The EPA-based Utrecht undergraduate clinical curriculum: Development and implementation

Abstract

Aim: As reports of the application of entrustable professional activities (EPAs) increase, not only for postgraduate but also for undergraduate medical education, there is a need for descriptions of what a UME curriculum with EPAs could look like. We provide such a description based on the experiences at University Medical Center Utrecht, the Netherlands, which can be used as an example by other curriculum developers.

Methods: In a three-year process, the UMC Utrecht Curriculum Committee developed a clinical workplace curriculum with an EPA structure, taking into account examples, such as the US Core EPAs for Entering Residency, and recommendations to integrate and increase the length of clerkships.

Results: In the resulting curriculum, operational from 2016, students train to be trusted with indirect supervision before graduation in five broad EPAs: the clinical consultation; general medical procedures; informing, advising and guiding patients and families; communicating and collaborating with colleagues; and extraordinary patient care. Each of these integrates smaller (nested) EPAs that receive focused training attention in integrated clerkships at various moments and must be signed off for entrustment with indirect supervision to complete the clerkship.

Discussion: The framework of EPAs went through many iterations before it was consolidated. Among the issues that required special attention was the application of a supervision levels scale for sign-off, the necessity to cover all relevant clinical content while not labeling too many small tasks each as a separate EPA, methods of EPA-focused assessment in the workplace and the creation of an e-portfolio model to serve assessment and entrustment.

Introduction

Entrustable professional activities (EPAs) were proposed in 2005 to operationalize postgraduate competency-based medical training (ten Cate 2005; ten Cate and Scheele 2007). EPAs are core units of professional practice that can be fully entrusted to a trainee as soon as he or she has demonstrated the necessary competence to execute the activity unsupervised, and thus reflect the objectives of postgraduate training (ten Cate 2013b; ten Cate 2014). Various authors have suggested they should be suitable for undergraduate training too (Chen et al. 2016; Chen et al. 2015; Englander et al. 2016). For example, the US Association for American Medical Colleges evoked national interest by proposing 13 EPAs that medical graduates should be able to do with limited supervision when starting residency (Englander et al. 2014), as did the Canadian medical schools (Touchie and Boucher 2016). The Medical Council of Ireland has proposed EPAs for the intern year (Boland et al. 2015) and in Switzerland, the Joint Commission of the Swiss Medical Schools recently launched a proposal to incorporate EPAs in all undergraduate medical programs (Jucker-kupper 2016). While there is considerable interest in working with EPAs, there are also many questions, confusions, and a need for clarifications (ten Cate 2013a; Gilhooly et al. 2014; van Loon et al. 2014; Sklar 2015). As with many curricular innovation processes, conceptual ideas need to get translated in practice, and devil tends to be in details.

Table

Practice points

The Utrecht Framework with five core EPAs and 31 small nested EPAs deviates from other EPA frameworks for undergraduate medical training. The nesting principle was created and applied to enhance an integrative vision of the objectives of medical training while providing sufficient affordances for junior medical students in the clinical workplace. The development of the EPA framework would not have been possible without a continuous dialog with clinical teachers involved in coordinating clerkships in the trenches. Time will tell what adaptations will be needed to sustain the vision of training students to be better prepared for responsibilities and contributions in patient care.

Creating an EPA framework is an important step, but creating a workplace curriculum with EPAs as part of the program requires more and different effort (Gale and Grant 1997; Thomas et al. 2016). This contribution discusses the exemplar of the Utrecht undergraduate medical education program that was reformed for a number of reasons. One was to incorporate EPAs in the clinical workplace curriculum, along with a major reorganization of the most clerkship.

Methods

In 2011, a curriculum review process for accreditation resulted in a number of recommendations for the future of the medical course at University Medical Center Utrecht. The Dean of this school decided to establish a horizon scanning committee, charged with collecting information about developments in medical education worldwide and recommending on innovations in the Utrecht curriculum. In 2012, based on the committee’s recommendations, a curriculum committee drafted a blueprint for a new Utrecht curriculum, which was delivered and accepted in 2013. Significant innovations proposed included several changes (ten Cate et al. 2018), one of which was the introduction of EPAs to operationalize the most important objectives of clinical training and to serve as a backbone of the workplace curriculum.

The framework of EPAs that was eventually established went through a series of iterations and was vetted against important documents. The 2009 Dutch Framework of objectives for medical training is the foundation for license in the Netherlands and any medical curriculum needs to comply with it. While this Framework is currently not based on EPAs, “professional activities” are quite prominent in the document (Van Herwaarden et al. 2009). As in the Netherlands the CanMEDS framework of objectives for medical training was adopted for both postgraduate and undergraduate education, this framework was used too (Frank 2005). Another source was the draft version of the Core EPAs for Entering Residency document of the Association of American Medical Colleges that appeared in the fall of 2013 and was launched formally in 2014 (Englander et al. 2014). Further inspiration was found in the Carnegie report on reform of medical education and residency (Cooke et al. 2010), Frenk et al.’s vision document on the future of medical education (Frenk et al. 2010) and a Dutch State-of-the-Art report on medical education (Hillen 2012).

The Curriculum Committee, meeting once a month in full and in smaller and diverse settings several times per month, included a pathologist, a pediatrician, a family physician, an educationalist, two student representatives, and four recent (bio)medical graduates. The latter four were hired to work on all details of the curriculum, in collaboration with a large number of senior faculty in coordinating positions, such as current and future unit coordinators and clerkship directors. Discussion meetings were also held with clinicians for all relevant departments of University Medical Center Utrecht and representatives of all hospitals in the region that are involved in clinical clerkships. At regular moments the Dean and the Faculty Council were informed about the progress and consented with steps to be taken.

In 2015–2016, a group of 36 students was asked to participate in the pilot execution of a 12-week integrated clerkship within the existing curriculum. The pilot included the use of EPAs and the use of an electronic portfolio. Lessons learned from this pilot implementation were used to guide the final structure and procedures in the new clinical curriculum as started in 2016–2017.

Results

The curriculum structure

To understand the EPA framework it is necessary to start with an overview of the new Utrecht curriculum CRU + (Curriculum Utrecht – Program of the Longitudinal Utrecht Study). Figure 1 shows CRU + graphically.

Figure 1. Graphic overview of the clinical curriculum of CRU+. B: bachelor; M: master; all colored clerkships are called LINK (longitudinal integration in the clinical setting).

The Utrecht curriculum is six years, divided into two phases of three years (Bachelor and Master), as prescribed by Dutch law. Entrance requirement is a high school diploma and meeting selection criteria as set by the school. The gray sections reflect the non-clinical courses or elective courses, the colored clerkships reflect the clinical curriculum. The final year is called “transitional year” and prepares for residency training. This year was completely revised in 2004 and has been very successful since (Wijnen-Meijer et al. 2013). The new, integrated clerkships are named after their color (LINK Green up to LINK Purple), and focus on multiple disciplines as mentioned in the figure.

Following the principles of a vertically integrated, Z-shaped curriculum (ten Cate 2007), the first two years provide foundational basic science knowledge in a series of blocks with classroom teaching and practice classes. Preceding each 12-week integrated clerkship, a 6-week block period prepares students with all necessary knowledge and skills to successfully complete the subsequent clerkship. In total 18 weeks is devoted to the domains of that LINK; e.g. for LINK Blue, neurology, psychiatry, and geriatrics have developed both Block Blue and the subsequent LINK.

The EPA framework

The final version of the overall framework for undergraduate medical education in Utrecht contains five broad core EPAs. After versions of lists ranging from 10 to 14 different EPAs, the committee concluded that broad, highly integrated EPAs would best reflect the activities expected at the start of residency training.

To prepare students for the competence to execute the core EPAs during the final, transitional year of medical school (M3 in Figure 1), many smaller activities must be practiced and mastered that can subsequently be integrated (nested) within broad EPAs. For example the clinical consultation, EPA1, requires that students are familiar with a wide range of history and physical examination activities, including the neurologic examination, psychiatric history taking, and other specialty-specific investigation procedures. Any patient that presents to the student in the final year should be approached with whatever history or examination is necessary, no matter the main complaint or reason for encounter. The medical graduate should have sufficient knowledge and skill to do a specialized consultation at a basic level and recognize when to refer to a specialist.

Each of these activities can be considered to be a small EPA, to be mastered during an integrated clerkship in the preceding years. Table 3 shows how deliberate attention is paid to specific elements of the core EPAs in different LINKs. In some cases, the program will require the student to have mastered a smaller nested, non-specialty-specific EPA in a period that extends one-integrated clerkship. Students have the responsibility to make sure they will master those somewhere in a year or across two years.

The connection between core EPAs and the competency-framework of CanMEDS is shown in Table 2. For each EPA the curriculum, committee has determined which domains or roles are most important to evaluate when observing a student conducting this EPA.

The full list of core EPAs and nested smaller EPAs is provided in Table 3. The second column shows in which LINK or year the student is expected to be entrusted with the activity at a level of independence as indicated in the third column to enable satisfactory completion of the LINK. Each of these EPAs is elaborated in a guide for students and clinical faculty, covering the recommended 1–2-page description of title, specification, and limitations, relevant competency domains, required knowledge, skills attitude and experience, grounding of entrustment, and targeted level of supervision to be reached before the end of the clerkship or curricular phase (ten Cate et al. 2015).

Supervision levels for entrustment decisions

EPAs are to be entrusted to be performed fully unsupervised, by definition, ultimately at the end of postgraduate training. In earlier phases, however, entrustment decisions may reflect a gradual increase of independence or decrease of required supervision. A framework of five supervision levels for postgraduate training was proposed by Ten Cate & Scheele (ten Cate and Scheele 2007). For undergraduate medical training, an adaptation of this general framework was deemed necessary. In general, unsupervised practice for EPAs is not the objective for the MD degree, as virtually all-medical practice requires subsequent medical training under supervision. An adaptation of the five levels was proposed for undergraduate training by Chen et al. (2015). Table 4 shows the CRU + translation of these levels which aligns well with Chen’s work and other recent recommendations (Peters et al. 2017).

Entrustment decisions in the LINKs must be taken for all students for all EPAs at the levels presented in column 3 of Table 3. In the course of the curriculum, some EPAs return to be signed off at a higher level of responsibility, i.e. a lower level of supervision. This reflects the holistic approach to avoid the suggestion of “completion” after sign-off for an EPA. An entrustment decision should be the beginning of trusting the learner with an activity, rather than only ending a period of training.

Assessment and documentation

The successful completion of a LINK requires that students (i) have successfully completed the preceding block exam, (ii) have been formally entrusted with the execution of each specific EPA of that LINK at the designated level of supervision (usually indirect supervision – see Table 3), (iii) meet expectations for professional behavior across the LINK, and (iv) meet expectations for general clinical proficiency across the LINK. Aligned with the principles of programmatic assessment (Schuwirth and Van der Vleuten 2011), many moments of evaluation across the 3 months of the LINK contribute to the scores. For EPA-focused assessment, two approaches of assessment apply in particular: short practice observations and case-based discussions (CBD).

Short practice observations are samples of observation of students conducting an EPA or parts of an EPA for 5–15 min, followed by feedback and a recommendation (ready for entrustment or not yet?). The recommendation is supplemented by a “below expectations – meets expectations – exceeds expectations” score for each of the CanMEDS competency domains that were deemed important for this EPA (see Table 2).

CBD or “entrustment-based discussions” (EBD) as a specific CBD form, also 5–15 min, usually after a student has conducted a certain EPA, focus on estimating whether the student would be trusted to execute the EPA with less supervision based on fictional variations in patient characteristics/situations suggested by the supervisor. New situations may pose new challenges, so the CBD/EBD focuses not only on what was done but also on the awareness of potential risk, and how the student would act when faced with unexpected findings or complications. As an entrustment decision involves taking a risk, we ask supervisors to discuss four questions with the student: (i) What has been done? (ii) What is your background understanding and reasoning related to this EPA? (iii) Which risks or complications were you aware of? And (iv) How would you have acted if the situation or patient had been different for any reason? This may relate to culture, medical history, unexpected findings, mental or physical abnormality, etc. Prepared scenarios may be used to include rare but critical cases (ten Cate and Hoff 2017).

While much of this can be done in the natural flow of clinical work, the documentation of the observations and conversations must be extremely efficient and student and clinician-friendly to be feasible. A tailor-made electronic portfolio system was deemed necessary to support the EPA-based curriculum. After a useful pilot with one commercial model, specifications were collected to choose a different model for permanent use in the clinical curriculum. The system allows for easy registration of the results of all formative assessment moments (short practice observations and CBD) and summative assessment moments. A student dashboard shows all progress to date, including entrustment decisions taken, and development in competency domains across observations over time. Clinical teachers have access to a version of the dashboard to determine whether students are ready for entrustment, based on the formative evaluation data available. Summative entrustment decisions must be signed by at least two clinicians. To further increase efficiency, in the near future mobile device apps will support faculty in creating short reports to be sent to student portfolios.

Discussion

The Utrecht curriculum was prepared for the launch of its clinical innovations in August 2016, in particular, the clinical phase of the curriculum. This contribution summarized the process of curriculum development and its result, with an emphasis on the design and implementation of an entrustable professional activities framework. The process may be viewed as an operationalization of guidelines for EPA-based curriculum development as published (ten Cate et al. 2015).

The curriculum will be more competency-based and the intention is to graduate students who are better prepared to start residency, as they have been more aware and focused on their responsibilities and contributions to health care. The curriculum also stimulates more individualized pathways. In addition to the framework of core EPAs, elective EPAs will be offered in elective periods and within LINKS for students who excel. One of the programs currently being developed for the transitional year is an integrated elective stream of “Vital Functions” that will prepare students particularly for emergency care, i.e. for postgraduate training in cardiology, intensive care, emergency medicine, and anesthesiology, and enable a shortening of those residencies (Jonker et al. 2017). Realizing true competency-based instead of predominantly time-based education is not easily attainable, as the history of competency-based medical education shows (Touchie and ten Cate 2016; Lucey et al. 2018), but the process so far gives hopes that we have moved at least a step forward. What lessons have we learned in this process that are useful to share?

The holistic nature of EPAs and the principle of nesting

One of the criticisms, misconceptions or pitfalls of using EPAs is that it would be another checklist that replaces competencies (Klamen et al. 2016). However, EPAs are not competencies but only units of work in healthcare and the entrustment with that work is a synthetic or holistic approach to education and assessment, in contrast with analytic competency frameworks (Pangaro and ten Cate 2013). The combination of both EPAs and competencies as shown in Table 2 provides integration. For that reason, the EPAs of undergraduate education should not be small and many, but broad and few. There is no sense in capturing all details of patient care in separate EPAs that must be signed off at graduation. Rather, it is important that during training students learn to widen their view and scope of practice. At early stages, a few small tasks in health care may reflect very significant responsibilities for junior learners, but while students mature these become part of larger, more encompassing responsibilities. In our program, we have translated this development in different levels of detail in bachelor en master years B3, M1, M2, and M3 of the curriculum. Smaller EPAs (B3) become nested within larger ones (M1 and M2) which in turn become nested within the broad M3 EPAs for graduation. At the end of the course, when learners are to be prepared for general readiness to be entrusted with patient care tasks such in EPA 1 “The Clinical Consultation,” the evaluation may shift from a focus on practical abilities to the more fundamental conditions that allow for trust. Supervising clinicians should then have the conversation with advanced medical students about the key qualities that enable trust. Ability (knowledge/skill to perform the EPA) needs to be complemented by integrity (truthfulness and benevolence), reliability (conscientiousness and predictable behavior), and humility (recognition of own limitations and willingness to ask for help if needed) (ten Cate 2016; Peters et al. 2017).

How do our EPAs map to other EPA frameworks?

Thirteen EPAs were proposed and are currently explored in many medical schools in the US (Englander et al. 2016), most of which are also incorporated in Canadian medical schools (Touchie and Boucher 2016). While we arrived at five core EPAs, naturally this is one choice and another school may create a different framework that could be equally defensible. We mapped the US Core EPAs against our EPAs and concluded that basically all are covered (table not provided). While some core EPAs may at first sight not meet the definition of an EPA (ten Cate 2013a), we found ourselves eventually using some EPA titles that could be subjected to the same criticism. However, from the specification of EPA 4 for example (communicating and collaborating with colleagues), it becomes readily clear that this EPA includes activities that do have a beginning and end and are observable and measurable in process and outcome (Table 1). Time will tell how feasible valid entrustment decisions for these EPAs are. We agree with Englander et al. that experience and evaluation are important (Englander et al. 2016).

Table 1. Core EPAs of the Utrecht undergraduate curriculum.

Core EPA	Specification	General limitations
1. The clinical consultation	History, physical examination, measuring vital signs, creating a differential diagnosis, ordering and interpreting diagnostic tests, and designing a management plan.	Hemodynamically stable, cognitively competent patients
2. General medical procedures	Preparing and executing 23 medical procedures including the necessary communication with patients	Hemodynamically stable, cognitively competent patients
3. Informing, advising and guiding patients and families	General guidance of patients, including discussing diagnostic options, obtaining informed consent, discussing test results and management plan, and discharge conversation	Patients with a non-life threatening condition
4. Communicating and collaborating with colleagues	Writing a discharge summary/letter; oral patient handovers; patient documentation and presentations; research documentation and presentations, collaborating with other healthcare workers and contributing to inter-professional teams	No general limitations
5. Extraordinary patient care	Basic life support; establishing death	No general limitations

Table 2. EPAs – competency domains matrix.

EPA	Medical expert	Communicator	Collaborator	Manager/ leader	Health advocate	Scholar	Professional
1. The clinical consultation	⊙	⊙	–	⊙	•	⊙	⊙
2. General medical procedures	⊙	•	–	⊙	–	–	⊙
3. Informing, advising, and guiding patients and families	•	⊙	•	–	•	•	⊙
4. Communicating and Collaborating with colleagues	•	–	⊙	•	•	⊙	⊙
5. Extraordinary patient care	⊙	•	•	•	–	–	⊙

⊙: essential, •: important

Table 3. Full overview of core EPAs and their nested EPAs in the Utrecht curriculum.

Core EPA 1: The clinical consultation	LINK/year	Level
1.1 General history and physical examination including vital signs	Green	3a
1.2 Gynecology clinical consultation	Red	3a
1.3 Clinical consultation of pregnant woman	Red	3a
1.3 Clinical consultation of neonate and infant	Red	3a
1.4 Pediatric clinical consultation	Red	3a
1.6 Clinical genetics consultation	Red	3b
1.7 Neurological clinical consultation	Blue	3a
1.8 Psychiatric clinical consultation	Blue	3b
1.9 Geriatric clinical consultation	Blue	3a
1.10 Consultation for brief-episode issues in primary care	Yellow	3b
1.11 Follow-up consultation in protocolized chronic primary care	Yellow	3b
1.12 Public health consultation	Yellow	3b
1.13 Clinical consultation into the out-patient setting	Purple	3b
1.14 Consultation of the hospital-admitted critically ill patient	Purple	3b
1.15 Peri-operative patient consultation	Purple	3b
1.16 Consultation in the acute-care setting	Purple	3b
Core EPA 2: general medical procedures
2.1 Venepuncture	Green	3b
2.2 Peripheral intravenous line placement and connection	Green & M1/M2	3a & 3b
2.3 Participation in the OR	Green	3b
2.4 Speculum/vaginal examination	Red	2b
2.5 Insertion of urinary catheter	M1 & M2	3b
2.6 Intramuscular, intra- and subcutaneous-injection	M1 & M2	3b
2.7 Rectal examination	M1 & M2	3a
2.8 Wound care	M1 & M2	2b
Core EPA 3: informing, advising, and guiding patients and families
3.1 Discussing diagnostic options and obtaining informed consent	M1 & M2	2a & 2b
3.2 Discussing test results, prognosis, and a management plan	M1 & M2	2a & 2b
3.3 Discharge conversation	Purple	2b
Core EPA 4: communicating and collaborating with colleagues
4.1 Patient handover documentation and presentation	Green&M1&M2	2a&2b&3b
4.2 Acting in interprofessional teams	M1 & M2	2b & 3b
Core EPA 5: extraordinary patient care
5.1 Establishing death	M1 or M2	2b
5.2 Basic life support	M1 or M2	3b

Table 4. Entrustment and supervision levels for postgraduate training and the Utrecht curriculum.

Entrustment and supervision scale for postgraduate training	Expanded entrustment and supervision scale for undergraduate training in Utrecht^a
1.Not permitted to practice the EPA	1.Permission to be present not to enact the EPA. This is the assumed level at entrance of any clerkship of CRU+
2.Permission to practice the EPA under direct, proactive supervision	2.Direct supervision. Supervisor is present in the room. a.EPA may be conducted as a co-activity with supervisor b.EPA may be conducted alone
3.Permission to practice the EPA under indirect, reactive/on-demand supervision	3.Indirect supervision. Supervisor is not in the room but in the immediate vicinity and quickly available for reactive/on-demand supervision. a.Supervisor will repeat the activity b.Supervisor will double check key findings and decisions c.Supervisor will double check findings within 24 h or earlier on the student’s request
4.Permission to practice EPA unsupervised	4.Limited supervision. Supervisor is not present in the healthcare facility. Generally not applicable in CRU+ a.Supervisor is available on call to come and provide supervision b.Supervisor is not available but may provide feedback and monitoring in hindsight
5.Permission to supervise others in the practice of the EPA	5.Permission to supervise others in practice of this EPA. This level is not applicable in CRU+

^a The numbering in this scale aligns with current internationally used levels. For reasons of accreditation by the Joint Commission International, UMC Utrecht uses a slightly adapted numbering that is not displayed, to avoid confusion. Levels 4 and 5 are not applicable in CRU+.

Are all essential disciplines covered with EPAs?

Much discussion was devoted to defining the nested EPAs under The Clinical Consultation Core EPA 1. Consultations in dermatology, ophthalmology, and ENT long served as mandatory but finally moved to the status of elective EPA. Brief times spent in the clinical context with these EPAs would not warrant these traditional disciplines to require this EPA, while at the same time space was created for new disciplines, such as clinical genetics and geriatrics. Family Medicine, a prominent specialty in the Netherlands, did not warrant and EPA as these would be too comprehensive and undefinable. Instead, “brief episodic care” (regarding minor ailments) and “follow-up consultation of protocolized chronic care” which cover much of the family doctor’s practice were considered the best focus for EPAs in this domain.

Even with the relatively extensive clinical experience in the CRU + curriculum, choices were made that could be debated, but met with sufficient consensus to build the curriculum.

Ad hoc entrustment and supervision to prepare for summative entrustment

Considerable debate and clarification for faculty were necessary to make the distinction between ad hoc and summative entrustment decisions. A student whose dashboard does not show formal permission to carry out an EPA without the supervisor in the room, can, and even must, be stimulated to do so in the learning process. However, at every ad hoc occasion, the supervisor should evaluate the situation for its safety to have a student practice and should evaluate the student’s performance afterward to estimate his or her readiness for the formal statement of awarded responsibility¹.

Translation into examination rules

A balanced approach to the assessment of students is important. A major goal is to stimulate learning through authentic practice. Monitoring and feedback are essential and there is agreement that one patient examination at the end of the clerkship is not a sufficient basis for satisfactory evaluation of the student. While some schools advocate the complete abandonment of grades in clinical education (Dannefer 2013; Hanson et al. 2013), our school chose a middle ground. Regular grades in clinical clerkships were abandoned, but the possibility to identify extraordinary excellence and students at risk remained. For summative entrustment decisions of LINK-specific EPAs in the EPA 1-series (clinical consultation), we created the rule that at least two recent short observations and two case-based discussions must have resulted in a recommendation to formally award the higher level of supervision toward the expected level at the end of the clerkship (see Table 3, column 3).

Faculty involvement and information

For most clinician faculty the EPA concept is completely new. EPA is a new acronym and resistance to new jargon is quite understandable. However, when explained, most faculties get the concept and can work with it, and some faculty has become great supporters.

Because of the large numbers of faculty involved in clinical education in various hospitals and primary care practices, a major effort is needed to inform and train faculty. The novelty of a different organization of clerkships than was the case for over a century, a new system of assessment and the use of an electronic portfolio requires extensive explanation and practice. A curriculum committee cannot assume that faculty will understand and sufficiently remember briefings in a lecture hall or written flyers. Active practice is necessary. During the process of curriculum and clerkship development, core clinical faculty at UMC Utrecht departments has substantially facilitated the further communication with teaching hospitals that will be involved. Finally, new tools used should be self-explanatory as much as possible.

Next, our pilot practice with LINK Green showed that students can be ambassadors of a new curriculum too. Their feeling of ownership of not only their e-portfolio but also of the whole learning process, including how to prepare to receive entrustment for EPAs may significantly clarify the process for faculty. Our first generation of students will likely face many such moments across a number of years, despite all effort to inform faculty.

What we cannot yet report is an evaluation of the curriculum in practice. There will be close monitoring in the coming years and the intention is to report on various parameters of achievement starting around the time of the first graduates of this curriculum.

Notes on contributors

Olle ten Cate, PhD, is Professor of Medical Education, Scientific Director of Education, and Senior Scientist at the Center for Research and Development of Education at University Medical Center, Utrecht, the Netherlands and was Vice-chair of the CRU + curriculum committee.

Lysanne Graafmans, MD, is a staff member and educational advisor of the Curriculum Committee 2016–2017 at University Medical Center, Utrecht, the Netherlands.

Indra Posthumus, MD, was a staff member and educational advisor of the Curriculum Committee 2016–2017 at University Medical Center, Utrecht, the Netherlands.

Lisanne Welink, MD, was staff member and educational advisor of the Curriculum Committee 2014–2016 at University Medical Center, Utrecht, the Netherlands, and now combines a PhD-trajectory with vocational training in General Practice at the Julius Center for Health Sciences and Primary Care.

Marijke R. van Dijk, MD, PhD, was Program Director and Chair of the CRU + Curriculum Committee until March 2017 at University Medical Center, Utrecht, the Netherlands.

Acknowledgments

The authors wish to particularly thank Menne van Boven MD, Sanne van de Munckhof MD, and Karlijn Hofstraat MSc, for their thoughtful contributions to the EPA framework. Further, the authors are grateful to other faculty and student members of the Curriculum Committee and associated clinical faculty involved in implementation of LINKs: Heleen Brehler, Carlijn Dolmans, Mick van Eijs, Samuel Fidder, Joost Frenkel, Sibyl Geelen, Timon van Haeften, Reinier Hoff, Laura van der Kamp, Bastiaan van der Klis, Bregje Koomen, Floor van Leeuwen, Berent Prakken, Joni Remmits, Patricia Schothorst, Anke Steerneman, Suzanne van der Velden, Renee van de Wetering, Tineke Westerveld, Janneke Witte, and Dorien Zwart.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Note

Additional information

Funding

The work on EPAs of the first, third and fourth author (OtC, IP, and LW) was partly funded by a multi-institutional project called Workplace-based e-Assessment Technology for Competency-based Higher Multi-professional Education (WATCHME) from EU’s Seventh Framework Programme for research, technological development, and demonstration, under grant agreement [619349].

Notes

1 In the Dutch language there is an accepted and well understood word (“bekwaamverklaring”) that has been translated as Statement of Awarded Responsibility (STAR (36)) based on a summative entrustment decision.