Gersten Jonker

General discussion   185 9 out in the Dutch Delphi since they were not relevant for all trainees graduating from the program [50]. Until now, there are no studies comparing EPA-based anesthesiology programs internationally. Certainly, many EPAs would look similar globally, but how cultural context and local healthcare needs affect EPA design, granularity, sequencing, and assessment is an area for future research. A systematic reviewof the 2011-2018 literature on EPAs in postgraduate training showed that 76%of papers reported on EPAdevelopment, while 20%addressed implementation and/or assessment of EPAs, and 4% reported both [87]. Implementation of CBME with or without EPAs is challenging [88, 89], and within anesthesiology training no studies reported on the implementation or assessment of EPAs. Thus, returning to the agenda in Chapter 8, there is a research gap regarding implementation and assessment. FUTURE RESEARCH This thesis offers multiple starting points for further research. A selection of possible studies is suggested below. Thematic transitional year The role of undergraduate EPAs in preparing for postgraduate work needs further elucidation, including the role of workplace assessments and entrustment decisions [56]. In 2016, UMC Utrecht medical school started implementing core undergraduate EPAs [48, 90]. Consequently, supervisors are familiarizing with the concept of EPAs and this makes foregrounding of EPAs in the ACTY feasible. A strengthened implementation of the ACTY in the workplace warrants a replication of the assessment study (Chapter 5) to detect further enhancement of competence development. In addition, a realist evaluation study could elucidate by which mechanisms and in which circumstances the intervention generates its outcome [91, 92]. Furthermore, similar effects from other thematic transitional years could triangulate our findings and support the idea of specialty streaming [93-96]. The ‘intercurricular’ period between undergraduate and postgraduate education, in which recent graduates work as a physician-not-in-training, has importance for professional identity formation and career orientation [97]. Currently, a follow-up study of ACTY graduates is conducted to illuminate their specialty choices and career paths toward the attainment of postgraduate training posts, as enhanced preparedness and competence in the ACTY could shorten the ‘intercurricular’ period. Additional research could concentrate on how supervisors and the clinical environment support learning in