Gersten Jonker

General discussion   179 9 undergraduate EPAs could prepare ACTY students for work in a range of specialties and could integrate into a larger acute care elective EPA. Elective EPAs help the student to identify capabilities and learning needs [45], motivate to work on those learning needs (Chapter 3), and aid to determine preparedness to transition into a specific postgraduate direction [46]. This would result in a relation between acute care EPAs as shown in Figure 2, fostering a continuum in competence development. The acute care undergraduate core EPA would be ‘Being first responder to patients with acute deterioration and mobilizing capable help’, akin to the acute care EPA in the core undergraduate set developed in Berlin [47] and somewhat broader than ‘Providing basic life support’, an Utrecht core undergraduate EPA regarding acute care [48]. Domain-specific interdisciplinary undergraduate EPAs, the redesigned ACTY objectives, would build on the core EPA by extending responsibilities to initiating diagnostic tests and first steps in management, e.g. ‘Being first responder, initiating diagnostic tests and first steps in management for patients with respiratory compromise’. One or more specialty-specific EPAs could flank the domain-specific EPAs to optimally prepare for the elective EPA. An example could be ‘Being first responder, initiating diagnostic tests and first steps in management for patients with altered consciousness’, which would also be a final year EPA for different students, aspiring postgraduate training in neurology or neurosurgery. The core EPA and the domain-specific and specialty-specific extensions could nest up into larger postgraduate advanced life support EPAs, e.g.‘Manage a high-acuity patient with a well- defined presentation, illness, or injury’ from emergency medicine [49] or ‘Resuscitation and admission of the adult patient in need of intensive care’ from anesthesiology [50]. A hierarchy of core, specialty-specific, domain-specific, and elective undergraduate EPAs, as depicted in Figure 2, better maps acute care competence development to prepare for work in this domain. The stepwise increase in difficulty resonates with the zone of proximal development in that learners can carry out tasks just beyond the current level that cause constructive friction necessary for competence development [22-25]. Supposedly, the stepwise model will increase hands-on experiences under appropriate guidance as it better fits with workplace affordances [36]. It will facilitate meaningful participation in the work of the community of practice [35], and improve the preparatory effect of the ACTY.