Gersten Jonker

180   Chapter 9 FIGURE 2: Hierarchical relation of undergraduate and postgraduate acute care EPAs. At the base is core EPA ‘Being first responder to patients with acute deterioration and mobilizing capable help’. For students preparing for work in acute care this EPA is extended with (middle, blue) domain-specific EPA 1 and 2 ‘Being first responder, initiating diagnostic tests and first steps in management for patients with respiratory compromise’and ‘Being first responder, initiating diagnostic tests and first steps in management for patients with circulatory compromise’. Together with a related specialty-specific EPA ‘Being first responder, initiating diagnostic tests and first steps in management for patients with altered consciousness’ (middle, amber), the domain-specific EPAs integrate into, but are not necessary equal to, elective EPAs (i.e. postgraduate EPAs) such as ‘Manage a high-acuity patient with a well-defined presentation, illness, or injury’ [49] or ‘Resuscitation and admission of the adult patient in need of intensive care’[50] (top). These postgraduate EPAs need further postgraduate expertise. A hierarchy of EPAs could be the unifying framework that leads to far-reaching vertical integration and shaping of a continuum [42]. The appropriate degree of supervision, i.e. thedegreeof independencegranted, couldbe tailoredtothedevelopmentof thestudent with a granular entrustment-supervision scale [51-54]. However, the implementation of assessment leading to entrustment decisions in undergraduate medical education is work in progress and is challenging [55, 56]. Emergency physicians suggest to resort to simulation-assessment for the evaluation of acute care EPAs, alluding to the lack of opportunities and concern for patient safety in the workplace, as well as the benefit of standardization and realistic portrayal of (classic) presentations [57]. The tension that exists between quality of care and student learning is omnipresent in medical education, but very salient in acute care and supervisors must negotiate this tension in ad hoc and summative entrustment decisions [58]. From a community of practice perspective, it requires commitment of supervising faculty to reconcile experiential learning and patient safety [59].