Clinical Distinction

Your future, by you

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Rubric of Entrustability

Thinking about using EPA’s as part of your Clinical Distinction Specialty Track Assessment Strategy? Understanding the rubric is imperative.

First – let’s take a look at the rubric:

Level 1: Not allowed to do the EPA

  • 1a Not allowed to observe –> “Please wait here and do some reading.”
  • 1b Allowed to observe,–> “Watch me do this.”

Level 2: Do with full direct supervision

  • 2a Coactivity with supervisor –> 2a. “Let’s do this together.”
  • 2b Supervisor in room ready to help–> 2b. “I’ll watch you.”

Level 3: Do with supervision on demand

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

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.

It’s so straightforward that most students and preceptors find it natural to use. But thinking about it a little before you dive in can improve your outcome dramatically.

So, let’s talk about how you will use the rubric:

The first place you’ll actually see the EPAs is in drafting your contract. You should notice there is an NA option – meaning you aren’t using EPAs. Not every student will use them! The simplest way to decide is based on doing clinical activities – if you are you should use them. If you aren’t most of the time you won’t use them. If you really want to, or think it’s applicable to you but aren’t doing clinical activities, talk to your CD course director.

Your contract and final evaluation are self-assessments. When you encounter the EPAs you’ll be asked two questions – which competency are you assessing by your EPA growth and what level are you at before and after.

EPAs and Competency Growth

One concept that can be hard to grasp is that EPAS are assessing competency growth. For example, if you are trusted to perform an H&P alone, it means you must:

  • have a level of professionalism
  • have a level of medical knowledge
  • have some communication skills
  • have some patient care skills

Notice how vague those statements are? Obviously, they refer to the competencies but EPAs allow a concrete way to say, this medical student is on the way to being a doctor. We can see that because of their competency growth, which we can infer from their capacity to perform these specific tasks of a physician.

Ok, now how do you pick a level of entrustment?

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.

Ready for a two-fer? (two rewards for one action)

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. Here are the two things you get from this:

  1. A sense of where you are in your development towards being a medical professional.
  2. A snapshot into your ability to self-assess.