Clinical Distinction

Your future, by you

Assessment Tools: Entrustable Professional Activities

person writing notes on her notebook

Tools for Lifelong Learning

The practice of evaluating entrustability is one that can be carried into all of a student’s clinical training.

The extra effort to select, understand, practice and self-assess EPAs during the specialty track offers the student an opportunity to own their education and move towards success in their profession.

Not all students will use EPAs but those that do benefit in multiple ways.

14 EPAs for a Medical Student

Entrustable Professional Activities are a key feature of Specialty Track Clinical Distinction courses that will help you with the assessment part of your course design.

These are TUCOM’s 14 EPAs, adopted from AACOM’s EPAs

  1. Gather a history and perform a physical examination
  2. Prioritize a differential diagnosis following a clinical encounter
  3. Recommend and interpret common diagnostic and screening tests
  4. Enter and discuss orders and prescriptions
  5. Document a clinical encounter in the patient record
  6. Provide an oral presentation of a clinical encounter
  7. Form clinical questions and retrieve evidence to advance patient care
  8. Give or receive a patient handover to transition care responsibility
  9. Collaborate as a member of an interprofessional team
  10. Recognize a patient requiring urgent or emergent care and initiate evaluation and management
  11. Obtain informed consent for tests and/or procedures
  12. Perform general procedures of a physician
  13. Identify system failures and contribute to a culture of safety and improvement
  14. Integrate Osteopathic Principles and Practice into clinical practice
low angle photography of tunnel

Benefits of Using EPAs

EPAs allow a student to understand what is expected of them as they begin residency.

EPAs allow a student a tool to improve their ability to practice medicine.

The practice of evaluating entrustability is one that can be carried into all of a student’s clinical training.

Language of Entrustability

EPAs are a foundational component of the language residency directors will recognize in reviewing the student MSPE.

Entrustment decisions indicate competency attainment because any one EPA requires a level of skill and knowledge in multiple competency areas. Taking a focused history requires communication skills, professionalism, and clinical reasoning skills of patient care.

arches hallway inside building
gray and white concrete staircase

Across Time

EPAs allow a student to track their progress in core competencies.

But doing an EPA once isn’t enough to verify entrustability.

For example, taking a history and physical, t is something a medical student might be able to do well in the setting of an adult well visit and yet struggle in the face of a pediatric patient or an emergency setting. Determining entrustability requires multiple workplace assessments across a variety of workplace settings.

Before and After: How it Works

An authentic assessment requires observation of the student by a preceptor or a more senior medical professional. Students should also self-assess. Comparing one’s self-assessment to an external observer’s assessment is a valuable learning strategy. Before beginning their course, students are asked to self-evaluate their level of entrustability. After the course, they repeat the evaluation to document growth.

If a preceptor watches you perform one of these tasks and decides “I trust this student to do this task on their own” it means several things.  First, you have achieved a certain level of entrustment in that particular moment, in that particular task, and perhaps in a particular patient population. Second, from it, one can infer that you have increased competence in aligned core competencies.

For example, you perform an H&P with an elderly patient, develop a good rapport, get an HPI, a medication list for reconciliation, and perform a screening physical examination. After observing you do this, your preceptor tells you to go see the next three patients alone. You have demonstrated professionalism, interpersonal communication skills, patient care skills, and perhaps even some medical knowledge. Your preceptor now trusts you to go see a few patients alone.

Entrustability Rubric

Using the following rubric allows for quick evaluation of your level of entrustability that can be completed in an instant even during a busy clinic day.

Level 1

photography of red rose plant

Not allowed to do the EPA

close up photo of green leafed plant
  • 1a Not allowed to observe –> “Please wait here and do some reading.”
  • 1b Allowed to observe,–> “Watch me do this.”

This rubric was adopted from that developed by: H. Carrie Chen, MD, MSEd, W.E. Sjoukje van den Broek, MD, and Olle ten Cate, PhD who published it in The Case for Use of Entrustable Professional Activities in Undergraduate Medical Education.

Level 2

background beautiful beauty bloom

Do with full direct supervision

close up photo of purple lilac flowers
  • 2a Co-activity with supervisor –> “Let’s do this together.”
  • 2b Supervisor in room ready to help–>  “I’ll watch you.”

There is a final level which we don’t expect you to reach:

Level 3

white petaled flower on grass

Do with supervision on demand

selective focus photography of green succulents
  • 3a Supervisor immediately available all findings checked –>  “You go ahead, and I’ll double-check all of your findings.”
  • 3b Supervisor immediately available key findings checked–> “You go ahead, and I’ll double-check key findings.”

3c Supervisor distantly available (phone) findings reviewed –> ( in most instances, a student must be licensed ( intern), for a supervisor to allow this level of supervision, therefore most students can only reach this stage hypothetically.


low angle photography of tunnel

It’s a good idea to have a before an after evaluation – not just your own opinion, but from your sponsor.

If you ask your sponsor to use the rubric when they first observe you and then again at the end, or throughout the rotation you will see your growth.

low angle photography of tunnel

In writing your contract and your final self-evaluation, base your self-assessment on where you believe you are clinically rather than on what you are allowed to do without supervision.

But consider that a level 3C means you are confidently functioning like an intern! You aren’t expected to achieve this level in medical school.

low angle photography of tunnel

After doing a self-assessment, a student will strongly benefit from asking a faculty member, who can observe them in the workplace setting or even in a simulated setting to give them an objective assessment of entrustability.

Even better, get your faculty member to evaluate you at the beginning and end of the project as well as throughout so that you can document your growth more authentically.

More Information

Learn How EPAs can benefit your learning and your MSPE. This is a great topic of conversation to have with your CD course director.

AAMC and AACOM describe 13 EPAs. AACOM has included osteopathic components into the 13 EPAs originally described by AAMC. TUCOM has added a 14th distinctly osteopathic EPA and published an article on it.  Here are some interesting documents to review:

Core Entrustable Professional Activities for Entering Residency