Alleviate resident stressors: 7 important EPA tips

April 27, 2021 | Author: Royal College Staff

If you’re involved in medical education, then you know that Entrustable Professional Activities (EPAs) are an important component to Canada’s new competency-based model of residency training. EPA observations can lead to powerful conversations and resident learning, but data also shows that the introduction of EPAs can add stress to a resident’s learning environment, particularly when:

  • – A resident’s observation request is not accepted or completed by an observer in a timely manner. Some residents report feeling the need to chase EPAs, which can become a significant source of frustration.
  • – Some residents feel the need to achieve high entrustment scores early in the stage and are very concerned when they receive lower scores.
  • – Some choose to time their observation requests to occur only once they are confident in their ability to be rated highly. This selective approach means that some residents will miss out on valuable opportunities for coaching and feedback.

Making a habit of accepting observation requests – as well as initiating your own observations – helps to lighten the burden on residents.  Here are seven EPA tips that can help you identify and relieve potential resident stressors during training:

  1. Prompt residents to identify an EPA to focus on during clinical work – don’t wait for them to come to you and ask.
  2. Provide feedback at the time of the patient encounter and record the EPA observation in a timely manner. Don’t let too much time go by in case you forget, making the details less useful to the resident.
  3. Share responsibility for triggering EPA observations with the resident. Make a goal, perhaps two EPAs per week or one per day – whatever works for you. Grade yourself on whether you are meeting your goal.
  4. Record EPA observations even when you had to provide significant prompting or redirection to the resident. Don’t wait until the resident has “got it.” Keeping track of these early experiences will show the program that the resident is progressing over time with a broad range of clinical activities.
  5. Identify three to five key EPAs you encounter on a regular basis. Ask your program director or colleagues to highlight the EPAs that are most likely to occur in the context in which you most regularly supervise residents. Review the main features of each so you know when they are most pertinent to the patients you are seeing with your residents. You will be more comfortable giving feedback when you know the focus of the EPA, and it may help you identify when to trigger the documentation of an EPA observation.
  6. Encourage a growth mindset and an openness to feedback to combat the pressure residents sometimes feel to achieve “perfection-from-the-start”. Ensure your residents know that it takes time to develop their stage-specific competencies and your observations are intended to help them track their progress over time.
  7. Share your feedback with the program director if an EPA requires refinement. The program director can and should bring this feedback forward to the specialty committees, who will collect recommendations over time. It could take 12 to 16 months for EPA changes to be approved and implemented. Refer to the CBD Versioning Policy for more details. 

What is an EPA? Learn more about EPA Developmental Design in the graphic below. Questions or comments can be sent to

Download the infographic: Developmental Design of EPAs


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Tadeusz (Tad) Pierscianowski | April 28, 2021
Very useful commentary. The CBD/EPA system could lead to better resident and physician competencies and professional care. your tips, however, do confirm the fear that the CBD/EPA system will be time, personnel and financially demanding, maybe beyond what is realistic and available presently. It could result in poorer outcomes as a result. Careful monitoring and auditing the system and outcomes will be critical. This has to be done with an open mind set namely one that is willing and courageous to turn back the clock rather than try to force a square peg into a round hole.
Royal College Staff | April 30, 2021
We appreciate the feedback and points you have raised. We fully agree that the system continues to need careful monitoring to ensure CBD is being implemented as intended. You’re right in saying we often encounter square pegs and round holes, as the overall health system definitely has its challenges. We are also extremely grateful to the dedicated PGME offices and educators on the ground across the country that are playing a critical role in supporting the rollout of CBD. Overall, feedback shows that we are moving in the right direction, and we are working openly and transparently with stakeholders to address issues raised. We have established a large and growing network for CBME Program Evaluation to answer the question Is CBD working? Results on this can be found in our recent article CBD Program Evaluation Results: Collaboration remains critical. We are also working closely with resident groups, universities and programs, where we continually invite feedback to tackle new and existing challenges in the system. We have adopted a “Listen, Learn, Adjust” approach and regularly respond to realities from the front lines. The program is designed with flexibilities that allow programs to meet training requirements under strained circumstances to compensate for limited resources. We recognize the innovation being shown in programs, as we collaborate and share ideas. We sincerely appreciate and encourage feedback like yours and invite ongoing participation in shaping the system that provides the highest standards in patient care.