Core Entrustable Professional Activities
For the complete publication published by the AAMC, which identifies the list of 13 Entrustable Professional Activities (EPAs) to be expected of all MD graduates transitioning from medical school to residency, please visit the AAMC website. The guide delineates the integrated activities that all entering residents should be expected to perform on day one of residency without direct supervision regardless of specialty choice.
EPA 1: Gather a history and perform a physical examination
Day 1 residents should be able to perform an accurate complete or focused history and physical exam in a prioritized, organized manner without supervision and with respect for the patient. The history and physical examination should be tailored to the clinical situation and specific patient encounter. This data gathering and patient interaction activity serves as the basis for clinical work and as the building block for patient evaluation and management. Learners need to integrate the scientific foundations of medicine with clinical reasoning skills to guide their information gathering.
EPA 2: Prioritize a differential diagnosis following a clinical encounter
To be prepared for the first day of residency, all physicians need to be able to integrate patient data to formulate an assessment, developing a list of potential diagnoses that can be prioritized and lead to selection of a working diagnosis. Developing a differential diagnosis is a dynamic and reflective process that requires continuous adaptation to avoid common errors of clinical reasoning such as premature closure.
EPA 3: Recommend and interpret common diagnostic and screening tests
This EPA describes the essential ability of the day 1 resident to select and interpret common diagnostic and screening tests using evidence-based and cost-effective principles as one approaches a patient in any setting.
EPA 4: Enter and discuss orders and prescriptions
Writing safe and indicated orders is fundamental to the physician’s ability to prescribe therapies or interventions beneficial to patients. It is expected that physicians will be able to do this without direct supervision when they matriculate to residency. Entering residents will have a comprehensive understanding of some but not necessarily all of the patient’s clinical problems for which they must provide orders. They must also recognize their limitations and seek review for any orders and prescriptions they are expected to provide but for which they do not understand the rationale. The expectation is that learners will be able to enter safe orders and prescriptions in a variety of settings (e.g., inpatient, ambulatory, urgent, or emergent care).
EPA 5: Document a clinical encounter in the patient record
Entering residents should be able to provide accurate, focused, and context-specific documentation of a clinical encounter in either written or electronic formats. Performance of this EPA is predicated on the ability to obtain information through history, using both primary and secondary sources, and physical exam in a variety of settings (e.g., office visit, admission, discharge summary, telephone call, email). Documentation is a critical form of communication that supports the ability to provide continuity of care to patients and allows all health care team members and consultants to
- Understand the evolution of the patient’s problems, diagnostic work-up, and impact of therapeutic interventions.
- Identify the social and cultural determinants that affect the health of the patient.
- View the illness through the lens of the patients and family.
- Incorporate the patient’s preferences into clinical decision making.
EPA 6: Provide an oral presentation of a clinical encounter
The day 1 resident should be able to concisely present a summary of a clinical encounter to one or more members of the health care team (including patients and families) in order to achieve a shared understanding of the patient’s current condition. A prerequisite for the ability to provide an oral presentation is synthesis of the information, gathered into an accurate assessment of the patient’s current condition.
EPA 7: Form clinical questions and retrieve evidence to advance patient care
On day 1 of residency, it is crucial that residents be able to identify key clinical questions in caring for patients, identify information resources, and retrieve information and evidence that will be used to address those questions. Day 1 residents should have basic skill in critiquing the quality of the evidence and assessing applicability to their patients and the clinical context. Underlying the skill set of practicing evidence-based medicine is the foundational knowledge an individual has and the self-awareness to identify gaps and fill them.
EPA 8: Give or receive a patient handover to transition care responsibility
Effective and efficient handover communication is critical for patient care. Handover communication ensures that patients continue to receive high-quality and safe care through transitions of responsibility from one health care team or practitioner to another. Handovers are also foundational to the success of many other types of interprofessional communication, including discharge from one provider to another and from one setting to another. Handovers may occur between settings (e.g., hospitalist to PCP; pediatric to adult caregiver; discharges to lower-acuity settings) or within settings (e.g., shift changes).
EPA 9: Collaborate as a member of an interprofessional team
Effective teamwork is necessary to achieve the Institute of Medicine competencies for care that is safe, timely, effective, efficient, and equitable. Introduction to the roles, responsibilities, and contributions of individual team members early in professional development is critical to fully embracing the value that teamwork adds to patient care outcomes.
EPA 10: Recognize a patient requiring urgent or emergent care and initiate evaluation and management
The ability to promptly recognize a patient who requires urgent or emergent care, initiate evaluation and management, and seek help is essential for all physicians. New residents in particular are often among the first responders in an acute care setting, or the first to receive notification of an abnormal lab or deterioration in a patient’s status. Early recognition and intervention provides the greatest chance for optimal outcomes in patient care. This EPA often calls for simultaneously recognizing need and initiating a call for assistance. Examples of conditions for which first-day interns might be expected to recognize, initiate evaluation and management, and seek help include the following:
- chest pain
- mental status changes
- shortness of breath and hypoxemia
- hypotension and hypertension
- tachycardia and arrhythmias (e.g., SVT, Afib, heart block)
- oliguria, anuria, urinary retention
- electrolyte abnormalities (e.g., hyponatremia, hyperkalemia)
- hypoglycemia and hyperglycemia
EPA 11: Obtain informed consent for tests and/or procedures
All physicians must be able to perform patient care interventions that require informed consent. From day 1, residents may be in a position to obtain informed consent for interventions, tests, or procedures they order or perform (e.g., immunizations, central lines, contrast and radiation exposures, blood transfusions). Of note, residents on day 1 should not be expected to obtain informed consent for procedures or tests for which they do not know the indications, contraindications, alternatives, risks, and benefits.
EPA 12: Perform general procedures of a physician
All physicians need to demonstrate competency in performing a few core procedures on completion of medical school in order to provide basic patient care. These procedures include:
- Basic cardiopulmonary resuscitation (CPR)
- Bag and mask ventilation
- Inserting an intravenous line
EPA 13: Identify system failures and contribute to a culture of safety and improvement
Since the publication of the IOM reports “To Err is Human”25 and “Crossing the Quality Chasm,”26 the public has been focused on the need to improve quality and safety in health care. Preventing unnecessary morbidity and mortality requires health professionals to have both an understanding of systems and a commitment to their improvement. This commitment must begin in the earliest stages of health professional education and training. Therefore, this EPA is critical to the professional formation of a physician and forms the foundation for a lifelong commitment to systems thinking and improvement.