Medical Teachers’ Entrustable Professional Activities for Clinical Education a five-star clinical educator

doi:10.21203/rs.3.rs-3112188/v1

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Medical Teachers’ Entrustable Professional Activities for Clinical Education a five-star clinical educator

https://doi.org/10.21203/rs.3.rs-3112188/v1

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Introduction A medical teacher has a wide range of roles and responsibilities that vary from a clinical teacher to a trainer and finally a clinical specialist. Most medical teachers receive limited training to prepare them to provide effective teaching and clinical supervision. the current study aims to develop core entrustable professional activities (EPAs) for medical teachers related to more effective clinical education.

Methods This study was conducted in two phases. The first phase focused on defining an initial set of EPAs. The second phase focused on developing this set via a nominal group technique (NGT) among 15 faculty clinical specialties until a consensus was reached.

Results The total of 29 EPAs in the five dimensions were agreed upon by more than 70% of the participants. Most of the activities were identified in the curriculum planning activities (n=11). Further details on the characteristics identified in each of the five dimensions of the EPAs of a five-star teacher are provided.

Conclusion Findings showed that One of the core EPAs for training the current generation of medical students is using enhanced technologies. Medical teachers should acquire these competencies by using faculty development programs.

entrustable professional activities

faculty development

nominal group technique

medical teachers

competencies.

The institutions try to improve or develop the competencies of medical teachers in their current responsibilities and continuously upgrade and redefine their competencies (1). A medical teacher has a wide range of roles and responsibilities that vary from a clinical teacher to a trainer and finally a clinical specialist (2). Most medical teachers receive limited training to prepare them to provide effective teaching and clinical supervision (3). It has been observed that they often deal with problems in effectively carrying out their academic responsibilities due to the lack of training (4–6). Furthermore, evidence shows that medical teachers have insufficiently prepared across traditional competencies of medical knowledge, clinical skills, professionalism, and newer competencies of evidence-based practice, quality improvement, interdisciplinary teamwork, and systems to perform their functions effectively (7). Indeed, attaining a qualified medical teacher has been associated with developing many roles, leadership positions, and responsibilities in medical education (1). However, if they see proper educational programs in this regard, they will definitely become better teachers (3).

Entrustable professional activities (EPAs) are units of professional activities, i.e., tasks or responsibilities that can be implemented, observed, and measured independently in terms of procedures and outcomes, and when an individual acquires sufficient competencies, EPAs can be led to unsupervised execution(1). Fitzgerald (2016) stated that educational methods, curriculum development, teaching community, evaluation, and leadership skills are competencies of clinical teachers required for achieving EPA-based competence(2). Iqbal et al. (2018) reviewed existing medical teacher education programs that incorporated EPAs in their frameworks to provide further insights into how the EPA concept is adopted(3). Furthermore, according to Iqbal (2019), EPAs can serve as a new framework for planning and implementing structured programs for faculty development and evaluating the skills of small-group facilitators after training(4). Van Dam et al. (2021) used EPAS to improve teaching at the patient’s bedside, including preparation, a safe learning environment, flexible teaching, and patient benefits, and introduced a description of structured EPAs (5). Van Bruggen et al. (2022) developed a set of nine EPAs as a foundation for improving the initial and continuous professional development of university teachers in health professions education(6). It appears that existing frameworks of EPAs for medical teachers are limited. Although they may successfully meet the requirements of a longitudinal training program, they do not clearly describe the activities and competencies required for comprehensive roles for a medical teacher. Indeed, the effort to implement effective faculty development programs for medical teachers to provide effective clinical education with the aim of assessing, training, and reassessing their competencies indicates the necessity of developing a comprehensive, flexible, and context-based framework. This is an entrustable professional activities framework for medical teachers that includes both personal and professional competencies and is needed for a teacher's academic activities. Furthermore, it also helps medical teachers who are looking for ways to increase student achievement, which could serve as a foundation for teaching and qualification competencies and professional opportunities. For this purpose, the current study aims to develop core entrustable professional activities for medical teachers related to more effective clinical education.

This study was conducted in two phases. The first phase focused on defining an initial set of EPAs. The second phase focused on developing this set via a nominal group technique (NGT) among faculty clinical specialties until consensus was reached. The ethics committee of the National Center for Strategic Research in Medical Education approved the protocol for this study (IR.NASRME.REC.1400.505).

Development of initial EPAs

The initial list of EPAs was used using the frameworks suggested in previous studies(7–10), as well as the list of competencies related to the faculty development program (FD) for faculty members for essential competencies of medical education at Kerman University of Medical Sciences (KUMS), and the initial list included 79 activities.

Study design and setting

This NGT study was conducted on clinical specialties affiliated with the KUMS who were invited to a nominal group technique meeting in 2022. First, a list of suggestions extracted from studies was provided to the group members, and they were asked to write down their suggestions silently. Subsequently, each participant shared their list with the group periodically, and clarifications were made through discussions.

Participants

A total of 15 clinical specialists in general surgery (3 persons), internal medicine (7 persons), obstetrics and gynecology (3 persons), and dermatology (2 persons) were invited to participate in this study. The criterion for enrollment in the study was at least five years of work experience in clinical education (13, 14).

Data collection

The NGT proposed by Humphrey Morto et al. (2017) with modifications of stage four (voting) was used to identify and reach a consensus about the most important EPAs of clinical teachers (13). Some instructions about the concept of EPA and the related examples were provided to the participants in the meeting, and the consent form was also sent in printed form. The NGT meeting was held at one of the KUMS-affiliated hospitals in September 2022 and was managed by a medical education specialist (S.S). In the first stage (silent idea generation), the purpose and procedures of the meeting and a brief overview of the EPA concept were presented by one of the authors. Then, two questions were asked about the main areas and related components.

During the initial evaluation of the competencies for medical teacher, the participants were asked to write their ideas on a table presented on a video projector or additional ideas independently and silently in response to questions without any permission to discuss their answers with others. At this stage, the participants were expected to determine the professional activities required by clinical teachers in medical education to train competent medical graduates, and a list of the initial ideas was provided to them. In the next stage, the responses were shared back and forth with all participants without discussion or explanation. The participants were encouraged to use other participants’ responses to write new ideas that may not have been considered in the previous round.

The round-robin stage continued until no new information was generated. All responses were typed word by word in Word Office@2016 (Microsoft Corporation, Redmond, Washington) by a medical education specialist and simultaneously displayed to the participants using a video projector. During these steps, the number of responses was not limited, and participants could list as many activities as they wanted. In the group discussion stage, the moderators briefly discussed each suggested item to clarify the ideas proposed by the team of clinical experts for the initial assessment and to consolidate similar responses without any judgment or criticism. In the voting and ranking stages, the participants’ responses were mainly narratives of their ideas. The members of the group were asked to prioritize each of the items and define a category for them. Then, they were asked to discuss their ideas one by one. If the ideas were not agreed upon by the members of the meeting, the next idea was discussed. Eventually, the group would say, 'Yes, yes, that is right now; yes, that is the way it is'. Overall, the process of ranking worked well. The priority list reflected group consensus. On reviewing the data upon completion, the five categories were remarkably similar across the ideas of the group. As a result, to extract and categorize the views of the team of clinical experts, the narratives were qualitatively analyzed. The voting stage was completed in the next session due to the business of the clinical teachers (participants in the nominal group). Therefore, the classified activities in the form of a questionnaire were presented to the participants of the NGT meeting in person at Afzalipoor Educational Hospital, and they were asked to evaluate the importance of each EPA on a five-point scale (unimportant = 1, very important = 5).

Data analysis

Quantitative and qualitative methods were used to analyze the data collected during the NGT meeting. For qualitative analysis, the first author (S.S) read and reread the narratives and extracted relevant characteristics. Then, another author (A.A) independently reviewed the initial coding procedure. Two authors discussed and agreed on the extracted characteristics. The extracted characteristics were merged based on similarities and then grouped into dimensions using a previously described framework (15). Table 1 shows the characteristics of a medical teacher with some examples of the participants’ quotes. The characteristics and dimensions were revised by other authors (M.O and M.I.).

In the quantitative analysis phase, descriptive statistics, including frequency, mean, and standard deviation, were calculated using Microsoft Excel 2016 (Microsoft Corporation, Redmond, Washington) to summarize the raw data collected from the voting phase. The frequency of votes was calculated to report the level of consensus, and the mean values were calculated based on the number of participants as well as a measure of dispersion to report the importance of rating each characteristic. The consensus was defined as 70% agreement for ratings 4 (important) and 5 (very important) (13). In addition, an existing valid framework (O’Neill’s framework) was used to classify medical teacher activities (15).

Findings

Participants

Fifteen specialists in internal medicine, general surgery, obstetrics and gynecology, and dermatology voluntarily participated in the three-hour NGT session (Tale 1). A total of 13 participants completed the questionnaire in the voting phase. Moreover, 7 participants (54%) in the NGT meeting and the voting stage were women; internal medicine had the highest clinical teaching experience among the participants. In the qualitative analysis phase, a total of 62 competencies were classified in the five dimensions as examples of quotes (Table 2). After quantitative analysis, 29 EPAs in the five dimensions were agreed upon by more than 70% of the participants. Most of the activities were identified in the curriculum planning activities (n = 11) (Table 3). Further details on the characteristics identified in each of the five dimensions of the EPAs of a five-star teacher are provided (Table 4).

Table 1

The participants’ demographic characteristics
Specialty	NGT session		Voting session
Specialty	Number (female/male)	Experience*	Number (female/male)	Experience*
General surgery	3 (1/2)	11 ± 0.81	2 (1/1)	11.5 ± 0.05
Internal medicine	7 (3/5)	8.55 ± 2.85	6 (2/4)	7.06 ± 1.33
Obstetrics and Gynecology	3 (3/0)	8 ± 2.16	3 (3/0)	8 ± 2.16
Dermatology	2 (1/1)	6.8 ± 1.13	2 (1/1)	6.8 ± 1.13
The data are presented as the mean ± SD. NGT: Nominal group technique; *: Year

Table 2

The dimensions of clinical teacher characteristics and examples of the participants’ quotes related to EPAs
Dimensions of medical teacher characteristics	Examples of quotes
Curriculum planning	“A teacher must be capable enough to develop their own lesson and course plans based on the curriculum”. “A teacher should be able to use appropriate teaching methods according to the nature of the course and not convey everything to the medical student through lectures”. “At the beginning of the course, the teachers should make all the necessary arrangements to offer the course in the best way possible”.
Curriculum planning	“In addition to teaching students, the teacher should lead them to lifelong learning and help the students as a supporter”. “The teacher teaches essential content and assesses each learner’s abilities in their area of expertise”. “Teachers should regularly update their knowledge and constantly engage in identifying the latest scientific articles and sources”. “Teachers are always known for their effective teaching, and students participate in their classes with great interest”.
Developing effective communication skills, and role modeling	“The teacher demonstrates a commitment both to learner success and to helping them grow in their professional roles”. “The teacher demonstrates the best behavior as a model for the learners and sets those behaviors as a model for them”.
Scholarship teaching of learning	“The teacher demonstrates continuous self-evaluation and ongoing training to improve one’s effectiveness and capacity as a medical teacher”. “The teacher is not aloof to the students’ issues and problems but tries to make them empowered to confront their problems”.
Evaluation and scholarship	“The teacher continuously seeks to evaluate the educational environment and solve challenges and tries to increase the quality of clinical education”. “The teacher is familiar with educational scholarship and identifies clinical education issues, and publishes the results of their work”.

Table 3

The dimensions and number of the generated and agreed characteristics of medical teachers
Dimensions	Generated competencies		Agreed EPAs
Dimensions	Positive	Negative	Positive	Negative
Curriculum planning	13	4	11	2(Merged)
Applying advanced enhance technologies	6	3	5	1(Merged)
Developing effective communication skills, and role modeling	5	2	4	1(Deleted)
Developing Professional activities	7	7	4	3(Merged)
Conducting scholarship teaching of learning	8	7	5	3(Merged & deleted)

Table 4

The consensus level of EPAs of medical teachers
Dimensions		EPAs	Consensus level
Dimensions		EPAs	%	Mean ± SD
Curriculum planning	EPA1	Determining and implementing educational goals (aim and objective) based on the curriculum,	100	4.53 ± 0.49
	EPA2	Compilation and implementation of the course and lesson plans	84.61	4.23 ± 0.69
	EPA3	Implementation of the appropriate teaching methods	76.99	3.69 ± 0.82
	EPA4	Collaboration with other colleagues in curriculum planning	100	4.46 ± 0.49
	EPA5	Management of the appropriate learning environment	100	4.30 ± 0.46
	EPA6	Providing effective feedback	100	4.23 ± 0.46
	EPA7	Evaluating the academic achievement of the trainee	100	4.23 ± 0.42
	EPA8	Producing a good learning environment for learners	99.1	4.18 ± 0.51
	EPA9	facilitating learning along with high-quality patient care	84.61	4.07 ± 0.61
	EPA10	Implementation of appropriate assessment methods	92.30	4.15 ± 0.53
	EPA11	Conducting of quantitative and qualitative analysis techniques to analyze test results	76.92	4.07 ± 0.72
Applying advanced enhance technologies	EPA1	Conducting e-learning and hybrid teaching strategies in clinical education	76.92	4.15 ± 0.76
	EPA2	Instructional designing based on new technologies in medical education	92.30	4.00 ± 0.78
	EPA3	Applying digital technologies in training, assessment and promotes rich learning experiences for trainees	76.92	4.00 ± 0.67
	EPA4	Developing knowledge, and skills in applying technologies enhancement,	76.92	4.07 ± 0.72
Developing effective communication skills, and role modeling	EPA1	Implementing the principles of professionalism in training,	84.61	4.15 ± 0.66
	EPA2	Counseling on dysfunction, personal crises, and professional issues to trainees	92.30	4.30 ± 0.60
	EPA3	Planning, directing, and supervising to train professionalism and effective communication skills with patients	84.61	4.23 ± 0.69
	EPA4	Mentoring in training professionalism programs, in parallel	92.30	4.00 ± 0.39
	EPA5	Identifying and reinforce the learning, skills, and behaviors	76.92	3.92 ± 0.91
Developing Professional activities	EPA1	Identifying strengths and weaknesses in teaching	84.61	4.00 ± 0.78
	EPA2	Applying results of assessing the teaching effectiveness	84.61	4.07 ± 0.61
	EPA3	Participating in faculty development (FD) and Continuing Professional Development (CPD)	100	4.53 ± 0.49
	EPA4	Monitoring and Reviewing advancement of knowledge in the specialized discipline	84.61	4.23 ± 0.69
	EPA5	Directing professional support programs	84.61	4.07 ± 0.61
Scholarship teaching of learning	EPA1	Evaluating the educational environment	92.30	4.53 ± 0.63
	EPA2	Planning to resolve or reduce challenges and problems in the clinical setting	84.61	4.53 ± 0.74
	EPA3	Writing, introducing, and communicating scholarship in teaching and learning activities	76.92	4.00 ± 0.67
	EPA4	Sharing and publishing the results of scholarship activities in scientific reports format	92.30	4.46 ± 0.63

The findings of this research showed five domains and 29 entrustable professional activities for medical teachers. These dimensions were curriculum planning, applying technology enhanced, developing effective communication skills, developing professional activities, and conducting scholarship teaching of learning. Among the strengths of this study is the presentation of a general framework with EPAs that were developed in collaboration with medical educators who were closely familiar with the strengths, challenges and needs of medical teachers. In addition, due to the limited evidence regarding the development of EPAs for medical teachers, this research will help to improve the existing evidence.

Similarly, Srinivasan et al. (2011) identified a set of competencies for effective medical teachers in addition to teaching skills (10). Groupon et al. (2016) used competency-based education and EPAs in the curriculum for the Master’s program in health professions. They used EPAs to determine the duties of medical education professionals in competency classifications such as teaching theory, curriculum development, and evaluation(11). Dewey et al. (2017) also suggested early EPAs such as trainee skill assessment, mentoring, individual or small group instruction, large group instruction, and learner-centered clinical learning and indicated that a faculty member must be assessed for competency in EPAs before beginning their role as a teacher(7). As Rosenbaum (2012) described, medical teachers in any setting need content knowledge, learner-centeredness, professionalism, communication, practice-based reflection, and systems-based practice (12).

The findings from this study show that the EPAs of medical teachers were related to their competencies in using advanced technologies in medical education. In fact, much evidence points to the increasing importance of technology in medical education. technology can enhance learning by providing interactive and engaging experiences for medical students, as well as improving access to educational resources. the potential benefits of using technology to simulate medical procedures and scenarios, allowing students to gain practical experience in a safe and controlled environment(13). Virtual reality (VR) in medical education can be used to simulate medical procedures and scenarios, allowing students to practice and develop their skills in a realistic environment(14). Gamification can be used to engage students and make learning more enjoyable while also promoting critical thinking and problem-solving skills. the potential benefits of using gamification for medical simulations, as it allows students to practice decision-making and teamwork in a fun and interactive way(15). Furthermore, many educators may not feel comfortable or confident using new technologies and may require training and support to effectively integrate them into their teaching. the potential benefits of providing continuum professional development opportunities for faculty, such as workshops, conferences, and online courses(16). Bray et al. (2020) proposed a systematic approach to faculty development with the desire to be flexible and reach potential participants, and using the existing infrastructure can facilitate the participation of evaluators in the new evaluation culture. Moreover, the interaction between the participants during the training sessions not only promoted their learning but also created cooperation to build a group(17).

Although the available evidence to express the competencies needed by medical professors in new technologies is limited, due to the advancement of technology in medicine, the required competencies of medical teachers have also changed. Suitable strategies for improving it, such as involving stakeholders in the decision-making process, providing clear communication and training, and ensuring that technology is aligned with educational goals and outcomes(18). Medical teachers must have the ability to use new technologies and be able to turn them into practical applications in the education of medical students. In addition, they must have the technical and analytical abilities necessary to evaluate and choose appropriate technologies for teaching students. Additionally, they must have the necessary management skills to implement educational programs using technology.

Furthermore, the findings of the present study indicated that effective communication skills and the role modeling of professional behavior improve the effectiveness of clinical education. Medical educators’ communication skills in clinical education play an important role in creating a positive and safe learning climate for students, leading to a happy and motivating environment for students, which improves student learning. Bremer et al. (2021) reported 5 EPAs for medical educators, including medical consultation, medical procedures, guidance and education, communication and collaboration, and nonclinical activities(19). One of the core activities for medical teachers was curriculum planning, leading to the effectiveness of clinical education. Curriculum planning involves clinical training course planning and implementation, which give meaning to this field. Furthermore, this study highlighted evaluation and scholarship as one of the aspects of EPAs, improving the effectiveness of clinical education. Boyer (1990) defined universities as knowledge institutions in which knowledge activities (production, management, transfer, and application of knowledge) take place. According to Boyer's definition, university faculty members, as knowledge activists, should provide the four knowledge activities in a proportionate manner (20).

It seems that providing FD programs and EPAs based on medical teachers at levels appropriate to the context and their level of competence in teaching can be a way forward. In fact, medical teachers whose teaching is a reliable aspect of their professional work should be assessed, trained, and periodically reassessed to determine if they maintain their qualifications. In this regard, EPAs have been proposed that will lead to the professional development of medical teachers and provide the best possible education for learners(7). Steinert (2006) states that medical teachers should be trained in areas such as teaching, barriers to successful teaching, competency-based assessment, hidden curriculum, educational technology, and scholarship of teaching and learning (SOTLs)(21). Additionally, in another article, he considers a successful FD program to include professional development, teaching, organizational development and program evaluation (22). McLean et al. (2008) has pointed to things such as higher education, curriculum, research knowledge, leadership and professional development, and teaching methods (23). Trowbridge & Bates (2008) refers to things such as improving teaching and learning, clinical skills, professional development, performance management techniques, and research skills (24). Eventually, since the present study examined the features of EPAs and the necessary capabilities of medical education for medical teachers, the extracted EPAs can be suitable options for evaluating and FD for medical teachers.

One limitation of this article is its focus on studying in one center and a small number of medical teachers. If it is conducted with the participation of several centers and internationally, better results will be achieved. Second, there was a lack of familiarity of medical teachers with EPAs before conducting this study, which requires providing educational lectures on this topic.

As a result, medical teachers should have the necessary competencies to use them in the training of medical students, considering the enhanced technology in medicine. These competencies include technical, analytical, and managerial abilities that must be present in medical teachers at the same time. As a result, medical teachers must continue to participate in faculty development programs so that they can keep up with changes in medicine and teach their medical students. As a result, the FD programs of medical teachers based on EPAs should be developed in which the competence level of the professors is evaluated first, and according to the competence level, they receive the necessary training and are re-evaluated, which leads to appropriate competencies and skills in the teaching of medical students.

EPA Entrustable Professional Activity

FD Faculty Development

NGT Nominal Group Technique

Acknowledgments

The authors kindly thank the clinical teachers of Afzalipoor Educational Hospital at Kerman University of Medical Sciences for their cooperation.

Authors’ contributions

All authors have conceived and designed the concept and road map of the study S.S, M.O and M.L contributed to the data collection, searching the literature, and writing the initial draft of the manuscript. M. I and A.A critically reviewed the manuscript for its content, originality, usage of English language, and accuracy of interpreted data. All authors have made substantive contributions and attest to approving the ﬁnal manuscript.

Funding

The authors received ﬁnancial support for the current study of the National Center for Strategic Research in Medical Education.

Availability of data and materials

The datasets used or analyzed during the current study are available from the corresponding author upon reasonable request.

Ethical considerations

Ethics approval and consent to participate All study protocols were conducted under approval of the Ethics Committee of National Center for Strategic Research in Medical Education (Ethics code: IR.NASRME.REC.1400.505). All methods were carried out in accordance with relevant guidelines and regulations. The participation of clinical teachers was completely voluntary, and informed consent was obtained from all participants.

Consent for publication

Not applicable.

Competing interests

The authors declare that no competing or ﬁnancial interests exist.

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No competing interests reported.

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Medical Teachers’ Entrustable Professional Activities for Clinical Education a five-star clinical educator

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Abstract

Introduction

Methods and materials

Development of initial EPAs

Study design and setting

Participants

Data collection

Data analysis

Findings

Participants

Discussion

Conclusion

Abbreviation

Declarations

References

Additional Declarations

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