HMS Focus: Recent Academy Publications

FazioCompetency Expectations in the Internal Medicine Clerkship

Sara B. Fazio, MD, FACP
Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School

A summary of Fazio SB, Ledford CH, Aronowitz PB, Chheda SG, Choe JH, Call SA, Gitlin SD, Muntz M, Nixon LJ, Pereira AG, Ragsdale JW, Stewart EA, Hauer KE. Competency-Based Medical Education in the Internal Medicine Clerkship: A Report from the Alliance for Academic Internal Medicine Undergraduate Medical Education Task Force. Academic Medicine. 93(3): 421-427, March 2018
Competency-based medical education (CBME) has become a defining feature of medical education reform over the past decade, with an increasing presence in undergraduate medical education (UME). A competency-based approach occurs along a continuum, facilitating the learner to proceed at a more flexible and individualized pace, within limits. It is also learner-centered and can support learners’ growth mindset. Learners benefit from frequent feedback on competencies and milestones to guide their course along a developmental trajectory. Rather than basing outcomes on an arbitrary construct of time, a CBME approach offers a behavioral paradigm. In CBME, a learner’s ability (knowledge, skill, or attitude) is determined based upon the learner’s demonstrated performance of specific tasks essential to the profession. Entrustable Professional Activities (EPAs) have thus emerged as a practical way to assess learner competency. (1,2) An EPA is a unit of work (an activity essential to the practice of medicine) that is both observable and measurable and encompasses one or more competency domains. (1,2)
In 2014, the Association of American Medical Colleges (AAMC) published the ‘Core Entrustable Activities for Entering Residency, or CEPAERs, creating a list of 13 EPAs expected of all graduating medical students (3) While their use has been successfully implemented in a number of medical schools, (4) they are broad in scope and don’t always differentiate between early and later student learners. In addition, there is currently no uniform approach to define competency expectations for students during their core clerkship year. How to assess time-variable CBME is even more nascent. The Alliance for Academic Internal Medicine (AAIM) created a task force to consider these educational advancements by developing a paradigm for competency-based assessment of students during the inpatient internal medicine (IM) clerkship.
Building on work at the resident and fellowship level (5,6), our task force focused on EPAs that were specific to educational experiences on the IM clerkship and identification of high-priority assessment domains. The goal was to highlight a small subset of EPAs that should be considered the principle responsibility of the IM clerkship, as well as observations that were achievable and measurable within the confines of a 6- to 12-week traditional block clerkship structure. The task force also considered how these EPAs could also be applied to clerkship models using longer time frames, where principles of EPAs and entrustment have been well-described. (7) Our work was informed by a national survey of clerkship directors, the Clerkship Directors of Internal Medicine (CDIM) annual survey. 
Six key EPAs emerged: generating a differential diagnosis, obtaining a complete and accurate history and physical exam, obtaining focused histories and clinically relevant physical exams, preparing an oral presentation, interpreting the results of basic diagnostic studies, and providing well-organized clinical documentation. While not meant to represent all that should be assessed in the IM clerkship, the AAIM UME Task Force Report highlights a subset of EPAs that could underpin a common means of assessment across all IM clerkships. We proposed a model for this assessment and a standardized template, including subcomponents for a given EPA with specific behavioral anchors. We aligned descriptors with the scale of supervision and mapped domains to the Accreditation Council for Graduate Medical Education (ACGME) domains of competence. (8,9)
The true value of a competency-based system is in structuring the assessment of a learner’s readiness for progression; CBME seeks to avoid being overly prescriptive as it requires direct observation of measurable behaviors in order to assess this progression and to institute corrective feedback where necessary. When EPA assessment overlaps between clerkships or is longitudinal in nature, educators will be able to accrue additional evidence to support generalizability of observations. A student may demonstrate a different performance in an EPA in one clerkship compared to another, either due to case-specificity or an individual’s different strengths and weaknesses. This further underscores the need for multiple assessments in a variety of different settings as well as a final determination of EPA “readiness” at the end of the clerkship year. We believe that a consistent approach in defining outcomes will better inform the design of practical and purposeful learning experiences within core internal medicine rotations. We hope that such an approach will facilitate the ability of educators to bridge competency evaluations within and across core clerkships and to extend this work to advanced electives and across the continuum into postgraduate training. (10)
3. Association of American Medical Colleges Core Entrustable Professional Activities for Entering Residency: Curriculum Developer’s Guide. Washington, DC: Association of American Medical Colleges; 2014:
6. Alliance for Academic Internal Medicine. Subspecialty fellowship milestones. Published February 2014.
8. Accreditation Council for Graduate Medical Education; American Board of Internal Medicine. The Internal Medicine Milestone Project Published July 2015.
9. NEJM Knowledge+ Team. Exploring the ACGME Core Competencies (Part 1 of 7). Accessed 4/8/19.