenet.blog/2023/01/12/transition-from-existing-systems-to-competency-based-medical-education-cbme-anchored-on-entrustable-professional-activities-epas-the-singapore-experience-part-1/

Part 2
https://icenet.blog/2023/01/19/transition-from-existing-systems-to-competency-based-medical-education-cbme-anchored-on-entrustable-professional-activities-epas-the-singapore-experience-part-2/

# data[].attributes.attachment_link.title
Transition from Existing Systems to Competency-Based Medical Education (CBME) Anchored on Entrustable Professional Activities (EPAs): The Singapore Experience [Part 1]

# data[].attributes.attachment_link.description
By: Mabel Yap, Kantharaj Reddy and Cedric Poh Singapore’s Graduate Medical Education System Singapore’s Graduate Medical Education (GME) system was primarily influenced by the United Kingdom (UK) s…

# data[].attributes.headline
EPA 1: Managing patients in the medical inpatient ward

# data[].attributes.subject
EPA 1: Managing patients in the medical inpatient ward

# data[].attributes.body
Components of this EPA

1. This EPA will require Residents to be assessed based on General Medical knowledge and competencies.

2. Evaluates patients’ problems (review history and physical examination)

3. Interprets laboratory and radiological results

4. Evaluates the problem list with differential diagnoses using clinical reasoning skills and formulates an evidence based diagnostic and management plan

5. Anticipates and manages complications

6. Identifies functional and psychosocial issues

7. Performs hand over and follow up when there is transition of care

8. Change in ward team / discipline

9. On call team / different shifts

10. Coordinates and communicates care plans of patients, in conjunction with other healthcare professionals within the hospital and community

11. Communicates care plans effectively to patients and family members

12. Communicates care plans effectively to health care professionals

13. Maintains professional behaviour and conduct

# data[].attributes.headline
EPA 2: Performing medical bedside procedures

# data[].attributes.subject
EPA 2: Performing medical bedside procedures

# data[].attributes.body
Components of this EPA

1. Identifies indication(s) for procedure

2. Identifies potential complications and contraindications of the procedure

3. Obtains informed consent

4. Conducts pre-procedure check

5. Documents procedure notes and post procedure instructions

6. Analyses and reflects on the factors that contributed to the success or failure of procedure

7. Communicates care plans effectively to patients and family members

8. Communicates care plans effectively to health care professionals

9. Maintains professional behaviour and conduct

# data[].attributes.body
Components of this EPA

1. This EPA will require Residents to be assessed based on General Medical knowledge and competencies necessary for managing acutely ill patients.

2. Recognises unstable patients for prompt escalation of care, for example from general ward setting to intensive care unit.

3. Manages acutely ill patients in general wards & intensive care units, provides medical management, and escalates care where appropriate

4. Coordinates resuscitation efforts

5. Involves multidisciplinary input where appropriate

6. Documents events of resuscitation (medications used and patient care outcome).

7. Discuss initial extent of care

8. Communicates care plans effectively to patients and family members

9. Communicates care plans effectively to health care professionals

10. Maintains professional behaviour and conduct

# data[].attributes.headline
EPA 4: Managing patients in the ambulatory care setting

# data[].attributes.subject
EPA 4: Managing patients in the ambulatory care setting

# data[].attributes.body
Components of this EPA

1. This EPA will require Residents to be assessed based on General Medical knowledge and competencies.

2. Assesses and manages patients with subacute and chronic medical conditions in a clinic or ambulatory medical centre

3. Manages and collaborates care with multi-disciplinary inputs

4. Identifies social, functional and cognitive problems and refers to appropriate community care services

5. Provides primary and secondary preventive care, counselling and management strategies

6. Communicates care plans effectively to patients and family members

7. Communicates care plans effectively to health care professionals

8. Maintains professional behaviour and conduct

# data[].attributes.attachment_caption
Most IM residents will be given an entrustment level varying from level 2 to 3B for each EPA

# data[].attributes.body
The number of workplace-based assessments (WBAs) required per posting will remain the similar. Some questions have been replaced to assess EPA e.g. entrustment based decision questions (refer to next segment for details).

Scores from each WBA will be collated to be reviewed by CCC. The final level of supervision will be based on the performance demonstrated across 6 months of postings with multiple assessments completed. The EPA entrustment level will be not based solely on a single WBA (e.g. 1 monthly performance evaluation).

# data[].attributes.attachment_caption
New IM residents from AY2023 will require to meet the entrustment level targets in order to progress to the next level of training. 

# data[].attributes.headline
EPA Entrustment Level Targets by year of training

# data[].attributes.subject
EPA Entrustment Level Targets by year of training

# data[].attributes.attachment_caption
The number of '+' indicates the likelihood of obtaining relevant data points from the WBA for each specific EPA.

# data[].attributes.headline
WBAs that provides data points for each EPA

# data[].attributes.subject
WBAs that provides data points for each EPA

# data[].attributes.body
Entrustment-based discussion (EbD) aims at estimation of adaptive competence of resident to cope with unfamiliar situations, ie. can the resident be trusted to perform the EPA with lesser supervision and the residents can trusted to care for their patients remain safely with lesser supervision.

Faculty often do not have the luxury of longitudinal exposure with residents, to observe them handle all types of medical conditions. EbD allows the faculty to evaluate residents whom they have limited exposure in the wards / clinic, how much they can trust the residents to manage their patients at lesser supervision.

4 steps in EBDs (intuitive and many are already doing this, focus on step 4)

1. Explain the activity

Resident explains the case / procedure

2. Show depth of knowledge

Resident is able to demonstrate knowledge about important knowledge of the important differentials / indications / therapeutic options)

3. Show awareness of risks

Resident is aware and prepared to deal with the potential risks / complications of the EPA

4. What if...? [key question to ask for EBD]**

Check resident's ability to manage the case in a different context.

What would the resident have done if the context of the patient changes (e.g. gender, age, renal impairment) or unexpected findings arose (e.g. frank blood noted during paracentesis).

# data[].attributes.body
1. How do we come to a shared mental model for each of the entrustment points?

Faculty will go through assessor standardisation through simulation and videos at department meetings to calibrate the frame of reference to assess the resident’s entrustment level.

2. Do AIM faculty consider the resident to be proficient at the same entrustment level, for example, when the resident exited from IM Residency at Level 3B?

It will be essential to grade the resident using the correct entrustment level scale as it differs from AIM and PGY1 programme. To add faculty with this, the entrustment levels will be clearly indicated in each WBAs.

3. Will there be changes to the existing MOPEX forms with the implementation of EPAs?

The MOPEX forms are unchanged for the time being.

4. What are the service and legal implications with the implementation of EPAs? For example, would a resident who is assessed to be at Level 1 be rostered for clinical calls, and if so, what are the medical and legal implications?

For underperforming residents who are not able to at least perform at level 2 or above, a detailed review will be performed to understand the reason for the poor performance to determine suitability to perform certain clinical duties. Under the NHG supervisory policy, all IM residents will receive supervision from their senior residents or consultant who are contactable either physically or telephone call.

5. How EPA grading will affect the residency progression?

All residents will be assessed using EPAs, but only incoming R1s from AY2023 will have summative CCC decisions made using EPA evaluation. IM residents will need to meet specific EPA entrustment levels (see under section on Entrustment level) to progress to the next level of training. The CCC will deliberate on the reasons when the resident is unable to reach the required level of entrustment.

6. Is EPA 2 broken down by specific procedures?

Yes, it is broken down by individual procedures mandated by IM RAC.

7. When will EPA be rolled out to Senior Residents?

IM and AIM Residency will implement EPAs with effect from July 2023.

8. Do you expect trainees to stumble more with this EPA assessment as opposed to the current way we are assessing trainees?

Workplace-based assessments (WBA) for IM residents remained generally similar with the replacement of some questions and addition of entrustment based questions. Therefore, the critical information that we have been using for the past decade to assess IM residents will be retained and the difficulty to do well for any WBA will not increase.

The usage of EPA evaluation can also help refine the feedback for residents.

# data[].attributes.attachment_link.title
The Clinical Teacher - 2017 - ten Cate - From case‐based to entrustment‐based discussions

# data[].attributes.body
https://youtu.be/2hB7ytdPh6A

# data[].attributes.attachment_link.title
Professor Olle ten Cate explains Entrustable Professional Activities

# data[].attributes.body
The number of assessments and types of assessments remain the same.

Some changes to the assessments:
1) RIME questions will be replaced by EPA entrustment levels
- ie. no more reporter-interpreter-manager-educator questions
- will be replaced with entrustment level of each EPA
>> Assessments affected: Monthly Performance Evaluation and Mini-CEX, DOPS

2) Addition of entrustment based discussion (EbD) questions
- these are the 'what if' questions [refer to 'Making Entrustment based decisions for details]
- e.g.
(a) DOPS for abdominal paracentesis, to ask 'what if there was frank blood after the needle injection? What are your differentials and what would be your next step of action?'.
(b) Mini-CEX: What if this patient who is admitted for pneumonia has significant immunosuppression? How does that change the way you investigate / manage?
>> Assessments affected: Mini-CEX, DOPS, CSR (CSR done b CCFM only)

# data[].attributes.body
The number of assessments you need to do remains the same.

However, it is important that you take charge of your own assessment, to ensure that all EPAs get evaluated. Do encourage your faculty to ask Entrustment Based Decision questions to help your learning and ask for feedback on your performance.

EPA 1 (inpatient): is the easiest to meet as it evaluates your inpatient performance

EPA 2 (procedure): assessed via DOPS, please ensure you get your DOPS completed after your procedure.

EPA 3 (sick patient): you can get this EPA assessed in your ICU rotations and sometimes in general ward rotation if you have unwell patients you need to manage. Do remind your faculty to assess more than 1 EPA in your Monthly Performance Evaluation

EPA 4 (ambulatory): trigger a performance evaluation to faculty whom you have worked with when you are the opportunity to cover the ambulatory care setting (e.g. clinic, medical ambulatory centre, ED).

# data[].attributes.headline
Mini CEX: Mini Clinical Evaluation Exercise

# data[].attributes.subject
Mini CEX: Mini Clinical Evaluation Exercise

# data[].attributes.headline
DOPS: Direct Observation of Procedural Skills

# data[].attributes.subject
DOPS: Direct Observation of Procedural Skills