Gersten Jonker

An agenda for development and research   157 8 INTRODUCTION Every day, attending anesthesiologists delegate clinical tasks to residents. Most decisions to delegate aremade informally and implicitly, often based on limited personal impressions of knowledge, skills, attitudes and trustworthiness of the trainee. Attending anesthesiologists should be able to justify these decisions. Such justification is of prime importance in the guarantee of quality of care, patient safety, supervisor’s liability and educational appropriateness. Justification becomes even more important as society increasingly expects the medical profession to account for the quality of its members, including that of residents and graduates [1, 2]. Demands aremade on specialty-training programs to demonstrate that their graduates have mastered all desirable abilities, or competencies, at completion of training [3, 4]. In addition, clear end-points in specialty- training make benchmarking and comparison of training programs on a national or international level possible. This is what competency-based education is aimed at [5]. However, competencies that set out the desirable traits of a doctor in general terms are difficult to observe and assess in day-to-day clinical practice [6–11], making proof of mastery of competencies and comparison of training programs difficult. In this article, we discuss competency- based training, its problems and move towards a potential solution: the emerging concept of entrustable professional activities (EPAs) [12]. We will describe how EPAs link competencies to clinical tasks and how EPAs allow justification of decisions to delegate by attention to observation of clinical performance. Lastly, we will set an agenda for curriculum development and research on this topic. COMPETENCY-BASED TRAINING For more than a decade, training in medical specialties has been based around competency frameworks, such as that of the Accreditation Council for Graduate Medical Education (ACGME) intheUnitedStatesor theCanMEDSof theRoyal Collegeof Physicians and Surgeons of Canada [13]. These frameworks set out for several competency domains what are considered to be the critical abilities needed for professional practice [3]. With competency-based training, a shift from knowledge acquisition to knowledge application is intended [14], with attained competence rather than time-in-training being the key [15]. Competency-based training has its limitations. A potential pitfall is that the art of medicine is broken down into a detailed list of competencies taken out of context [12, 15–17]. Often behavioral descriptors are formulated in universal terms that are not designed for a specific specialty [18]. Many clinical educators see current