INTRODUCTION

Competency-based medical education has brought important changes to the training of residents, including the possibility of training directed to their learning needs and focuses on the outcomes of the professional practice of the student in training. In addition, it also brought improvements to the quality of care delivered to patients and allowed the description of curricula based on the needs of the health system^1),(2. Competencies describe the student’s individual attributes to perform a given task in a specific context and these attributes may vary, for example, according to the student’s degree of education and the action scenario. The competencies, therefore, describe important qualities to be developed by the resident in training, but do not delimit the practical activities that should be performed by a given specialty³.

A complexity observed in the literature about competencies is the fact that they are usually presented in a textually extensive way^4),(5. As an example, there is the matrix of competencies for Family and Community Medicine (FCM) residency described by the National Medical Residency Commission (CNRM, Comissão Nacional de Residência Médica) in 2019, which brings a total of 334 items to be evaluated during the two years of residency training⁶. These items are separated by year of training, some have repeated thematics, only increasing the level of complexity, which can make their use difficult in practice. Moreover, it is considered that competencies, as they describe attributes or qualities expected of physicians in training, can often be described in an abstract way and make it difficult for educators to evaluate the residents’ performance⁵.

To serve as a bridge between the residents’ competencies and professional practice, the Entrustable Professional Activities (EPAs)⁷ were described. While the competencies describe individual attributes of the resident in training, the EPAs describe practical and essential tasks of the specialty, which enable an inference whether the student has the competencies to work within the specialty scope^5),(8.

EPAs are defined as a set of fundamental practice units that define a specialty. They may be entrusted to a resident once they have demonstrated proficiency to perform them without supervision. They are, by definition, observable activities that can be carried out independently. Because of that, they facilitate the measurement of the resident’s evolution in their practice. With a more accurate assessment of the resident’s progression, the result is an increase in the provided quality of care and an increase in the safety of patients, educators and residents^9),(10.

Entrustable Professional Activities and competencies are complementary and non-exclusive concepts. EPAs enable a practice-focused assessment of the resident’s acquisition of skills. The implementation of an EPA requires the recruitment of one or more of the competencies by the individual performing them. As an example, the hypothetical EPA “Perform anamnesis and physical examination” would recruit the competencies of medical expertise, patient care, communication, and professionalism¹¹. And, therefore, the evaluation of this practical and observable activity would allow us to infer the individual’s acquisition of competencies^5),(8.

In summary, the original description of the literature cites as competencies the individual’s attributes or qualities for professional practice, while the EPAs describe the work to be done in practice. Despite the difference between the concepts of competencies and EPAs, they can be mistaken, as the common use of language over time has often attributed as competencies concepts that are actually entrustable professional activities⁸. As an example, the CNRM⁶ FCM competency matrix for the year 2019 has some items listed as competencies that could be classified as “educational objectives” or even “entrustable professional activities”.

Considering the importance of these two concepts, it is recommended that a matrix be made in the curriculum descriptions that integrates EPAs and competencies^5),(8.

Figure 1 schematically illustrates a model of integration between competencies and EPAs proposed by Ten Cate, Snell and Carraccio in 2010⁵.

Source: Adapted from Ten Cate, Snell and Carraccio 2010⁵

Figure 1 Integration matrix between EPAs and competencies. 

There are already international descriptions of EPAs for residency in Family and Community Medicine (FCM)^{12),(13),(14),(15}. In the national context, some specialties such as Gynecology and Obstetrics made an effort to describe the EPAs for the context in our country¹⁶. There is yet no description of the EPAs for the Family and Community Medicine Residency Programs in the Brazilian context. This description is important as an effort to define fundamental activities of the specialty and to support the definition of the specialty itself and differentiate it from the practice of the general practitioner.

It is recommended that each country develop its own Entrustable Professional Activities for residency, since local health contexts and needs vary¹⁷. The model proposed for this establishment involves the elaboration of an initial description of the EPAs by physicians of the specialty who have expertise in medical education and a subsequent validation, through consensus methodologies, by a larger group of physicians of the specialty¹⁰.

This study aims to describe the processes carried out for the initial proposal of EPAs for the Family and Community Medicine residency in the Brazilian context and the validation of these EPAs using the Delphi methodology to establish consensus.

METHOD

This study consisted of two phases: the first comprised the creation of the EPAs and tasks by a core group of experts, and a second of consensus using the Delphi technique. This consensus methodology is used to systematically combine the experts’ opinion to answer a problem^18),(19. The model used was e-Delphi, with digital questionnaires, using the Google Forms® platform. This method was chosen because it allows greater agility and versatility in the response processes by participants and in the analysis by researchers, and this method does not detract from the traditional method^20),(21),(22. Through this methodology, we aimed to reach consensus about the entrustable professional activities (EPA) and their task descriptions initially prepared by the group of researchers. Figure 2 illustrates and summarizes the methodology used in the research.

Source: Adapted from: Chueiri PS, 2017²⁵

Figure 2 Illustrative flowchart of the Delphi methodology. 

RESULTS

A total of 60 people accepted the initial invitation from the SBMFC to constitute the panel of experts to respond to Delphi. Among the participants, 24 people met the inclusion criteria and agreed to participate and answered the first round of the Delphi survey, after reading and signing the FICF. In the second round, it was decided not to include new panelists and there was a loss of half of the panelists of the first round, and 12 people, of the initial group of 24 panelists, responded to the study. The participants’ sociodemographic profile in the first and second rounds is described in Table 1.

As for the composition of the panel of experts who agreed to participate in the survey, 75% were aged between 25 and 45 years. Regarding the place of work, 91.7% reported working in urban centers and 70.8% worked in public institutions. Most of the participants, 62.5%, worked in the southeast region of the country. The mean time working in Family and Community Medicine was 12.35 years and the mean time working in medical education was 10.64 years.

A total of 14 EPAs were created by the group of researchers and a total of 115 tasks describing these activities. In the first Delphi round, the participants answered a questionnaire containing 115 items, corresponding to the tasks and 37 of these tasks received suggestions for changes, including changes of terms to increase the clarity of writing, addition of contents and suggestion of transferring the described task to another EPA where it could fit better. It was also suggested in the first round the inclusion of a new task in the EPA called “to offer mental health care to the assisted individuals”, which is described as “knowing the criteria and making the diagnosis of common mental disorders indicating adequate initial therapy”.

Among the described tasks, two did not achieve a content validity index (CVI) greater than 80% in either of the rounds, and thus, they were excluded from the final description of the EPAs. The tasks were “to provide remote care to expand access in the first contact and continuity of care for patients”, which obtained a CVI of 66.7%, and “to recognize urgent and emergency situations in the virtual care modality and determine the action plan with patients and caregivers”, which obtained an IVC of 75%. The first belonged to the EPA named “to provide first contact access and longitudinality of care as part of a health system” and the second belonged to the EPA named “to manage the care of patients with medical emergencies”.

All 14 EPAs proposed by the researchers achieved an average CVI of the tasks greater than 80% and, therefore, were included. Consensus was reached with two Delphi rounds. Table 2 describes the average CVI of each EPA at the end of each of the two Delphi rounds and shows the final decision on the consensus.

The EPA with the highest degree of consensus were “Participate in interprofessional care activities” and “Offer care in a broad and longitudinal way to children and adolescents”, both with a CVI of 100%.

On the other hand, the EPAs “Managing information continuity, coordinating care, and advocating for patients’ rights”, “Act according to the needs of the local community context and provide patient- and family-centered home care “, “To play a leading role in interprofessional health teams and act in a guided manner with a sustainable practice “ and “Perform medical procedures in the primary health care setting” had the lowest CVIs, less than 95%. No EPA had a CVI < 90%.

At the end of the second Delphi round, Table 3 was constructed, containing the final description of the tasks of each EPA, as well as the CVI of each task. This CVI was obtained by the panelists’ voting in this second round, which contained the changes and written suggestions proposed by them in the first round.

DISCUSSION

The initiatives of local EPA creation are important and encouraged by the literature, since they take into account the specificities of each context^27),(28. In Brazil, there are differences in relation to other countries in Family and Community Medicine residency: the time of training of the resident, which has a shorter duration of two years, the context of action focused on the needs of a universal and public health system, the SUS, and a territorialized PHC, with these factors not being contemplated in the evaluated international descriptions of EPAs for FCM. In addition, there is a variability of medical residency programs in FCM within the country itself²⁹, which reinforces the importance of describing the activities and offers that are crucial for quality training.

Considering these needs, the group of researchers developed the EPAs taking into account international references for EPAs in FCM^{12),(13),(14),(15} and national curriculum descriptions for residency in Family and Community Medicine^6),(23. For that purpose, it relied on the expertise of specialists working in Brazil. In the end, the fourteen EPAs prepared brought important elements of FCM into the Brazilian context, such as community care, action in the territory and work in health care networks (HCNs).

An unprecedented EPA in the literature was proposed by the group and approved with high CVI by the Delphi panel. This EPA is named “Addressing Vulnerabilities and Complex Conditions in PHC at All Stages of the Lifecycle”. It exemplifies the need for descriptions that respond to the local reality and needs, since for FCM training in Brazil it is important to act on individual, socioeconomic and territorial context vulnerabilities. Although the vulnerabilities are transversal in any reality, none of the descriptions of EPAs in FCM reported in the literature brought this focus and in our proposal this EPA was included with a high degree of agreement by the Delphi panel. By bringing this description as an EPA, the need to work on the topic in the residency curriculum is made explicit, highlights it as a fundamental task to be trained by the resident and denotes the reference to a socially responsible education¹⁷.

All the proposed EPAs described observable activities in the practice of the Family and Community Medicine resident, being innovative in the attempt to describe the specialty based on its main tasks. The use of the specialty description based on the EPAs, according to the literature, is expected to bring greater clarity to the content to be taught and in the practical offers provided by the residency programs^9),(10.

The description of EPAs also has the potential to support the review of the description of the competencies expected of the FCM resident in training, since they are interdependent concepts. Author Olle Ten Cate^5),(8, creator of the concept of EPAs, recommends the use of a matrix that correlates EPAs and competencies for a better assessment of the resident, and suggests that the way of starting from EPAs to describe competencies can be more effective and meaningful in the context of training and evaluation⁵.

Thus, the definition of national EPAs can support the orientation and reduction of differences in FCM residency training in Brazil by bringing greater clarity to the essential activities of the specialty and, consequently, the training offers of the programs¹³ and can also contribute to the strengthening of the specialty and its practice scenarios. Additionally, in the context of the country, the definition of EPAs contributes to the differentiation between the performance and practice of a Family and Community physician and a general practitioner.

All fourteen EPAs were approved by the Delphi panel through consensus. Only two tasks from two different EPAs did not reach consensus and were excluded, both of which were related to telecare and remote care. The group of researchers attributed this to the fact that telecare has been recently regulated in the country³⁰ and that not all services and residency programs have availability and training to provide remote care.

As a weakness of the study, we must cite the low adherence to the Delphi panel, as in the first round 40% of those who received invitations from the SBMFC responded to the survey and in the second round we had a loss of 50% of those who responded to the first round. However, there was a high rate of agreement with the EPAs and proposed tasks.

The Delphi methodology has this difficulty because it requires evaluation more than once by the group of panelists^18),(19. Furthermore, the questionnaire used took an average of 30 minutes to be answered, which was considered a potential factor for low adherence.

Nevertheless, in the participants’ analysis, a good representation of specialists was identified, and it was possible to select a good quality panel, considering experiences of work in the specialty and in teaching. The criteria for a qualified Delphi group according to the literature^19),(20 incorporated by this study are: high average time of experience in the specialty and in the teaching of residents, representativeness of different regions of the country, representativeness of schools with different forms of financing, and the inclusion of diversity of generations of educators.

CONCLUSION

This study is innovative because, by describing the EPAs for the specialty of Family and Community Medicine in the Brazilian context, it contrasts the essential activities of the practice of the Family and Community physician and the expectations of the general practitioner’s working activities. This differentiation is important, because medical graduation in Brazil allows recently graduated physicians to work and they have PHC as one of the main action settings. By specifying the activities of Family and Community Medicine, it is possible to differentiate the performance in the complex and unique context of PHC and strengthen the specialty

The importance of developing EPAs for residency programs at the national level was evidenced, and that the transposition of EPAs described in other countries alone does not contemplate local needs. This was evidenced because thematics such as community care, activities related to specific public policies of our health system, network action and care for vulnerable populations, were highlighted by the group of researchers as specific to the Brazilian context and were validated by the Delphi group.

In addition, the potential of a qualified Delphi sample in the refinement and consensus of EPAs was demonstrated. The study offers as perspectives the initial implementation in FCM Residency Programs in different scenarios in Brazil, providing a methodology described for the programs that identify needs for local changes. It is recognized that future studies derived from this approach can be carried out to obtain a greater overview of national needs in FCM training.