Using a Lego to explain the difference between competencies and EPA's

People in medical education often have trouble figuring out the difference between competencies and EPA (entrustable professional activities). There is a pretty big philosophical difference. The competencies are definitions of observable behaviors and the EPA's are about observing a learner do a specific work task. Here is a recent article from Carraccio and others  that tries to ties the concepts together.

I was in a meeting yesterday where we were discussing the differences between EPA's and competencies. The group was trying to determine whether you are obligated to assess one first. We have 43 competencies in our new curriculum and 13 EPA's. The question that came up was if EPA 2 is going to be assessed in a student, and it is identified to require multiple competencies, do I need to measure the competencies first to allow me to get into an assessment for EPA's? The reverse of this question is if I am found to be entrustable to an acceptable level for graduation for EPA2, does this automatically allow me to be entrustable on all the related competencies.

While this discussion was going on, my mind wandered to Legos. I've been building Lego sets for years. My son and daughters now have large tubs of Legos in our house. It's really cool how you can make all sorts of wonderful things with the simple building blocks that are Legos. You can think of competencies as the individual building blocks. These are the behaviors necessary to build cool stuff. If you don't have the basic building blocks, you can't really make many cool sets (EPA's). The blocks come in lots of different shapes. Think of each shape as a competency. There are long flat short pieces and long flat long pieces. There are two by four bricks and two by eight bricks. There are all sorts of bricks. The bricks also come in different colors which can represent that a competency must be demonstrated in many different environments prior to saying for sure that it has been acheived. In other word, you may be good at applying medical knowledge in a pediatrics outpatient clinic, but not in an inpatient ICU with a critically ill patient. So, to check out on any given competency, the student may need a green two by four brick (applying medical knowledge in peds clinic), and a red two by four brick (applying medical knowledge in an ICU).

EPA's then are like the ability to build the sets. An EPA would be like taking all those Lego bricks and putting them together to make a car or a boat or a house. The act of making the car or boat or house means that you not only have the bricks needed to make the set, you can use them appropriately. So to enter an order in the ICU would be like making a house. The learner needs some two by four red bricks to make the house, but will also need roof pieces (say an infomatics competency) as well as other pieces. And they need to all be the right color to make a house in the ICU setting. Having a red two by four brick does not mean a student can build a house (they need specific skills to put it all together and other pieces), and building a house in the ICU does not mean you can build a house in the peds clinic (you need green pieces for that).

So, in other words, the EPA's and competencies are each dependent on each other. But both need to be assessed in parallel to assure that students Lego buckets are full of lots of cool and useful pieces, but also to assure that they can actually use the cool pieces to make stuff. Let me know if this helps you understand how EPA's and competencies work together, and what you think of this analogy in the comments below.

Is there an upside to the noise of seemingly irrelevant content in medical education?

As I have worked in planning curriculum in medical school either as a course/ clerkship director or in various school-level committees, a common question keeps coming up. How much is too much information?  Or conversely how little do you need to know about basic science to be able to competently practice medicine?

The age of the 'Google' search and other tools like Epocrates and PubMed being capable of getting a seemingly endless stream of factoids answered instantly makes this question more difficult. How much do I need to know versus how much do I need to be able to know how to look it up?

I don't think there is a perfect answer to this question, but let's use as an example GI histology. As a neurologist, if you asked me how much I have used my knowledge from medical school of GI histology in the past six months, I would probably laugh. Most neurologists would probably laugh as when you ask that, what comes to mind immediately is the day in med school microscopy lab where we looked at the slides of intestines and identified the villi cells. I don't do that anymore - like ever.

However, in the last six months I have taken care of Parkinson's patients with gut motility problems and constipation and I've also taken care of people on whom we were considering gluten-sensitivity as differential diagnostic points. We also know the carbidopa/levodopa competes with protein in small intestine absorption. How much of my ability to understand these basic problems with occur daily in my clinic is founded in part on my original knowledge of GI histology? What I think it critical to consider when considering what level of detail of GI histology is important to physician training is to consider what is implicit knowledge that allows me to solve problems. This means looking beyond the typical response to any given topic where a practicing physician says, "I never use that." (Biochemistry anyone?) This means spending time unpacking the implicit framework knowledge on which you have built much more complex concepts. On the flip side, there are some things which I learned in med school which I really don't ever seem to use much now even as much as I try to rack my brain to figure out if I do use them.

I'm not sure of the best way to puzzle this question out. I'm a little worried about running the grand experiment of just stopping teaching the med students all the tiny details we have taught in the past without first pausing to understand the repercussions. There is not likely going to be a firm line in the sand somewhere where a given topic is relevant or irrelevant, it'll look likely more like a large sandy smudge. However, every teacher of med students has to draw their line somewhere, and it would be good to have some alignment within a med school system.