The Development Status of Entrustable Professional Activities-Based Curricula in Orthopedic and Neurosurgical Spinal Surgery: A Systematic Review

doi:10.21203/rs.3.rs-3758792/v1

Background:

Postgraduate medical specialists´curricula often lack clearly defined and assessable outcomes. Entrustable Professional Activities (EPAs) emerge as a promising teaching concept aiming at competency-based training. This scoping review explores the current status of EPA-based curricula in orthopedic and neurosurgical spinal surgery and seeks to underscore the potential of EPAs in addressing the contemporary challenges in medical education and professional training in spinal surgery.

Methods:

A systematic review was executed employing two research methods: a literature review using the PubMed database with specified search terms related to EPAs in spinal surgery, and an examination of various professional societies' publications and direct inquiries regarding EPAs in spinal surgery.

Results:

The PubMed search yielded only two papers relevant to spinal surgery EPAs, with one identifying four EPAs in orthopedics and another presenting one explicit EPA in neurosurgery. Among the nine professional societies explored, only the AO Foundation, AO Spine, had defined EPAs for spinal surgery. The lack of substantial results underscores a noticeable gap in the research and application of EPAs within spinal surgery curricula.

Conclusions:

The sparse literature and limited engagement from professional societies reveal a substantial research gap in EPA-based curricula in spinal surgery, despite the promising potential of EPAs in enhancing medical education and professional training. This scoping review lays a foundation for future research, urging a collaborative effort among professional societies and educational stakeholders to develop and implement EPA-based curricula in spinal surgery, aiming at a more efficient, competency-centered professional training paradigm.

Entrustable Professional Activities (EPAs)

Spinal Surgery

Medical Education

Postgraduate Training

Competency-Based Curriculum

Systematic Review

Medical Curriculum Development

The quality of postgraduate training for medical professionals is a key factor in the effectiveness of the healthcare system. A significant pillar of this training is known as "workplace learning," which comprises practical work as a resident, theoretical further education courses, and self-study (1). Various "enablers" and "challengers" have been identified that either assist or hinder the learning process, often acting as bottlenecks (1). It was highlighted that active involvement in tasks is a positive aspect, but there is often an inappropriate level of responsibility placed on the learner, either too much or too little (1). Unclearly defined training goals or a lack of these also poses a substantial hurdle for the learning success of prospective doctors (1).

However, from the perspective of medical education research, these aspects can be influenced by an adequately structured specialist´s curriculum or appropriate teaching methods. Here, the concept of “Entrustable Professional Activities,” or EPAs for short, is potentially highly valuable. For some time now, those responsible for teaching in medical education have been giving growing attention to these, which represent a didactic concept that aims to create a competency-based training curriculum with a focus on acquiring specific, pre-defined competencies resulting in a more flexible training duration (2). The major characteristic feature of EPAs is the gradual reduction of the level of supervision until learners can eventually perform tasks entirely independently. This occurs within five levels, starting with level 1, which allows the learner to be present and observe, up to level 4, which attests complete independence for the first time. Finally, level 5 additionally permits guiding younger learners independently (2, 3). It is crucial to emphasize that EPAs should not merely be viewed as learning objectives, as they represent specific professional activities (4). Thus, the entirety of EPAs, a multitude of professional activities, defines a profession, making a direct contribution to the healthcare system (2). By focusing a corresponding teaching concept primarily on acquiring competencies, it could contribute to shortening the training time for faster learners without reducing the quality of the trained doctors (5). In general, potential savings of 30% have already been reported when considering the entire medical education (6). Such a system would not only benefit medical students but also teaching staff and other employees and colleagues. They could clearly see which tasks may be performed with what degree of autonomy, thereby defining responsibilities clearly while simultaneously creating the possibility of evaluability (2) (4). In Europe, this concept received particular attention at the Charité in Berlin, where a study was conducted, ultimately identifying 12 central EPAs of seven distinct categories (3).

However, when searching for Entrustable Professional Activities (EPAs) specific to specialist surgical training areas, it is observed that the majority of publications predominantly focus on EPAs in the domain of general surgery (7). Other surgical specialties or subspecialities have not been defined yet. This includes neurosurgical or orthopedic spinal surgery. This is despite a significant risk of these procedures, such as irreversible neurological damage, highlighting the need for an optimal training curriculum (8) Considering the medical-economic pressure, the professional training challenge of spinal surgery, and the possibility of promoting transparency and autonomy of aspiring doctors through EPAs, this study investigates the following research question: What is the current development status of curricula for orthopedic and neurosurgical spinal surgery based on EPAs?

To answer the research question, a systematic review was conducted which included two research approaches.

2.1 Literature research

For the purpose of a thorough search of the existing literature on EPAs in orthopedic and neurosurgical spinal surgery, the PubMed database was used. The following search terms were used in PubMed: “(EPAs) AND (neuro surgery)”, “(Entrustable professional activities) AND (neuro surgery)”, “(EPAs) AND (spine surgery)”, “(Entrustable professional activities) AND (spine surgery)”, “(EPAs) AND (orthopedic surgery)”, and “(Entrustable professional activities) AND (orthopedic surgery)”, additionally, articles from the year 2005 onwards were filtered because of their initial conceptualization in that same year. Duplicates were accordingly removed before evaluation, considering the following inclusion criteria: English or German language, explicit mention of EPAs, and direct reference to spinal surgery from an orthopedic or neurosurgical perspective. At the same time, the following exclusion criteria were applied: Articles that discuss the necessity of Entrustable Professional Activities (EPAs) without providing specific recommendations of EPAs. This research took place from September 2023 to October 2023

2.2 Medical professional societies

To increase the amount of literature about this topic websites of various professional societies, including their publications, as well as direct statements via email communication from the same societies, were also included. The following professional societies were considered: German Society for Orthopedics and Orthopedic Surgery (DGOOC), German Society for Neurosurgery (DGNC), Swiss Institute for Medical Further and Continuing Education (SIWF), Swiss Society for Orthopedics and Traumatology (SGOT), American Board of Orthopedic Surgery (ABOS), American Board of Neurological Surgery (ABNS), North American Spine Society (NASS), American Association of Neurological Surgeons (AANS), and the “Arbeitsgemeinschaft für Osteosysnthesefragen (AO) Foundation, AO Spine”. In selecting the professional societies, an effort was made to gain a broad perspective by encompassing various geographical locations, reflecting both orthopedic and neurosurgical aspects of spinal surgery, and also illustrating specific medical didactics. Further all institutions are representative in their fields of expertise and are among the largest and most relevant.

For the publication database search of the professional societies, the term “Entrustable professional activities” was used as a search term from 2005 onwards. Due to some websites not having the function to filter for publications only, all results of the search were included. This research took place from September 2023 to October 2023. Figure 1 visualizes both research approaches.

3.1 PubMed Search:

After searching with the above terms, a total of 39 papers were found, with the number decreasing to 31 after the removal of duplicates. Ultimately, only 2 papers were included.

One of the papers developed EPAs based on existing orthopedic competencies and ultimately presented a list of a total of 49 EPAs for orthopedics, of which four were related to the spine, using a modified Delphi methodology (9). This paper originated from North America, specifically Canada (9). The second paper had developed a competency-based European curriculum for neurosurgery. In total, 5 EPAs were embedded in the curriculum, of which one explicitly mentions spinal surgery and a second one that might include spinal surgery as a “special interest training” (10). Table 1 summarizes all EPAs that have been found during the research process.

Table 1

Summary of all Entrustable Professional Activities (EPAs) Related to Spine Surgery
EPA	Origin
• Emergency on-call neurosurgery (including the performance of crania, spinal, peripheral nerve (where available), adult and pediatric neurological surgery) • Elective operative neurosurgery (including advanced technical skills in one or two special interest areas)	(10)
• Management of the patient with spinal cord injury • Management of the patient with cauda equina injury • Management of the patient with lumbar herniated disc • Management of the patient with spinal infection	(9)
• [1]Assessment of and consent from the preoperative patient • Position the patient • Perform a preoperative team briefing • Perform the procedure safely • Document the procedure • Transfer the patient to the recovery area • Check the patient postoperatively	(11)

[1] The EPAs listed represent a selection from the AO Spine Curriculum. This selection was made explicitly because of its direct relevance to the surgical aspect of spinal surgery. Nevertheless, additional EPAs were named that should not be viewed as either 'exhaustive' or 'exclusive' according to the curriculum, but rather as examples that illustrate spinal surgery (11) . For this reason, EPAs are mentioned that do not directly contribute to surgical training, but also exemplarily represent aspects of teaching, quality management, or the billing system (11) . The more general nature of the EPAs, which belong to the holistic profession, was the reason for excluding these and focusing on the operative ones. It is also worth noting that the so-called Core-EPAs, upon which the curriculum is based, are also not mentioned due to their general nature (11) .

3.2 Results of the Professional Societies Search:

Table 2 summarizes all results of the professional societies search in detail. However, it is noteworthy that out of a total of 9 professional societies, only one had a specific publication in their database that deals with EPAs in spinal surgery. Only 2 others yielded results related to the topic of EPA, but none of these were related to spinal surgery. Of the two, only the SIWF featured a dedicated website tab for EPAs and, from 2005 onwards, had the highest number of search results with 120 publications; however, none specifically addressed spine surgery. Only the AO Foundation, AO Spine, with their AO Spine Curriculum Second Edition, defined EPAs for spinal surgery, totaling 7 (11). Table 2 summarizes all EPAs that have been found during the research process.

Table 2

List of Professional Medical Societies and Their Publications on Entrustable Professional Activities (EPAs)
Professional Society	Database Research	Inquiry
AO Foundation, AO Spine	A total of two publications, one of which has a direct relation to EPAs in spinal surgery (s. Table 1)	No additional inquiry neccessary
German Society for Orthopedics and Orthopedic Surgery (DGOOC)	A total of three search results, but none related to EPAs	No response to our inquiry
German Society for Neurosurgery (DGNC)	No publications	There is no such catalog from the NCA to date
Swiss Institute for Medical Further and Continuing Education (SIWF)	There are a total of 120 search results for the term "Entrustable Professional Activities", none of which were related to spinal surgery EPAs.	Pending response from the spine subgroup
Swiss Society for Orthopedics and Traumatology (SGOT)	No publications	No preliminary work is in progress, let alone finalized. However, there is a planned implementation set for 2027
American Board of Orthopedic Surgery (ABOS)	No publications	No direct research but partners with researchers
American Board of Neurological Surgery (ABNS)	No publications	No response to our inquiry
North American Spine Society (NASS)	No publications	There is no EPA-based training provided by NASS, and none is currently being developed
American Association of Neurological Surgeons (AANS)	There was a total of three publications, but only two of them were related to the topic of EPAs. However, none of them were related to spinal surgery	No response to our inquiry

This study explored the current developmental status of EPA-based curricula in orthopedic and neurosurgical spinal surgery. The background of this inquiry is the issue of lengthy and costly training periods in medical education, which could potentially be shortened through the innovative concept of EPAs. To investigate this, a systematic review was conducted, searching the PubMed database and contacting numerous professional societies.

The results, more specifically the lack of results, of the exploratory question indicates that while the "EPAs" concept is highly popular, it has only been sporadically integrated into further education. Particularly at the beginning of medical residency, more tangible information can be found. The already limited result of the PubMed search, with only 31 papers, is further substantiated by the mere two papers that formulate EPAs for spinal surgery from both orthopedic and neurosurgical perspectives (9)(10). Both set their EPAs as benchmarks for future curriculum designs, indicating that actual implementation into the daily training routine of doctors has only been carried out in terms of theoretical preparatory work.

A comparable picture is provided by the professional societies. Some of the described societies seem to be interested in EPAs, but none except the "AO Foundation, AO Spine" provide actual work on spine surgery EPAs. All others have either not provided current work on an EPA-based curriculum, or no evidence was found in their databases for that. This particularly underscores the lack of publications on this topic. These results underline the relevance of the research question and clearly demonstrate that EPA-based curricula in spinal surgery represent a gap in research.

To bridge this gap, we recommend using the results of this study as a starting point to have an initial collection of current EPAs for spinal surgery. In addition, textbooks and existing learning objective catalogs should be used to develop further EPAs based on their content. To specify more EPAs the approach of Watson et al. (2021) would be suitable to derive an expert consensus on spinal EPAs from a preliminary EPA list using their modified Delphi methodology, ensuring a comprehensive representation of spinal surgery. Further we specifically recommend using Cate´s eight sections for a complete EPA description (2).

Describing them using so-called "nested EPAs," meaning EPAs within an overarching EPA, appears particularly useful in the context of the scope of spinal surgery and spinal surgical activities (2). Cate et al. (2018) exemplarily described a core EPA like “the clinical consultation” which contained a total of 16 nested EPAs such as ”General history and physical examination including vital signs” (12).

Especially the research among professional societies has shown that there are large differences regarding the development stage of EPAs. It would be desirable if there would be more collaboration among these in the future, so that a more efficient exchange of knowledge can take place and more concrete EPA-based curricula could be created.

In interpreting the results of this systematic review, it is important to keep in mind that only German and English literature. However, this decision was made because the first competency-based postgraduate medical training programs originated from Canada's CanMEDS competencies and the ACGME in the USA (13) (14). Additionally, Switzerland is a pioneer, as they introduced a competency-based catalog in 2017, called PROFILES, at least for medical education, which includes not only the CanMEDS framework but also specific EPAs (15, 16). Nevertheless, publications in other languages such as French, Spanish, or Chinese languages could provide valuable insights into further EPAs, which is why future research in this regard should be undertaken. The narrow focus on spinal surgery also leads to fewer findings; however explicitly due to the high relevance of this field and its potentially fatal consequences in case of errors, the search was conducted so strictly and closely. Finally, filtering from 2005 onwards is also a limitation, but it was chosen due to the introduction of the specific didactic methodology of EPAs by Cate in the same year (17). Overall, a practically unexplored field of EPAs for spinal surgery is emerging, whereas this situation could also apply to other specializations, which should be the subject of further future research. It will be necessary not only to advance the implementation of general EPA-based curricula but also to become more specific, particularly in the context of specialist medical training.

This scoping review has shown that there is scarce literature on EPA-based curricula in spinal surgery, and professional societies are equally sporadic in their current work on corresponding educational concepts. In the context of the promising potential of EPAs and the time-consuming and costly training to become a doctor, more research and implementation should be conducted in the future. Together with the results and the suggested potential EPAs for this discipline, this systematic review offers a benchmark for

future studies on this topic and hopefully encourages further research efforts for the field of spinal surgery.

Word	Abbreviation
Entrustable Professional Activity	EPA
German Society for Orthopedics and Orthopedic Surgery	DGOOC
German Society for Neurosurgery	DGNC
Swiss Institute for Medical Further and Continuing Education	SIWF
Swiss Society for Orthopedics and Traumatology	SGOT
American Board of Orthopedic Surgery	ABOS
American Board of Neurological Surgery	ABNS
North American Spine Society	NASS
American Association of Neurological Surgeons	AANS
Arbeitsgemeinschaft für Osteosysnthesefragen Foundation, Arbeitsgemeinschaft für Osteosysnthesefragen Spine	AO Foundation, AO Spine

6.1 Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Availability of data and materials

Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.

6.4 Competing interests

The authors declare that they have no competing interests.

6.5 Funding

The author Maximilian Domann has received a funding during the research for this paper from the “Promotionsstipendium” of the medical faculty of the LMU.

6.6 Authors' contributions

MD was responsible for visualizations and writing the initial draft including substantive translation. FB, MF and MS extensively contributed to the writing process by reviewing and editing the initial draft. Further MS had the role of the supervisor for the project as well as project administration. All authors read and approved the final manuscript.

6.7. Acknowledgements

Not applicable.

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No competing interests reported.

The Development Status of Entrustable Professional Activities-Based Curricula in Orthopedic and Neurosurgical Spinal Surgery: A Systematic Review

Status:

Version 1

Abstract

Figures

1. Background

2. Methods

2.1 Literature research

2.2 Medical professional societies

3. Results

3.1 PubMed Search:

3.2 Results of the Professional Societies Search:

4. Discussion

5. Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1