Abstract
The College of Medicine South Africa (CMSA) has embarked on developing Entrustable Professional Activities (EPAs) for workplace-based training. There is currently limited guidance for developing EPAs in Chemical Pathology. This report explores factors that impact EPA development in Chemical Pathology, derived from health education theory and evidence, as well as relevant contextual variables impacting registrar training in South Africa. We discuss four factors to consider during the elaboration of EPAs for South African registrars in Chemical Pathology to enhance fitness for workplace-based assessment. Firstly, EPAs require the application of constructive alignment to link the national syllabus, core competencies and milestones, training methods, and formative assessment strategies during the trainee learning trajectory. Secondly, the elaboration of a complete EPA is assisted by utilising a standardised template with defined sectional headings and contents structured for laboratory medicine. Thirdly, quality assurance of draft EPAs requires validation to improve curriculum alignment, and facilitate EPA revision. Finally, a critical emergent issue for Chemical Pathology workplace-based training is the development of standardised learning opportunities for operationalising a national EPA programme.
Contribution: Charting the early steps in developing EPAs for training Chemical Pathology registrars in South Africa identifies the application of the educational tenet of constructive alignment, utilising a standardised template for EPA design, validating draft EPAs and creating equitable learning opportunities for all trainees.
Keywords: EPA; Entrustable Professional Activities; workplace-based training; Chemical Pathology; laboratory medicine; constructive alignment; validation of EPAs; standardisation of learning opportunities.
Introduction
The training of South African registrars in Chemical Pathology is conducted at universities linked to academic hospitals and National Health Laboratory Service (NHLS) platforms. The registrars are formally taught by pathologist consultants at each institution with ad hoc external training opportunities, such as national NHLS pathology conferences and online NHLS webinar programmes. Registrars can also access training support from private laboratory pathologists and scientists for day visits to explore novel test methodologies, specialist testing and conduct case-based tutorials – although, these practices show inter-institutional variability. Many NHLS platforms also accommodate scientists who contribute to teaching, especially, scientific methodology for specialist tests and wet-bench practicals. Registrars also interact with medical technologists and technicians in their daily work to resolve laboratory problems and support operational delivery. While registrars write primary and exit specialist examinations, current training does not evaluate performance of registrars on workplace-based tasks and provide feedback to support their learning on the job.
Entrustable Professional Activities (EPAs) define discrete professional units of work that are independently executable and measurable, and operationalise medical competencies for trainees in the healthcare environment. Entrustable Professional Activities allow assessors to make entrustment decisions about a trainee’s performance on essential tasks.1,2
The College of Medicine South Africa (CMSA) has embarked on introducing EPAs for national post-graduate specialist training. The introduction of EPAs will contribute to formative assessment for trainees to enable entrustment decisions for unsupervised work practice and provide multiple feedback opportunities to enhance learning.
The development of EPAs for registrar training in Chemical Pathology in South Africa highlights the need to consider essential educational principles and evidence to construct a set of work activities that span the post-graduate curriculum. Currently, there is no clear framework to guide EPA formulation in Chemical Pathology.3
This brief practice report highlights four factors that can assist the early steps in EPA design for Chemical Pathology. These factors are constructive alignment within a national curriculum to develop core EPAs, elaborating EPAs by a standardised template, validating EPAs for fitness of purpose, and developing accessible and fair training opportunities for registrars.
Constructive alignment in Entrustable Professional Activities development
Constructive alignment forges an explicit linkage between learning outcomes articulated in the syllabus, teaching methodologies, and assessment approaches measured against an acceptable standard.4 The task selection for an EPA can be guided by essential everyday professional work activities, high-risk or error-prone tasks, or tasks that function as exemplars for competency – all EPAs then can be mapped to the curriculum and connected with entrustment milestones.1,5 In a scoping review to identify the rationalisation and selection of EPAs, Hennus et al. identified three dominant logics that guide EPA development in health sciences: service provision, procedures, and disease or patient categories.6 These categories are helpful to Chemical Pathology in defining essential professional work units from the national syllabus, which holistically encompasses daily professional practice. These categories also assist the alignment of EPAs to specified learning objectives, competency domains, and relevant knowledge, skills, and attitude categories stated or alluded to in the registrar’s national curriculum.
Constructive alignment facilitates the integration of relevant competencies within each EPA, emphasising a synthetic approach to operationalising competencies.7 Further, it identifies linkage to relevant learning opportunities available to trainees to learn and practise EPAs. Figure 1 summarises the core elements of constructive alignment for EPA development in Chemical Pathology in South Africa.
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FIGURE 1: Essential steps in developing Entrustable Professional Activities for Chemical Pathology (created with BioRender.com). |
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One or more competency domains derived from the national curriculum are formulated and mapped to each EPA. Therefore, the competency domains selected are specific for each EPA and describe the core qualities necessary to perform the task. Nested and stand-alone EPAs (shown within the blue circle) are then formulated to cover all essential professional tasks spanning the profession. The ‘nested’ EPAs are within the rectangle shape circumscribed by a dashed line. The yellow hexagon indicates a stand-alone EPA. The cognitive, psychomotor, and affective dimensions required for each EPA are indicated by the abbreviations K (Knowledge), S (Skills) and A (Attitudes). The resources that are aligned to achieve learning are labelled in the blue stacked rectangle block.
Elaborating Entrustable Professional Activities by adopting a standardised template
The writing of EPAs is challenging and requires a content expert panel and guidance from persons trained formally in health education to ensure respective contributions of sound subject matter expertise and the application of pedagogic tenets in developing EPAs. A standardised template is available to write up generic EPAs (Table 1),2,5,8,9 and the sectional headings expand a fully detailed mini-curriculum that enables the professional task to be performed.5 A well-elaborated EPA has a clear goal to prepare learners and assessors for entrustment decisions. Table 1 provides further guidance on how to expand each section when writing Chemical Pathology EPAs.
| TABLE 1: A template of sectional headers, and guidelines to elaborate content areas for a full Entrustable Professional Activities description.5,10 |
A basic example of an EPA is provided in Box 1 that applies guiding points listed in Table 1 to a real-world professional task in the Chemical Pathology laboratory.
| BOX 1: Example of an authentic task in the Chemical Pathology laboratory written as an Entrustable Professional Activity. |
Validation of Entrustable Professional Activities improves structure, quality and implementation
Validating draft EPAs nationally will ensure the Chemical Pathology EPAs are relevant, aligned with purpose, span discrete and essential professional work, and encourage revisions to achieve a consensus list by stakeholders. Various strategies are described to validate EPAs. These include expert meetings, surveys and interviews, the Delphi procedure, the nominal group technique, and EPA evaluation rubric tools.1,11 The NHLS Chemistry Expert Committee is a valuable resource for developing EPAs among Chemical Pathology experts and iteratively reviewing drafts to achieve a consolidated EPA list. The engagement of local experts also encourages commitment to finalising EPA development and implementation.
Standardising learning opportunities across national registrar training sites
The active construction of learning opportunities for all registrars during all training phases will enable the standardisation of learning between national training sites. Standardisation of learning opportunities is important in South Africa as university resource variation reflects historical geo-political inequities in resource allocation. Additionally, pathology test menus show regional variation between the training state laboratory academic hospitals, such as variation in specialist test menus.
Initiatives to equalise training opportunities for Chemical Pathology should consider the development of feasible interventions and further integration with current training opportunities supported by the National Health Laboratory Service (NHLS) platform. Examples of potential learning opportunities are highlighted in Table 2. These training resources and opportunities need to be built into the broader EPA curriculum, which explicitly states the essential resources required for training each EPA.
| TABLE 2: Development of national training opportunities to support essential Knowledge, Skills and Attitudes domains articulated in Entrustable Professional Activities. |
The shortage of pathologists at some training sites also requires redress by NHLS and universities to support the daily training needs of registrars at regional training sites. Notably, adequate consultant availability and faculty development to conduct regular EPA assessments are crucial for valid and reliable assessments and registrars’ formative learning.12
Conclusion
The initial steps to construct EPAs in Chemical Pathology for South African registrars should be informed by aligning the national syllabus with a core competency framework, aligning learning opportunities, and selecting appropriate workplace-based assessment (WBA) tools for formative assessment. Entrustable Professional Activities can be elaborated using a standardised template, and education tools and expert panels can validate the draft versions to ensure fitness for purpose. During the development of EPAs in Chemical Pathology, fair access to learning opportunities should be cultivated for the national EPA programme rollout.
Acknowledgements
Competing interests
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
Authors’ contributions
R.P. and T.S.P. conceptualised the article, drafted and reviewed the final version of the article, and images and tables were created by R.P.
Ethical considerations
Ethical clearance to conduct this study was obtained from the University of Cape Town Faculty of Health Sciences Human Research Ethics Committee (No. 775/2024).
Funding information
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Data availability
The data are available from the corresponding author, R.P., on reasonable request.
Disclaimer
The views and opinions expressed in this article are those of the authors and are the product of professional research. It does not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings and content.
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