Strand Alicia C, Gingerich Andrea, Daniels Vijay John
Division of General Internal Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
Division of Medical Sciences, University of Northern British Columbia, Prince George, British Columbia, Canada.
PLoS One. 2025 Jan 2;20(1):e0313021. doi: 10.1371/journal.pone.0313021. eCollection 2025.
Within competency-based medical education (CBME) residency programs, Entrustable Professional Activity (EPA) assessments endeavor to both bolster learning and inform promotion decisions. Recent implementation studies describe successes but also adverse effects, including residents and preceptors drifting towards bureaucratic / purely administrative behaviors and attitudes, although the drivers behind this tendency are not adequately understood. This study sought to examine resident and faculty experiences with implemented EPA processes to elucidate what leads them toward a 'tick-box' approach that has been described in the literature. The internal medicine residency program at the University of Alberta implemented a CBME pilot in 2016. From March to June 2018, a research assistant interviewed 16 residents and 27 preceptors shortly after they completed an EPA assessment. They described their goals, judgements, and actions during a recent EPA observation. Three researchers analyzed the data to identify themes following qualitative description methodology. The requirement to accrue EPA assessments turned them into currency exchanged by preceptors and residents to acknowledge clinical work. Predicaments arose when the prescriptive EPA process felt misaligned with the assessment context. The selected encounter sometimes suited formative but not summative purposes. Preceptors variably prioritized the dual formative and summative purposes and framed the message for either the resident's or the program's benefit. The drift toward bureaucracy in workplace-based assessments is becoming a predictable implementation pattern. Instead of solely attributing this pattern to residents and preceptors misusing the assessment process, viewing their actions as workarounds suggests that users make rational choices to overcome obstacles in the assessment system. Obstacles identified by workarounds could be targeted by design modifications.
在基于能力的医学教育（CBME）住院医师培训项目中，可托付专业活动（EPA）评估旨在促进学习并为晋升决策提供依据。近期的实施研究描述了其成功之处，但也指出了一些负面影响，包括住院医师和带教教师逐渐倾向于官僚主义/纯粹的行政行为和态度，尽管这种趋势背后的驱动因素尚未得到充分理解。本研究旨在考察住院医师和教师在已实施的EPA流程中的经历，以阐明导致他们采用文献中所描述的“打勾”方法的原因。阿尔伯塔大学的内科住院医师培训项目于2016年实施了一项CBME试点。2018年3月至6月，一名研究助理在16名住院医师和27名带教教师完成EPA评估后不久对他们进行了访谈。他们描述了在最近一次EPA观察期间的目标、判断和行动。三名研究人员采用定性描述方法分析数据以确定主题。积累EPA评估的要求将其变成了带教教师和住院医师用来认可临床工作的一种“货币”。当规定性的EPA流程与评估背景不一致时就会出现困境。所选的病例有时适合形成性目的但不适合总结性目的。带教教师对形成性和总结性双重目的的重视程度各不相同，并为了住院医师或项目的利益来组织信息。基于工作场所的评估中向官僚主义的转变正成为一种可预测的实施模式。与其将这种模式仅仅归因于住院医师和带教教师滥用评估流程，将他们的行为视为权宜之计表明使用者会做出理性选择以克服评估系统中的障碍。通过权宜之计识别出的障碍可以通过设计修改来解决。
