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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.

Aim: The aim of this report, written for the 40th anniversary issue of Medical Teacher, is to document 20 years of development of the Utrecht undergraduate medical curriculum, as both to exhibit accountability and to inform the community of the process and choices that can be made in long-term curriculum development., Methods: We used the SPICES model, created by Medical Teacher's Editor Ronald Harden and colleagues in 1984., Results: The Utrecht six-year program, now called "CRU+", has many distinct features that were introduced, most of which are well documented. A limited selection includes  • A new 3+3 years Bachelor-Master structure following the EU Bologna rules leading to MD registration for cohorts of about 300.  • Horizontally integrated classroom teaching of basic sciences with clinical disciplines predominantly in groups of 12 and limited lectures.  • Mandatory knowledge retention tests, retesting the clinically relevant core knowledge from block tests of semesters one through four.  • Vertical integration not only linking clinical experience with background knowledge, but also exemplified by a stepwise increase in health care responsibilities throughout the curriculum.  • A final year focussing on growth towards the level of a primary responsible physician in a 12-week sub-internship for a limited number of patients and beds, in a chosen specialty. The student is called a semi-physician in the clerkship of this transitional year to residency.  • Teaching skills training for all medical graduates, an elective teaching rotation and various peer-teaching arrangements throughout the curriculum.  • Integrated semi-longitudinal clerkships with an assessment focus on entrustment decisions for Entrustable Professional Activities., Conclusion: UMC Utrecht has made a continuous attempt to both develop its medical curriculum and to study and report on its development in the literature, regarding new methods found and insights derived. UMC Utrecht will remain committed to developing training to meet twenty-first century demands of medical graduates.

Context: Transitions of patient care responsibility occur frequently between physicians. Resultant discontinuities make it difficult for physicians to observe clinical outcomes. Little is known about what physicians do to overcome the practical challenges to learning these discontinuities create. This study explored physicians' activities in practice as they sought follow-up information about patients., Methods: Using a constructivist grounded theory approach, semi-structured interviews with 18 internal medicine hospitalist and resident physicians at a single tertiary care academic medical center explored participants' strategies when deliberately conducting follow-up after they transitioned responsibility for patients to other physicians. Following open coding, the authors used activity theory (AT) to explore interactions among the social, cultural and material influences related to follow-up., Results: The authors identified three themes related to follow-up: (i) keeping lists to track patients, (ii) learning to create tracking systems and (iii) conducting follow-up. Analysis of participants' follow-up processes as an activity system highlighted key tensions in the system and participants' work adaptations. Tension within functionality of electronic health records for keeping lists (tools) to find information about patients' outcomes (object) resulted in using paper lists as workarounds. Tension between paper lists (tools) and protecting patients' health information (rules) led to rule-breaking or abandoning activities of locating information. Finding time to conduct desired follow-up produced tension between this and other activity systems., Conclusion: In clinical environments characterised by discontinuity, lists of patients served as tools for guiding patient care follow-up. The authors offer four recommendations to address the tensions identified through AT: (i) optimise electronic health record tracking systems to eliminate the need for paper lists; (ii) support physicians' skill development in developing and maintaining tracking systems for follow-up; (iii) dedicate time in physicians' work schedules for conducting follow-up; and (iv) engage physicians and patients in determining guidelines for longitudinal tracking that optimise physicians' learning and respect patients' privacy., (© 2018 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Health care systems around the world are transforming to align with the needs of 21st-century patients and populations. Transformation must also occur in the educational systems that prepare the health professionals who deliver care, advance discovery, and educate the next generation of physicians in these evolving systems. Competency-based, time-variable education, a comprehensive educational strategy guided by the roles and responsibilities that health professionals must assume to meet the needs of contemporary patients and communities, has the potential to catalyze optimization of educational and health care delivery systems. By designing educational and assessment programs that require learners to meet specific competencies before transitioning between the stages of formal education and into practice, this framework assures the public that every physician is capable of providing high-quality care. By engaging learners as partners in assessment, competency-based, time-variable education prepares graduates for careers as lifelong learners. While the medical education community has embraced the notion of competencies as a guiding framework for educational institutions, the structure and conduct of formal educational programs remain more aligned with a time-based, competency-variable paradigm.The authors outline the rationale behind this recommended shift to a competency-based, time-variable education system. They then introduce the other articles included in this supplement to Academic Medicine, which summarize the history of, theories behind, examples demonstrating, and challenges associated with competency-based, time-variable education in the health professions.

Postgraduate medical training in the Netherlands has become increasingly individualized. In this article, the authors describe current practices for three residency programs at the University Medical Center Utrecht: anesthesiology, pediatrics, and ophthalmology. These programs are diverse yet share characteristics allowing for individualized residency training. New residents enter each program throughout the year, avoiding a large simultaneous influx of inexperienced doctors. The usual duration of each is five years. However, the actual duration of rotations or of the program as a whole can be reduced because of residents' previous medical experience or demonstration of early mastery of relevant competencies. If necessary, the duration of training can also increase.Although working hours are already restricted by the European Working Time Directive, most residents choose to train on a part-time basis. The length of their program then is extended proportionally. The extension period added for those residents training part-time can be used to develop specific competencies, complete an elective rotation or research, or explore a focus area. If the resident meets all training objectives before the extension period is completed, the program director can choose to shorten the program length. Recently, entrustable professional activities have been introduced to strengthen workplace-based assessment. The effects on program duration have yet to be demonstrated.Flexible postgraduate training is feasible. Although improving work-life balance for residents is a necessity, attention must be paid to ensuring that they gain the necessary experience and competencies and maintain continuity of care to ensure that high-quality patient care is provided.

As competency-based medical education is adopted across the training continuum, discussions regarding time-variable medical education have gained momentum, raising important issues that challenge the current regulatory environment and infrastructure of both undergraduate and graduate medical education in the United States. Implementing time-variable medical training will require recognizing, revising, and potentially reworking the multiple existing structures and regulations both internal and external to medical education that are not currently aligned with this type of system. In this article, the authors explore the impact of university financial structures, hospital infrastructures, national accrediting body standards and regulations, licensure and certification requirements, government funding, and clinical workforce models in the United States that are all intimately tied to discussions about flexible training times in undergraduate and graduate medical education. They also explore the implications of time-variable training to learners' transitions between medical school and residency, residency and fellowship, and ultimately graduate training and independent practice. Recommendations to realign existing structures to support and enhance competency-based, time-variable training across the continuum and suggestions for additional experimentation/demonstration projects to explore new training models are provided.

The logical consequence of implementing competency-based education is moving to time-variable training. Competency-based, time-variable training (CBTVT) requires an understanding of how learners interact with their learning context and how that leads to competence. In this article, the authors discuss this relationship. They first explain that the time required to achieve competence in clinical practice depends on the availability of clinical experiences that are conducive to ongoing competence development. This requires both curricular flexibility in light of the differences in individual learners' development and a balance between longitudinal placements and transitions to different environments.Along with the deliberate use of the opportunities that learning environments offer, there is value for learners in spending ample time-in-context. For instance, guided independence is possible when trainees do not progress immediately after meeting curricular learning objectives. Next, the potential implications of CBTVT can be illustrated by two learning perspectives-Sfard's acquisition and participation metaphors-which leads to the assertion that competence is both an individual characteristic and a quality that emerges from a purposeful social interaction between individuals and their context. This theory recognizes that the deliberate use of context could be used to approach learning as acquiring collective competence.Based on this relationship between learner, context, and competence, the authors propose an approach to CBTVT that recognizes that all learners will have to meet a number of standard preset learning targets in their workplace, while still having room for further context-specific competence development and personal growth within strategically organized learning environments.

Competency-based, time-variable medical education has reshaped the perceptions and practices of teachers, curriculum designers, faculty developers, clinician educators, and program administrators. This increasingly popular approach highlights the fact that learning among different individuals varies in duration, foundation, and goal. Time variability places particular demands on the assessment data that are so necessary for making decisions about learner progress. These decisions may be formative (e.g., feedback for improvement) or summative (e.g., decisions about advancing a student). This article identifies challenges to collecting assessment data and to making assessment decisions in a time-variable system. These challenges include managing assessment data, defining and making valid assessment decisions, innovating in assessment, and modeling the considerable complexity of assessment in real-world settings and richly interconnected social systems. There are hopeful signs of creativity in assessment both from researchers and practitioners, but the transition from a traditional to a competency-based medical education system will likely continue to create much controversy and offer opportunities for originality and innovation in assessment.

The introduction of competency-based medical education has shifted thinking from a fixed-time model to one stressing attained competencies, independent of the time needed to arrive at those competencies. In this article, the authors explore theoretical and conceptual issues related to time variability in medical training, starting with the Carroll model from the 1960s that put time in the equation of learning. They discuss mastery learning, deliberate practice, and learning curves.While such behaviorist theories apply well to structured courses and highly structured training settings, learning in the clinical workplace is not well captured in such theories or in the model that Carroll proposed. Important in clinical training are self-regulation and motivation; neurocognitive perspectives of time and learning; professional identity formation; and entrustment as an objective of training-all of which may be viewed from the perspective of the time needed to complete training. The authors conclude that, in approaching time variability, the Carroll equation is too simplistic in its application to the breadth of medical training. The equation may be expanded to include variables that determine effective workplace learning, but future work will need to examine the validity of these additional factors.

Purpose: To conduct a scoping review to explore the construct of shared mental models (SMMs) in the context of clinical teamwork among health professions learners., Method: The authors searched the PubMed, ERIC, CINAHL, Scopus, Web of Science, PsychINFO, and EMBASE databases for English-language articles published between 2000 and 2016. Eligible articles mentioned SMMs in relation to clinical teamwork and included health professions learners. Two reviewers screened studies for eligibility and extracted data to determine the depth and breadth of the literature on SMMs. The authors examined definitions of the SMM construct in the context of clinical teams, educational interventions using SMMs, and the measurement of SMMs., Results: Of the 1,273 articles retrieved, 23 met the inclusion criteria. SMMs were defined in less than two-fifths of the articles (9/23). All articles applied the construct to improvements in hospital-based patient safety, often in high-intensity settings (14/23). Most articles included graduate-level physicians (21/23) within clinical teams (18/23). Interventions designed to foster SMMs (6/23) included teamwork curricula/training and teamwork supportive tools. Measurements of SMMs (7/23) included a qualitative task analysis, quantitative analyses of speech, a concept mapping, and Likert-type surveys., Conclusions: In health professions education, the SMM construct lacks clear definition. Few studies described educational interventions aimed at SMM development, and few attempted to measure the construct. The authors propose an operational definition of SMMs in health care and illustrate how interventions intended to foster SMMs, such as team trainings or planning exercises and communication tools, could be developed, implemented, and assessed.

Objectives: The present study aimed to investigate residents' preferences in dealing with personal multi-source feedback (MSF) reports with or without the support of a coach., Methods: Residents employed for at least half a year in the study hospital were eligible to participate. All 43 residents opting to discuss their MSF report with a psychologist-coach before discussing results with the program director were included. Semi-structured interviews were conducted following individual coaching sessions. Qualitative and quantitative data were gathered using field notes., Results: Seventy-four percent (n= 32) preferred sharing the MFS report always with a coach, 21% (n= 9) if either the feedback or the relationship with the program director was less favorable, and 5% (n=2) saw no difference between discussing with a coach or with the program director. In the final stage of training residents more often preferred the coach (82.6%, n=19) than in the first stages (65%, n=13).  Reasons for discussing the report with a coach included her neutral and objective position, her expertise, and the open and safe context during the discussion., Conclusions: Most residents preferred discussing multisource feedback results with a coach before their meeting with a program director, particularly if the results were negative. They appeared to struggle with the dual role of the program director (coaching and judging) and appreciated the expertise of a dedicated coach to navigate this confrontation. We encourage residency programs to consider offering residents neutral coaching when processing multisource feedback.

Objectives: To assess illness script richness and maturity in preclinical students after they attended a specifically structured instructional format, i.e., a case based clinical reasoning (CBCR) course., Methods: In a within-subject experimental design, medical students who had finished the CBCR course participated in an illness script experiment. In the first session, richness and maturity of students' illness scripts for diseases discussed during the CBCR course were compared to illness script richness and maturity for similar diseases not included in the course. In the second session, diagnostic performance was tested, to test for differences between CBCR cases and non-CBCR cases. Scores on the CBCR course exam were related to both experimental outcomes., Results: Thirty-two medical students participated. Illness script richness for CBCR diseases was almost 20% higher than for non-CBCR diseases, on average 14.47 (SD=3.25) versus 12.14 (SD=2.80), respectively (p<0.001). In addition, students provided more information on Enabling Conditions and less on Fault-related aspects of the disease. Diagnostic performance was better for the diseases discussed in the CBCR course, mean score 1.63 (SD=0.32) versus 1.15 (SD=0.29) for non-CBCR diseases (p<0.001). A significant correlation of exam results with recognition of CBCR cases was found (r=0.571, p<0.001), but not with illness script richness (r=-0.006, p=NS)., Conclusions: The CBCR-course fosters early development of clinical reasoning skills by increasing the illness script richness and diagnostic performance of pre-clinical students. However, these results are disease-specific and therefore we cannot conclude that students develop a more general clinical reasoning ability.

Background: Today's nursing school applicants are considered "digital natives." This study investigated students' views of new health care technologies., Method: In a cross-sectional survey among first-year nursing students, 23 common nursing activities and five telehealth nursing activities were presented along with three statements: "I consider this a core task of nursing," "I look forward to becoming trained in this task," and "I think I will do very well in performing this task.", Results: Internet-generation nursing students (n = 1,113) reported a significantly (p ⩽ .001) less positive view of telehealth activities than of common nursing activities. Median differences were 0.7 (effect size [ES], -0.54), 0.4 (ES, -0.48), and 0.3 (ES, -0.39), measured on a 7-point scale., Conclusion: Internet-generation nursing students do not naturally have a positive view of technology-based health care provision. The results emphasize that adequate technology and telehealth education is still needed for nursing students. [J Nurs Educ. 2017;56(12):717-724.]., (© 2017 van Houwelingen, Ettema, Kort, ten Cate.)

An at first sight seemingly coherent, global medical workforce, with clearly recognizable specialities, subspecialties and primary care doctors, appears at a closer look quite variable. Even within the most progressive countries as to the development of medical education, with educators who regularly meet at conferences and share major journals about medical education, the differences in structures and regulations are big. This contribution focuses on the preparation, admission policy, duration, examinations, and national competency frameworks in postgraduate speciality training in Germany, the USA, Canada, the UK, Australia and the Netherlands. While general objectives for postgraduate training programs have not been very clear, only recently competency-frameworks, created in a limited number of countries, serve harmonize objectives. This process appears to be a challenge and the recent creation of milestones for the reporting on progress of individual trainees (in the US and in Canada in different ways) and the adoption of entrustable professional activities, a most recent concept that is quickly spreading internationally as a framework for teaching and assessing in the clinical workplace is an interesting and hopeful development, but time will tell whether true harmonization across countries will happen.

Objective: A well-designed final year may ease the transition from medical school to postgraduate training, if it has enough depth to enable the acquisition of early specialty expertise, while keeping enough breadth to support the graduation as all-round physician. Aim of this article is to describe the design of a multidisciplinary dedicated transitional year (DTY) around the theme of recognition and initial treatment of vitally threatened patients. Methods: Undergraduate and postgraduate training directors from the departments of Anaesthesiology, Cardiology, Emergency Medicine, Intensive Care Medicine and Respiratory Medicine at UMC Utrecht and partnering hospitals have collaboratively developed and implemented a curriculum for a final year focusing on three entrustable professional activities (EPAs) in the domain of acute care. These EPAs represent authentic tasks of starting residents in each of the participating specialties, align student training objectives with postgraduate expectations, and are the primary focus of learning, teaching, and assessment throughout the year. Students are developmentally supported by a mentor and educationally supported by monthly academic half days. Results: Between October 2014 and November 2016,, 47 students chose DTY Acute Care. The set-up of our DTY is inspiring other specialties to develop multidisciplinary DTYs. Attainment of clinical competence, experience of students and staff, and exploration of graduates' early careers are subjects of current research projects. Conclusion: This multidisciplinary dedicated transitional year aims to graduate students with profile-specific competence in acute care. It prepares for residency in a range of specialties.

Since the turn of the twenty-first century, competency-based medical education (CBME) has become a dominant approach to postgraduate medical education in many countries. CBME has a history dating back half a century and is rooted in general educational approaches such as outcome-based education and mastery learning. Despite controversies around the terminology and the CBME approach, important national medical regulatory bodies in Canada, the United States, and other countries have embraced CBME. CBME can be characterized as having two distinct features: a focus on specific domains of competence, and a relative independence of time in training, making it an individualized approach that is particularly applicable in workplace training. It is not the length of training that determines a person's readiness for unsupervised practice, but the attained competence or competencies. This shift in focus makes CBME different from traditional training. In this contribution, definitions of CBME and related concepts are detailed.

Objectives: This study adds to the ongoing discussion on how to ease the transition from undergraduate medical training to postgraduate training. In the Netherlands there is no central matching system for admission to residency. Medical school graduates just apply for a position in an open job market. Many choose to acquire general or specialty-specific clinical experiences after the medical degree before residency, to further explore career opportunities and to increase their chances to get into their preferred specialty. To shorten this gap between undergraduate and the start of postgraduate training, the sixth and final year of most Dutch medical schools is designed as a "transitional year". Students work with more clinical responsibilities than in the earlier clerkships, and this year includes many elective options. Our study focuses on these elective options and explores how medical students use these transitional year electives to prepare for transition to postgraduate training. Methods: In 2012-2013 we asked all 274 graduating students at one Dutch medical school to complete an open-answer questionnaire with the following topics: their preferred specialty at the start of the transitional year, electives they chose during this year and reasons for these choices, and whether the transitional year electives changed their career considerations. Questionnaire results were coded by two researchers and were discussed with all members of the research team. Results: A total of 235 students responded (86%). Answers about motivation for choices revealed that most electives where chosen for career orientation and to optimize chances to get into a residency program. Students also focused on additional experiences in specialties related to their preferred specialty. Many students chose electives logically related to each other, e.g. combinations of surgery and radiology. About two-thirds of the respondents stated that their elective experiences did confirm their specialty preferences or resulted in a more clear insight. Conclusion: We conclude that students use the transitional year electives to focus on their future postgraduate training program, i.e. for orientation and to align their curriculum vitae with their preferred specialty, resulting in spontaneous early specialty streaming. To take advantages of this streaming, and to make sure students can transfer their experiences to other specialties if their career preferences change, individual elective Entrustable Professional Activities (EPAs), next to the core EPAs for all medical students, may serve to prepare a smooth transition to a specialty of choice and should be fully documented.

Purpose: Cognitive load theory, focusing on limits of the working memory, is relevant to medical education; however, factors associated with cognitive load during procedural skills training are not well characterized. The authors sought to determine how features of learners, patients/tasks, settings, and supervisors were associated with three types of cognitive load among learners performing a specific procedure, colonoscopy, to identify implications for procedural teaching., Method: Data were collected through an electronically administered survey sent to 1,061 U.S. gastroenterology fellows during the 2014-2015 academic year; 477 (45.0%) participated. Participants completed the survey immediately following a colonoscopy. Using multivariable linear regression analyses, the authors identified sets of features associated with intrinsic, extraneous, and germane loads., Results: Features associated with intrinsic load included learners (prior experience and year in training negatively associated, fatigue positively associated) and patient/tasks (procedural complexity positively associated, better patient tolerance negatively associated). Features associated with extraneous load included learners (fatigue positively associated), setting (queue order positively associated), and supervisors (supervisor engagement and confidence negatively associated). Only one feature, supervisor engagement, was (positively) associated with germane load., Conclusions: These data support practical recommendations for teaching procedural skills through the lens of cognitive load theory. To optimize intrinsic load, level of experience and competence of learners should be balanced with procedural complexity; part-task approaches and scaffolding may be beneficial. To reduce extraneous load, teachers should remain engaged, and factors within the procedural setting that may interfere with learning should be minimized. To optimize germane load, teachers should remain engaged.

Purpose: Physicians routinely transition responsibility for patient care to other physicians. When transitions of responsibility occur before the clinical outcome is known, physicians may lose opportunities to learn from the consequences of their decision making. Sometimes curiosity about patients does not end with the transition and physicians continue to follow them. This study explores physicians' motivations to follow up after transitioning responsibilities., Method: Using a constructivist grounded theory approach, the authors conducted 18 semistructured interviews in 2016 with internal medicine hospitalist and resident physicians at a single tertiary care academic medical center. Constant comparative methods guided the qualitative analysis, using motivation theories as sensitizing constructs., Results: The authors identified themes that characterized participants' motivations to follow up. Curiosity about patients' outcomes determined whether or not follow-up occurred. Insufficient curiosity about predictable clinical problems resulted in the choice to forgo follow-up. Sufficient curiosity due to clinical uncertainty, personal attachment to patients, and/or concern for patient vulnerability motivated follow-up to fulfill goals of knowledge building and professionalism. The authors interpret these findings through the lenses of expectancy-value (EVT) and self-determination (SDT) theories of motivation., Conclusions: Participants' curiosity about what happened to their patients motivated them to follow up. EVT may explain how participants made choices in time-pressured work settings. SDT may help interpret how follow-up fulfills needs of relatedness. These findings add to a growing body of literature endorsing learning environments that consider task-value trade-offs and support basic psychological needs of autonomy, competency, and relatedness to motivate learning.

Peer teaching or peer-assisted learning is a popular topic in the medical education literature. While not one method of education, a categorization is possible according to (a) the developmental distance between learner and peer teacher, (b) the scale or group size of learners in peer teaching arrangements and (c) the extent of formality or structure of the arrangement. That yields many different forms of peer teaching. Viewing peer teaching as a multifaceted method shows several benefits. On a deeper level however peer teaching may be viewed as a philosophy of medical education that has historical roots but aligns well with current thinking of teaching and learning across the continuum of medical education., (Copyright © 2017. Published by Elsevier GmbH.)

The authors of this perspective contribution have served two terms (2014 and 2016) in the Jury of the biennial Best PhD Dissertation Award committee of the Netherlands Association for Medical Education. During this period, the committee reviewed 32 dissertations. Based on discussions among the jury regarding elements of an award winning dissertation and existing literature, we propose seven criteria to evaluate PhD dissertations: size, breadth of research skills exhibited, coherence of studies, relevance to field, validity, style, communicative power and ethics, and impact of the work. We anticipate these may not only assist similar committees but also provide criteria of excellence for future doctoral work in health professions education.

Purpose To investigate knowledge and image interpretation skill development in residency by studying scores on knowledge and image questions on radiology tests, mediated by the training environment. Materials and Methods Ethical approval for the study was obtained from the ethical review board of the Netherlands Association for Medical Education. Longitudinal test data of 577 of 2884 radiology residents who took semiannual progress tests during 5 years were retrospectively analyzed by using a nonlinear mixed-effects model taking training length as input variable. Tests included nonimage and image questions that assessed knowledge and image interpretation skill. Hypothesized predictors were hospital type (academic or nonacademic), training hospital, enrollment age, sex, and test date. Results Scores showed a curvilinear growth during residency. Image scores increased faster during the first 3 years of residency and reached a higher maximum than knowledge scores (55.8% vs 45.1%). The slope of image score development versus knowledge question scores of 1st-year residents was 16.8% versus 12.4%, respectively. Training hospital environment appeared to be an important predictor in both knowledge and image interpretation skill development (maximum score difference between training hospitals was 23.2%; P < .001). Conclusion Expertise developed rapidly in the initial years of radiology residency and leveled off in the 3rd and 4th training year. The shape of the curve was mainly influenced by the specific training hospital. © RSNA, 2017 Online supplemental material is available for this article.

On a daily basis, patients put their trust in the healthcare system for safe and high-quality healthcare. However, what evidence do we have as an educational community that our supervising faculty members are competent to fulfill this responsibility? Few, if any, requirements exist for faculty members to have continuous professional development in the field of medical education. Many faculty "love to teach", however, this love of teaching does not make them competent to teach or assess the competence of trainees whom they supervise. Faculty members who have a significant role as a teacher in the clinical setting should be assessed with regards to their baseline competence in applicable teaching EPAs. When competence is reached, an entrustment decision can be made. Once proficient or expert, a statement of awarded responsibility (STAR) may be granted. The time has come to reach beyond the "standards" of the old adage "see one, do one, teach one" in medical education. In this personal view, the authors outline an argument for and list the potential benefits for teachers, learners, and patients when we assess clinical teachers using EPAs within a competency-based medical education framework.

Purpose: Health professions education scholarship units (HPESUs) are organizational structures within which a group is substantively engaged in health professions education scholarship. Little research investigates the strategies employed by HPESU administrative leaders to secure and maintain HPESU success. Using institutional entrepreneurship as a theoretical lens, this study asks: Do HPESU administrative leaders act as institutional entrepreneurs (IEs)?, Method: This study recontextualizes two preexisting qualitative datasets that comprised interviews with leaders in health professions education in Canada (2011-2012) and Australia and New Zealand (2013-1014). Two researchers iteratively analyzed the data using the institutional entrepreneurship construct until consensus was achieved. A third investigator independently reviewed and contributed to the recontextualized analyses. A summary of the analyses was shared with all authors, and their feedback was incorporated into the final interpretations., Results: HPESU leaders act as IEs in three ways. First, HPESU leaders construct arguments and position statements about how the HPESU resolves an institution's problem(s). This theorization discourse justifies the existence and support of the HPESU. Second, the leaders strategically cultivate relationships with the leader of the institution within which the HPESU sits, the leaders of large academic groups with which the HPESU partners, and the clinician educators who want careers in health professions education. Third, the leaders work to increase the local visibility of the HPESU., Conclusions: Practical insights into how institutional leaders interested in launching an HPESU can harness these findings are discussed.

The concept of entrustable professional activities (EPAs) reframes the approach to assessment in competency-based medical education. Key to this concept is the linking of assessment to decision making about entrusting learners with clinical responsibilities. Based on recent literature and the authors' experiences with implementing EPAs, this article provides practical recommendations for how to implement EPAs for assessment and entrustment decisions in the workplace. Tips for supervising clinicians include talking to learners about trust, using EPA descriptions to guide learning and teaching, providing learners with greater ad hoc responsibilities, using EPAs to identify/create opportunities for assessment and feedback, including case-based discussions and acknowledging gut feelings about learner readiness for more autonomy. Tips for curriculum leaders entail enabling the trust development, applying trust decisions at all levels of the supervision scale, employing all available information sources for entrustment, empowering learner ownership of the assessment process and using technology for learner tracking and program evaluation.

Purpose: To describe ophthalmology residents' motivation and self-efficacy during cataract surgery training and to assess the relationship of self-efficacy and motivation on both simulator (Eyesi) and real-life surgical performance., Methods: Prospective cohort study using a within-subject design. Eight residents were asked to fill out questionnaires on self-efficacy and motivation towards the Eyesi simulator and real-life cataract surgery at three different moments. Simulator performance was derived from the instrument's output. Patient charts were reviewed to assess real-life surgical performance., Results: Comparative analysis, using a paired sampled t-test, showed a significant increase in self-efficacy towards real-life cataract surgery after completing the cataract training on the simulator (p=0.005). Furthermore, we found a significant correlation between total tasks to complete the cataract training and self-efficacy scored after working with the simulator (p=0.038). Motivation towards the simulator remained stable over time and seemed not to be influenced by simulator or real-life performance., Conclusions: We found evidence that performance on the simulator correlated with residents' self-efficacy scored after the simulator training, supporting the theory that self-efficacy is determined by prior performance. Self-efficacy seemed inversely related to the ease of completion of a task: delivery of a greater effort leads to more satisfaction and a higher perceived self-efficacy towards this particular task. Future studies should include more subjects to provide a more accurate insight in the role of self-efficacy and motivation in training complex surgical skills., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Context: Although health professions education scholarship units (HPESUs) share a commitment to the production and dissemination of rigorous educational practices and research, they are situated in many different contexts and have a wide range of structures and functions., Objectives: In this study, the authors explore the institutional logics common across HPESUs, and how these logics influence the organisation and activities of HPESUs., Methods: The authors analysed interviews with HPESU leaders in Canada (n = 12), Australia (n = 21), New Zealand (n = 3) and the USA (n = 11). Using an iterative process, they engaged in inductive and deductive analyses to identify institutional logics across all participating HPESUs. They explored the contextual factors that influence how these institutional logics impact each HPESU's structure and function., Results: Participants identified three institutional logics influencing the organisational structure and functions of an HPESU: (i) the logic of financial accountability; (ii) the logic of a cohesive education continuum, and (iii) the logic of academic research, service and teaching. Although most HPESUs embodied all three logics, the power of the logics varied among units. The relative power of each logic influenced leaders' decisions about how members of the unit allocate their time, and what kinds of scholarly contribution and product are valued by the HPESU., Conclusions: Identifying the configuration of these three logics within and across HPESUs provides insights into the reasons why individual units are structured and function in particular ways. Having a common language in which to discuss these logics can enhance transparency, facilitate evaluation, and help leaders select appropriate indicators of HPESU success., (© 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Background: Misinterpretation of medical images is an important source of diagnostic error. Errors can occur in different phases of the diagnostic process. Insight in the error types made by learners is crucial for training and giving effective feedback. Most diagnostic skill tests however penalize diagnostic mistakes without an eye for the diagnostic process and the type of error. A radiology test with stepwise reasoning questions was used to distinguish error types in the visual diagnostic process. We evaluated the additional value of a stepwise question-format, in comparison with only diagnostic questions in radiology tests., Methods: Medical students in a radiology elective (n=109) took a radiology test including 11-13 cases in stepwise question-format: marking an abnormality, describing the abnormality and giving a diagnosis. Errors were coded by two independent researchers as perception, analysis, diagnosis, or undefined. Erroneous cases were further evaluated for the presence of latent errors or partial knowledge. Inter-rater reliabilities and percentages of cases with latent errors and partial knowledge were calculated., Results: The stepwise question-format procedure applied to 1351 cases completed by 109 medical students revealed 828 errors. Mean inter-rater reliability of error type coding was Cohen's κ=0.79. Six hundred and fifty errors (79%) could be coded as perception, analysis or diagnosis errors. The stepwise question-format revealed latent errors in 9% and partial knowledge in 18% of cases., Conclusions: A stepwise question-format can reliably distinguish error types in the visual diagnostic process, and reveals latent errors and partial knowledge.

With the increased interest in the use of entrustable professional activities (EPAs) in undergraduate medical education (UME) and graduate medical education (GME) come questions about the implications for assessment. Entrustment assessment combines the evaluation of learners' knowledge, skills, and behaviors with the evaluation of their readiness to be entrusted to perform critical patient care responsibilities. Patient safety, then, should be an explicit component of educational assessments. The validity of these assessments in the clinical workplace becomes the validity of the entrustment decisions.Modern definitions of the validity of educational assessments stress the importance of the purpose of the test and the consequences of the learner's score. Thus, if the learner is a trainee in a clinical workplace and entrusting her or him to perform an EPA is the focus of the assessment, the validity argument for that assessment should include a patient safety component.While the decision to allow a learner to practice unsupervised is typically geared toward GME, similar decisions are made in UME regarding learners' readiness to perform EPAs with indirect supervision (i.e., without a supervisor present in the room). Three articles in this issue address implementing EPAs in UME.The author of this Commentary discusses the possibility of implementing true entrustment decisions in UME. He argues that bringing the patient into the educational assessment equation is marrying educational and health care responsibilities. Building trust in learners from early on, gradually throughout the continuum of medical education, may reframe our vision on assessment in the workplace.

Background: Medical students often do not feel prepared to manage emergency situations after graduation. They experience a lack of practical skills and show significant deficits in cognitive performance to assess and stabilize trauma patients. Most reports in the literature about simulation-based education pertain to postgraduate training. Simulation-based trauma education (SBTE) in undergraduate medical education could improve confidence and performance of recently graduated doctors in trauma resuscitation. We reviewed the literature in search of SBTE effectiveness for medical students., Methods: A PubMed, Embase and CINAHL literature search was performed to identify all studies that reported on the effectiveness of SBTE for medical students, on student perception on SBTE or on the effectiveness of different simulation modalities., Results: Eight studies were included. Three out of four studies reporting on the effectiveness of SBTE demonstrated an increase in performance of students after SBTE. SBTE is generally highly appreciated by medical students. Only one study directly compared two modalities of SBTE and reported favorable results for the mechanical model rather than the standardized live patient model., Conclusion: SBTE appears to be an effective method to prepare medical students for trauma resuscitation. Furthermore, students enjoy SBTE and they perceive SBTE as a very useful learning method.

Competency-based medical education (CBME) is both an educational philosophy and an approach to educational design. CBME has already had a broad impact on medical schools, residency programs, and continuing professional development in health professions around the world. As the CBME movement evolves and CBME programs are implemented, a wide range of emerging research questions will warrant scholarly examination. In this paper, we describe a proposed CBME research agenda developed by the International CBME Collaborators. The resulting framework includes questions about the meaning of key concepts of CBME and their implications for learners, faculty members, and institutional structures. Other research questions relate to the learning process, the meaning of entrustment decisions, fundamental measurement issues, and the nature and definition of standards. The exploration of these questions will help to solidify the theoretical foundation of CBME, but many issues related to implementation also need to be addressed. These pertain to, among other things, nurturing independent learning, assembling and using assessment results to make decisions about competence, structuring feedback, supporting remediation, and how best to evaluate the longer-term outcomes of CBME. High-quality research on these questions will require rigorous outcome measures with strong validity evidence. The complexity of CBME necessitates theoretical and methodological diversity. It also requires multi-institutional studies that examine effects at multiple levels, from the learner to the team, the institution, and the health care system. Such a framework of research questions can guide and facilitate scholarly discourse on the theoretical and practical body of knowledge related to competency-based health professions education.

Medical education is under increasing pressure to more effectively prepare physicians to meet the needs of patients and populations. With its emphasis on individual, programmatic, and institutional outcomes, competency-based medical education (CBME) has the potential to realign medical education with this societal expectation. Implementing CBME, however, comes with significant challenges. This manuscript describes four overarching challenges that must be confronted by medical educators worldwide in the implementation of CBME: (1) the need to align all regulatory stakeholders in order to facilitate the optimization of training programs and learning environments so that they support competency-based progression; (2) the purposeful integration of efforts to redesign both medical education and the delivery of clinical care; (3) the need to establish expected outcomes for individuals, programs, training institutions, and health care systems so that performance can be measured; and (4) the need to establish a culture of mutual accountability for the achievement of these defined outcomes. In overcoming these challenges, medical educators, leaders, and policy-makers will need to seek collaborative approaches to common problems and to learn from innovators who have already successfully made the transition to CBME.

Background: Entrustable professional activities (EPAs) were introduced as a principle for individualized physician assistant (PA) workplace curricula at the University of Applied Sciences (UAS) Utrecht in 2008. We studied how the focus on EPAs served the competency-based flexibility intention of the program., Methods: We analyzed data of those 119 students who enrolled in the program 2010 through 2013, and completed the program before April 2016. We analyzed the number of EPAs per student at start and end of the program, number changed during training and the reasons for change., Results: Data of 101 students were suitable for evaluation. Excluded were 16 students ending the program prematurely and two with study delay. Mean number of EPAs per student at the start was 6.8 (range 4-12) and at the end 6.6 (range 3-13). On average 1.5 EPAs were altered (range 0-13). Reasons included extension of the EPA package during training (n = 10), lack of proficiency at planned moments of summative entrustment decisions (n = 9) and procedures not being suitable for PAs at closer look (n = 6). All changes resulted in a curriculum meeting the school's standards for graduation., Conclusions: The flexibility of the EPA concept enabled changes in the individualized curriculum of students, according to the intended competency-based nature of the educational program.

In medical contexts around the world, supervising physicians continuously decide what degree of supervision to apply as trainees carry out professional activities. Although the implications for patients can be far-reaching, little is known about how these entrustment decisions are formed. The concept of 'Entrustable Professional Activities' has initiated interest and valuable research on factors that may influence the entrustment decision process.The aim of the current article is to link models of entrustment developed in the fields of occupational and organizational psychology and military psychology to medical education studies that have explored the factors influencing physicians' entrustment decisions. We provide a conceptual framework of the entrustment decision-making process, which we suggest will contribute to the understanding of how supervising physicians arrive at the decision to entrust a medical trainee with a professional activity.

Problem: Health professions education scholarship (HPES) is an important and growing field of inquiry. Problematically, consistent use of terminology regarding the individual roles and organizational structures that are active in this field are lacking. This inconsistency impedes the transferability of current and future findings related to the roles and organizational structures of HPES., Approach: Based on data collected during interviews with HPES leaders in Canada, Australia, New Zealand, the United States, and the Netherlands, the authors constructed working definitions for some of the professional roles and an organizational structure that support HPES. All authors reviewed the definitions to ensure relevance across multiple countries., Outcomes: The authors define and offer illustrative examples of three professional roles in HPES (clinician educator, HPES research scientist, and HPES administrative leader) and an organizational structure that can support HPES participation (HPES unit). These working definitions are foundational and not all-encompassing and, thus, are offered as stimulus for international dialogue and understanding., Next Steps: With these working definitions, scholars and administrative leaders can examine HPES roles and organizational structures across and between national contexts to decide how lessons learned in other contexts can be applied to their local contexts. Although rigorously constructed, these definitions need to be vetted by the international HPES community. The authors argue that these definitions are sufficiently transferable to support such scholarly investigation and debate.