Is There a Need for an Entrustable Professional Activity-Based Psychiatry Curriculum for Medical Interns?

To the Editor,

The Competency-based Medical Education (CBME) curriculum intends to produce Indian Medical Graduates (IMGs) of global standards who are professionals, leaders, communicators, and physicians responsive to local needs. The focus on knowledge-based training has shifted to skills-based training. CBME provides an opportunity for a structured curriculum and innovations in teaching-learning methods and clinical training. While knowledge is being assessed through written assessments and viva voce, skill assessment is hardly done, though medical educators recommend using more robust assessment methods for skills assessment. ¹ Observed Structured Clinical Examination (OSCE) is less commonly carried out at the under- graduate (UG) level.

The initiative by the Indian Psychiatric Society has resulted in increased psychiatry postings during UG training, which converts into a more significant number of theory lectures and a greater duration of clinical exposures. Also, during the internship, the students now spend two weeks in the department of psychiatry. This provides psychiatry educators with an excellent opportunity to structure the training in terms of addressing not only knowledge but also attitude and skills, which are paramount in psychiatry training. ² As per the CBME, clinical skills must be taught during the internship posting and assessed with appropriate measures at completion. There is a need to devise assessment methods considering the learning objectives focusing on clinical psychiatry skills. Focusing on clinical psychiatry can potentially reduce the unmet mental health needs of the Indian population. Entrustable Professional Activities (EPAs) provide the technique of combined assessment of competencies of knowledge, attitudes, and skills by assessing professional activities. EPAs are defined as professional activities gained by training, a set of competencies unique to a specialty, and assessments based on whether the trainees can be trusted to carry out professional activities without supervision after they have achieved a certain level of professional competence. Hence, EPAs inherently involve trusting the trainee to carry out professional tasks with some level of competency that can be improved by training. Compared to competency-based assessments, which focus on single elements of knowledge, attitude or skills, EPAs assess integrated domains of professional skills. ³ For instance, the “Conduct Mental Status Examination” EPA integrates cognitive, affective, and skills domains and assesses the learner’s performance as a clinician, professional, and communicator. Thus, EPAs are designed to bridge the gap between competency and clinical skills, making assessments feasible and relevant to routine clinical requirements.

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EPAs have been formulated by professional bodies at the graduate level as per the local graduate medical council’s requirements to ensure adequate professional skills and standardization of training.^4,5 The EPA-based curriculum has been developed for postgraduate psychiatry training, focusing on clinical-achievement-based outcome ratings, with favorable student ratings. ⁶

In India, EPAs have been formulated for postgraduate-level training in Pediatrics, and recommendations have been made to introduce them at the UG level. ⁷ There is a need to formulate core EPAs for IMGs in psychiatry, enabling them to function as first-contact physicians capable of providing primary-level psychiatry care in the general medical and the community settings. A few EPAs for IMG can be formulated for interns posted in psychiatry: Elicit, present, and document history in patients presenting with a mental disorder; Conduct Mental Status Examination; Perform, demonstrate, and document a Mini-Mental Status Examination. At the point of entry in the internship, these EPAs can be kept at level 2, which means the learner (intern) is allowed to carry out the history taking or Mental Status Examination under the supervision of a trainer. The two weeks of clinical training can aim at level 4 achievement of the same EPAs (Figure 1).

Figure 1.

Levels of Entrustment and Supervision of EPAs: An Intern Progresses from Level 1 at Entry Level to Level 3 at Two Weeks Course Completion.

EPA: Entrustable Professional Activity.

EPAs are increasingly used in specialties like internal medicine, emergency medicine, pediatrics, and psychiatry, adopting the framework for the graduate medical curriculum. ⁸ Introducing an EPA-based curriculum for the intern provides a first-hand opportunity for clinical psychiatry assessment and creating a psychiatric diagnosis, potentially generating interest in psychiatry interns and may influence their future specialization choice. An EPA-based assessment method can provide a way to prepare future IMGs with the professional competencies of physicians, communicators, and health advocates relevant to the local societal needs and of a global standard.