Bridging Gaps in Residency Readiness

All medical school graduates should be ready to conduct routine clinical activities when they begin residencies, but gaps exist that reveal disparities between what residency program directors expect interns to do and what the interns feel ready to do. 

In response, the Association of American Medical Colleges developed a list of 13 core “entrustable professional activities”—EPAs—that new physicians should be able to perform without supervision on their first day of residency. P&S is one of 10 U.S. medical schools chosen for a pilot program to integrate EPAs into their curricula.

EPAs range from relatively simple things—taking a medical history, performing a physical exam, doing common procedures, writing notes, and making oral presentations—to more sophisticated activities, such as getting involved in quality improvement projects or handing off cases to other members of the care team, says Jonathan Amiel, MD, associate professor of psychiatry and associate dean for curricular affairs at P&S. “All of these are clearly important in terms of taking care of patients.”

Results of an AAMC poll of program directors and graduating students showed agreement in confidence on certain EPAs—getting a history, taking a physical, and making presentations—but significant gaps in other areas. “For instance, the program directors had significantly less confidence in students’ ability to do handoffs than the students had. Program directors had more confidence in students’ abilities to do common procedures than the students did,” says Dr. Amiel. “What happens when there’s this kind of gap is that when interns are just starting their graduate medical education, they may be cautious in communicating what they’re not confident in because they want to make a good impression on their supervisors, and if they’re assigned to something that they don’t feel qualified or confident to do, they may try to do it anyway without asking for enough training or supervision, and that could result in pretty significant lapses in patient safety.”

Basic procedures cannot be learned overnight, says Dr. Amiel. “You have to learn the basic principles and then practice them over time with some kind of supervision, some kind of assessment—and opportunities for remediation if you need them. The kind of curriculum that you have to develop is pretty significant.”

The 10 schools tapped for the five-year pilot program have worked together for the past few years to develop more consistent curricula, assessment methods, and an overall structure of coaching. “Coaching is meant to help students reflect on what kind of information they’re getting back about their own performance so that they can improve it over time and can request or seek out additional opportunities for enrichment. The hope is that by the end of medical school, every medical student will feel confident to perform the activities that we’re focusing on and be really strong when they start out their internships.”

Of the 13 EPAs, P&S has focused on four:

  • taking a medical history and performing a physical exam
  • documenting a clinical encounter in the patient record
  • providing an oral presentation of a clinical encounter
  • performing general procedures of a physician

Educational content addressing those EPAs was incorporated into the P&S curriculum beginning with the Class of 2019. “We’ve set up a longitudinal coaching program where each student has a coach that teaches in our Foundations of Clinical Medicine seminar course for first-year students but also stays with the student over the course of the four years,” says Dr. Amiel. “The students meet with the coaches once or twice a semester to go over how medical school is going, what kind of feedback they’re getting—both directly observed by the coach in the Foundations course and later on clinical services and in clinical skills assessments. Our aim is to establish a trusting relationship between the coach and the student so that students can come to coaches over the course of their medical school education with the feedback that they’ve gotten and try to interpret it so that they can create their own short-term and long-term learning plan.”