Gersten Jonker

158   Chapter 8 competency frameworks as theoretical and somewhat detached from day-to-day practice [6–9]. Competencies are difficult to assess as separate entities while supervising residents [10, 11]. The true goal of training should not be to attain competencies, but rather to become a doctor with expertise, who is ready to bear professional responsibility and who can be entrusted with the care of patients [1, 12, 16, 18]. A possible way to link competencies to clinical activities is the concept of EPAs [19]. When the performance of daily clinical activities is evaluated well, it is possible to draw inferences about the attainment of predefined competencies [12,18]. ENTRUSTABLE PROFESSIONAL ACTIVITIES An EPA is a task or responsibility, essential to the practice of a specialty. It can be executed individually by a trained professional within a circumscriptive time frame and it requires specific knowledge, skills and attitudes. Each EPA encompasses competencies from different domains and can be observed and assessed by a supervisor. Supervisors can entrust a residentwithanEPA, onceanadequate level of performancehas beenobtained, to execute a task without direct supervision [18–21]. EPAs remove competencies from a theoretical framework by attaching them to the familiar context of clinical practice [16, 22]. They clarify the learning objectives of a program or rotation by displaying the training opportunities that exist in daily work, and offering guidance to assessors on what they should assess [19–21, 23, 24]. Examples of EPAs in anesthesiology are general anesthesia in an American Society of Anesthesiologists (ASA) I to II day surgery patient, handover of a patient to the recovery room, epidural analgesia for labor, admitting a critically ill patient to an ICU, anesthesia for a common procedure in an ASA I to II infant, and trauma life support (Appendix 1). One could think of approximately 5 to 10 EPAs per year of training, with the complete set of EPAs covering the breadth and depth of the specialty. A practical procedure such as inserting a central venous line, would not, on its own, be considered an EPA, but would be incorporated as an item (skill) in several EPAs across several subspecialties, that in this case might include intensive care, cardiac anesthesia and neuro-anesthesia. The same holds true for clinical knowledge, wherein for example, use of inotropes might feature as an item in several EPAs from different subspecialties, but would not stand alone as an EPA. Also, competencies such as participating in an interprofessional healthcare team may be observed in many EPAs such as trauma life support, but would not constitute an independent EPA.