Investigations into the use of entrustable professional activities in postgraduate medical education

Postgraduate medical education (PME) is constantly subject to change. New insights in the medical field cause the content of PME programmes to change, as well as the emergence of new educational methods and guidelines regarding how content can best be translated into training practice. Chapter 1 of this dissertation, the general introduction, describes the emergences of the entrustable professional activity (EPA). This chapter presents how the EPA method is designed for PME and why it has been applied in numerous PME programmes. The EPA is considered the ideal instrument for translating competencies into clinical practice. It intends to create a better fit between the intended curriculum on paper and the enacted curriculum in practice. This promise has ensured the widespread use of EPA in the curricula of PME programmes around the world. The rapid development and popularity of the EPA method has also led to a significant amount of research regarding how EPAs can be best created and written down. Nevertheless, research on the use of the EPA method in clinical practice lagged behind. This gap in the literature has led to the main question of this dissertation: how are EPAs used in practice, and does this use correspond with how EPAs were intended to be used in theory? In addition, this work interrogates whether, from the perspective of users, the introduction of EPAs has been a meaningful addition for PME programmes. Chapter 2 describes the emergence of EPAs in PME and the potential benefits and pitfalls of working with EPAs. To describe the use of EPAs in practice, Chapter 3 focuses on programme directors’ and residents’ justifications for entrustment decisions recorded in an electronic portfolio. Chapter 4 focuses on the extent to which faculty within the obstetrics and gynaecology training programme recognise and acknowledge the results found in Chapter 3. The work then turns from faculty experiences to the experiences of residents with EPAs. Chapter 5 provides an impression regarding how residents used EPAs during their training and to what extent they noticed that the level of supervision was adjusted to their level of entrustment. The analysis provides insights into the differences in how residents use EPAs for their own training. In addition to the experiences of faculty and residents, this work addresses a third stakeholder who is majorly impacted by the EPAs: the curriculum developers. Chapter 6 investigates four national training programmes with different backgrounds. Chapter 7 then examines whether further detailed training programmes contribute to better training. Chapter 8 provides the general discussion of this thesis. We reflect on the results from previous chapters and address the main question from chapter 1: how are EPAs used and to what extent are EPAs an addition for their stakeholders? This chapter discusses how stakeholders value the use of EPAs differently. Some residents see the benefits for making individual training easier, and some faculty members find that EPAs are a useful method for mapping entrustment levels. This work questions, however, whether these contributions are sufficient to draw the conclusion that EPAs create better training programmes. The general discussion continues with an elucidation that methods such as EPAs do not create better training but that it is faculty members and residents who determine the success of a training programme. We must be wary of systems that impose rules which ultimately restrict the freedom of users and supress creativity. The discussion argues for a balance between the harmonisation of training programmes through methods such as EPA and freedom for stakeholders to interpret the training guidelines themselves.