Gersten Jonker

General discussion   189 9 1. Clearly articulated competencies for practice as outcome Core EPAs in undergraduate education cover the outcomes that all learners need in the early postgraduate stage. Specialty-specific EPAs add what learners need in specific fields of medicine. Demonstrable competence in these EPAs are taken into account in the individualization and shortening of postgraduate training time [140]. Postgraduate EPAs describe the demands of specialists at certification. Predefined outcomes as a central aim of CBME does not imply that graduates are all the same. All trainees need to achieve competence in the core set of EPAs of the program. In addition trainees can develop and demonstrate competence for elective EPAs belonging to an area of interest such as a subspecialty [138], for example in fellowship training. EPAs need to be explicitly defined and designed according to guidelines [82] and be based on adequate consensus to allow widespread application and implementation. 2. Sequenced progression on a path of expertise development Core EPAs in undergraduate education are expanded with specialty-specific EPAs that fit with the specialty orientation of the learner. Rather than specialty-specific, these EPAs may well be domain-specific, serving as preparation for work in a range of related specialties. Gaining domain-specific competence can be perceived as a fork in the path of development. Longitudinal clerkships, because of continuity in supervision and patient care, optimize the use of EPAs and forming of trust [4, 141-143]. A coherent thematic transitional year must provide longitudinal learning objectives, rotations, and supervision. The undergraduate EPAs are foundational building blocks of larger postgraduate EPAs, which means that a learner expands her accumulated expertise with growth in patient care responsibilities. Learners develop at individual rates in different EPAs. The variable training time model will replace the current model of fixed duration [108, 144- 146]. Issues around workforce planning, professional identity formation, regulatory minimum time requirements, and the traditional emphasis on numbers of exposures need to be addressed. For example, with the focus on outcomes, assured by proper assessment, flexible timing of graduation from undergraduate education is possible – and is occasionally an urgent requirement, such as during the Covid-19 pandemic [147]. Adding to the variation in time are the increased flexibility required by part-time working trainees, individualized training opportunities, and differences in experience prior to commencing postgraduate training. Nonetheless, time is a factor in the growing of trust and entrustment of tasks which are central to assessment around EPAs [142,