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

Figures & data

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.

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).

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+.