Discordance between global versus reductionist approach in competency-based assessment for medical students in a transition to residency course

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INTRODUCTION: The advent of competency-based education has led to concerns regarding reductionism in the assessment of clinical competence. This apprehension stems from using the assessment of isolated subunit competencies to build a complete picture of clinical competence. Some argue that the entrustable professional activity (EPA) framework complements the construct of competencies, as EPAs describe units of work and require a global approach to their assessment. To that end, we aimed to discern whether the assessment of separate subunit competencies subsequently aggregated is equivalent to the global assessment of EPAs. METHODS: We designed a simulation-based workshop and assessed each student using the subunit competencies mapped to the core EPAs (the bottom-up approach) compared to the assessment of the global EPAs (the top-down approach) using 1) a supervision scale, 2) a global statement regarding entrustment and 3) a statement regarding readiness for residency. We aimed to determine whether the global assessment of EPAs was equivalent to aggregating the corresponding subunit competency assessments. The subunit competency assessments were additionally compared to aggregate workplace-based assessment data on the various subunit competencies from core clerkships. RESULTS: All eligible students participated (136/136). Assessment data obtained using the subunit competencies mapped to the EPAs were highly correlated with the assessment of subunit competencies obtained in the workplace during core clerkships. However, these subunit competency assessments obtained during the TTR course did not correlate with EPA-based global supervision scale ratings, entrustment decisions, or perceived readiness for residency. DISCUSSION: Global assessment of EPAs and the judgment of entrustment appear to be separate processes from aggregating the assessment of subunit competencies. This may reflect variations in the approach to global assessment when compared to the assessment of subunit competencies and the need to consider the construct of trustworthiness in addition to the learner's ability to perform each activity.

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