Open Space • Interface 24 16 Mar 20202020 • https://doi.org/10.1590/Interface.190455   copy

The time has come for Brazil: translating Competence Based Medical Education into practice by Entrustable Professional Activities (EPAs) **This article received financial support from the Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), from the research project under process number 2018 / 26011-2.

Ieda Francischetti Ylva Holzhausen Harm Peters About the authors

Abstract

The medical competencies presented by the National Curriculum Guidelines and the policies to encourage the education of more physicians have popularized themes such as competence and active learning. Distortions in the curricular implementation resulted in a fragmented and reproductive approach of the practices distancing them of the work process. Several Western countries seeking improvement of the Competence-Based Medical Education (CBME), have recently adopted the concept of Entrustable Professional Activities (EPAs) to better translate this benchmark into clinical practice. This article presents the EPAs for Brazilian medical education as a possible solution for CBME accomplishment. The study explores the EPAs, from their concept to their realization. It aims to provide insights for their understanding and analysis of their capacity as a mediator for more qualified training and more responsivity to local health needs, contributing to the literature in the area.

Clinical practice; Competency; Curriculum; Entrustable professional activities; Medical education

In Brazil, the National Curriculum Guidelines (NCG) call for medical curricula to be committed to a Unified Health System 11. Brasil . Ministério da Educação . Resolução CNE/CES nº 4, de 7 de Novembro de 2001. Institui diretrizes curriculares nacionais do curso de graduação em medicina . Diário Oficial da União [ Internet ]. 9 Nov 2001 [ citado 3 Jun 2019 ]. Disponível em: http://portal.mec.gov.br/cne/arquivos/pdf/CES04.pdf
http://portal.mec.gov.br/cne/arquivos/pd... , 22. Brasil . Ministério da Educação . Resolução CNE/CES nº 3, de 20 de Junho de 2014. Institui diretrizes curriculares nacionais do curso de graduação em medicina e dá outras providências . Diário Oficial da União [ Internet ]. 23 Jun 2014 [ citado 3 Jun 2019 ]. Disponível em: http://portal.mec.gov.br/index.php?option=com_docman&view=download&alias=15874-rces003-14&category_slug=junho-2014-pdf&Itemid=30192
http://portal.mec.gov.br/index.php?optio... . The NCG of 2014 emphasize quality of care and critical thinking as key goals for medical education. This should be approached on the best evidence considering principles of Evidence-Based Medical Education (EBME) and using Competence Based Medical Education (CBME) as framework to convey the needed competencies in a medical program 22. Brasil . Ministério da Educação . Resolução CNE/CES nº 3, de 20 de Junho de 2014. Institui diretrizes curriculares nacionais do curso de graduação em medicina e dá outras providências . Diário Oficial da União [ Internet ]. 23 Jun 2014 [ citado 3 Jun 2019 ]. Disponível em: http://portal.mec.gov.br/index.php?option=com_docman&view=download&alias=15874-rces003-14&category_slug=junho-2014-pdf&Itemid=30192
http://portal.mec.gov.br/index.php?optio... . As result of the government’s policies to encourage the graduation of more physicians, the number of medical schools increased to 336 in Brazil, heating the investment market in this niche and popularizing themes such as Active Learning and Competence 33. Brasil . Presidência da República . Lei nº 12.871, de 22 de Outubro de 2013. Institui o Programa Mais Médicos, altera as Leis nº 8.745, de 9 de Dezembro de 1993, e nº 6.932, de 7 de Julho de 1981, e dá outras providências . Diário Oficial da União [ Internet ]. 2 Out 2013 [ citado 3 Jun 2019 ]. Disponível em: http://pesquisa.in.gov.br/imprensa/jsp/visualiza/index.jsp?jornal=1&pagina=1&data=23/10/2013
http://pesquisa.in.gov.br/imprensa/jsp/v...

4. Oliveira NA , Meirelles RMS , Cury GC , Alves LA . Mudanças curriculares no ensino médico brasileiro: um debate crucial no contexto do Promed . Rev Bras Educ Med 2008 ; 32 ( 3 ): 333 - 46 .

5. Brasil . Ministério da Saúde . Ministério da Educação . Portaria Interministerial nº 610, de 26 de Março de 2002. Institui o Programa Nacional de Incentivo às Mudanças Curriculares para as Escolas Médicas . Diário Oficial da União [ Internet ]. 1 Abr 2002 [ citado 3 Jun 2019 ]. Disponível em: https://www.jusbrasil.com.br/diarios/496301/pg-75-secao-1-diario-oficial-da-uniao-dou-de-01-04-2002
https://www.jusbrasil.com.br/diarios/496...

6. Brasil . Ministério da Saúde . Ministério da Educação . Portaria Interministerial nº 2.101, de 3 de Novembro de 2005. Institui o Programa Nacional de Reorientação da Formação Profissional em Saúde (Pró-Saúde) para os cursos de Medicina, Enfermagem e Odontologia . Diário Oficial da União [ Internet ]. 3 Nov 2005 . [ citado 3 Jun 2019 ]. Disponível em: http://www.lex.com.br/doc_541196_PORTARIA_INTERMINISTERIAL_N_2101_DE_3_DE_NOVEMBRO_DE_2005.aspx
http://www.lex.com.br/doc_541196_PORTARI...

7. Brasil . Ministério da Saúde . Programa Nacional de Reorientação da Formação Profissional em Saúde (Pró-Saúde): objetivos, implementação e desenvolvimento potencial [ Internet ]. Brasília : Ministério da Saúde ; 2009 [ citado 3 Jun 2019 ]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/programa_nacional_reorientacao_profissional_saude.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...

8. Scheffer M , coordenador . Demografia médica no Brasil 2018 . São Paulo : Faculdade de Medicina, Universidade de São Paulo ; 2018 . - 99. Escolas Médicas do Brasil . Estatísticas nacionais [ Internet ]. 2007 [ citado 3 Jun 2019 ]. Disponível em: https://www.escolasmedicas.com.br/estatisticas-nacionais.php
https://www.escolasmedicas.com.br/estati... . If on the one hand we face positive transformations 88. Scheffer M , coordenador . Demografia médica no Brasil 2018 . São Paulo : Faculdade de Medicina, Universidade de São Paulo ; 2018 . , on the other hand, the speedy acquisition of material resources and bureaucratic construction for activation of courses with curricula of competence was faster than the qualified preparation of human resources, which was supposed to lead this new context 1010. Lopes AC . A explosão numérica das escolas médicas brasileiras . Educ Med . 2018 ; 19 Suppl 1 : 19 - 24 . doi: https://dx.doi.org/10.1016/j.edumed.2018.03.004
https://dx.doi.org/10.1016/j.edumed.2018... - 1111. Amaral E , Domingues RCL , Zeferino AMB . Avaliando a competência clínica: o método de avaliação estruturada observacional . Rev Bras Educ Med . 2007 ; 31 ( 3 ): 287 - 90 . doi: https://dx.doi.org/10.1590/S0100-55022007000300011 .
https://dx.doi.org/10.1590/S0100-5502200... . Thus, distortions in the curricular evaluation and implementation have resulted in a fragmented and reproductive approach of the practices with distance from the actual variables of the work process 1010. Lopes AC . A explosão numérica das escolas médicas brasileiras . Educ Med . 2018 ; 19 Suppl 1 : 19 - 24 . doi: https://dx.doi.org/10.1016/j.edumed.2018.03.004
https://dx.doi.org/10.1016/j.edumed.2018...

11. Amaral E , Domingues RCL , Zeferino AMB . Avaliando a competência clínica: o método de avaliação estruturada observacional . Rev Bras Educ Med . 2007 ; 31 ( 3 ): 287 - 90 . doi: https://dx.doi.org/10.1590/S0100-55022007000300011 .
https://dx.doi.org/10.1590/S0100-5502200... - 1212. Braccialli LAD , Oliveira MAC . Desafios na formação médica: a contribuição da avaliação . Rev Bras Educ Med . 2012 ; 36 ( 2 ): 280 - 8 . doi: https://dx.doi.org/10.1590/S0100-55022012000400018 .
https://dx.doi.org/10.1590/S0100-5502201... .

Several Western countries, including: United States, Canada, and Netherlands, are seeking the improvement of CBME, and have recently adopted the concept of Entrustable Professional Activities (EPAs) in the better translation of this benchmark into clinical practice 1313. ten Cate O , Chen HC , Hoff RG , Peters H , Bok H , van der Schaaf M . Curriculum development for the workplace using Entrustable Professional Activities (EPAs): AMEE Guide No. 99 . Med Teach . 2015 ; 37 ( 11 ): 983 - 1002 . doi: https://dx.doi.org/10.3109/0142159X.2015.1060308 .
https://dx.doi.org/10.3109/0142159X.2015...

14. ten Cate O , Graafmans L , Posthumus I , Welink L , van Dijk M . The EPA-based Utrecht undergraduate clinical curriculum: development and implementation . Med Teach . 2018 ; 40 ( 5 ): 506 - 13 . doi: https://dx.doi.org/10.1080/0142159X.2018.1435856 .
https://dx.doi.org/10.1080/0142159X.2018...

15. Chen HC , van den Broek WE , ten Cate O . The case for use of entrustable professional activities in undergraduate medical education . Acad Med . 2015 ; 90 ( 4 ): 431 - 6 . doi: https://dx.doi.org/10.1097/ACM.0000000000000586 .
https://dx.doi.org/10.1097/ACM.000000000...

16. Lomis K , Amiel JM , Ryan MS , Esposito K , Green M , Stagnaro-Green A , et al . Implementing an entrustable professional activities framework in undergraduate medical education: early lessons from the AAMC Core Entrustable Professional Activities for Entering Residency Pilot . Acad Med . 2017 ; 92 ( 6 ): 765 - 70 . doi: https://dx.doi.org/10.1097/ACM.0000000000001543 .
https://dx.doi.org/10.1097/ACM.000000000...

17. Touchie C , Boucher A , Allen T , Bhanji F , Chan M-K , Clarizia N , et al . AFMC Entrustable Professional Activities for the Transition from Medical School to Residency . Ottawa : Association of Faculties of Medicine of Canada ; 2016 .

18. Gutiérrez-Barreto S , Durán-Pérez VD , Flores-Morones F , Esqueda-Nuñez RI , Sánchez-Mojica CA , Hamui-Sutton A . Importance of context in entrustable professional activities on surgical undergraduate medical education . Med Ed Publish . 2018 . doi: https://dx.doi.org/10.15694/mep.2018.0000109.1 .
https://dx.doi.org/10.15694/mep.2018.000... - 1919. Obeso V , Brown D , Aiyer M , Barron B , Bull J , Carter T , et al . Toolkits for the 13 core entrustable professional activities for entering residency . Washington : Association of American Medical Colleges ; 2017 . . Therefore, this work resumes the care inherent to the implementation of competency-based curricula and discusses EPAs from its concepts to its realization, presenting them as a feasible solution for a readjustment of directions in the design of medical education in Brazil.

Ideas about competencies in the medical profession had emerged first in literature in the seventies and eighties of the last century, they soon became a milestone in the Western medical education. They occupy great prominence in the curricula that, now, guided by competence, should enable the egress to correspond to the desires for empathy, commitment and quality care 2020. Carraccio C , Wolfsthal SD , Englander R , Ferentz K , Martin C . Shifting paradigms: from Flexner to competencies . Acad Med . 2002 ; 77 ( 5 ): 361 - 7 . .

Since the late 1990s, national education and health policies, according to Lampert, have been aimed at encouraging qualitative and relevant curriculum changes that respond to social needs and whose success is linked to the reach of their practices in the social context in which they operate. It seeks to formalize the commitment of a generalist medical education that ensures competence for the immediate insertion of the professional in the labor market, whose quality care is focused on health surveillance, teaching-service integration and ability to teamwork 2121. Lampert JB . Tendências de mudanças na formação médica no Brasil [ tese ]. Rio de Janeiro : Escola Nacional de Saúde Pública Sérgio Arouca ; 2002 . , 2222. Aguiar AC , Ribeiro ECO . Conceito e avaliação de habilidades e competência na educação médica: percepções atuais dos especialistas . Rev Bras Educ Med . 2010 ; 34 ( 3 ): 371 - 8 . doi: https://dx.doi.org/10.1590/S0100-55022010000300006 .
https://dx.doi.org/10.1590/S0100-5502201... .

Sá and Paixão found converging characteristics in the various concepts of competence: their hybrid, multi-dimensional, complex, mobilizable and transferable constitution, as well as their practical and combinatory nature 2323. Sá P , Paixão F . Contributos para a clarificação do conceito de competência numa perspetiva integrada e sistémica . Rev Port Educ . 2013 ; 26 ( 1 ): 87 - 114 . . The competence-oriented curriculum may differ in its approach from the result-oriented functionalist, the constructivist related to the social construction of competence and the dialogical competence-based curriculum that considers meaningful learning 2424. Moreira MA . Aprendizagem significativa . Brasília : Editora UnB ; 1999 . , values the student’s insertion in the practice scenarios and the development of their autonomy 2525. Lima VV . Competência: distintas abordagens e implicações na formação de profissionais de saúde . Interface (Botucatu) . 2005 ; 9 ( 17 ): 369 - 79 . doi: http://dx.doi.org/10.1590/S1414-32832005000200012 .
http://dx.doi.org/10.1590/S1414-32832005... . In this sense, the dialogic framework translates competence more broadly, considering its application to real life, where learning is the result of social interaction 2525. Lima VV . Competência: distintas abordagens e implicações na formação de profissionais de saúde . Interface (Botucatu) . 2005 ; 9 ( 17 ): 369 - 79 . doi: http://dx.doi.org/10.1590/S1414-32832005000200012 .
http://dx.doi.org/10.1590/S1414-32832005...

26. Tsuji H , Aguilar-da-Silva RH . Currículo integrado por Competências Profissionais: reflexão sobre o trabalho desenvolvido na Faculdade de Medicina de Marília (Famema) [ Internet ]. Marília : Famema ; 2006 [ citado 17 Set 2019 ]. Disponível em: http://gestaouniversitaria.com.br/artigos/curriculo-integrado-por-competencias-profissionais
http://gestaouniversitaria.com.br/artigo...

27. Perrenoud P . Avaliação: da excelência à regulação das aprendizagens: entre duas lógicas . Porto Alegre : Artmed ; 1999 . - 2828. Epstein RM , Hundert EM . Defining and assessing professional competence . JAMA . 2002 ; 287 ( 2 ): 226 - 35 . doi: http://dx.doi.org/10.1001/JAMA.287.2.226 .
http://dx.doi.org/10.1001/JAMA.287.2.226... .

In the past 15 years, in our medical schools, the CBME framework, in its different strands, has become widely adopted by Brazilian institutions 11. Brasil . Ministério da Educação . Resolução CNE/CES nº 4, de 7 de Novembro de 2001. Institui diretrizes curriculares nacionais do curso de graduação em medicina . Diário Oficial da União [ Internet ]. 9 Nov 2001 [ citado 3 Jun 2019 ]. Disponível em: http://portal.mec.gov.br/cne/arquivos/pdf/CES04.pdf
http://portal.mec.gov.br/cne/arquivos/pd... , 22. Brasil . Ministério da Educação . Resolução CNE/CES nº 3, de 20 de Junho de 2014. Institui diretrizes curriculares nacionais do curso de graduação em medicina e dá outras providências . Diário Oficial da União [ Internet ]. 23 Jun 2014 [ citado 3 Jun 2019 ]. Disponível em: http://portal.mec.gov.br/index.php?option=com_docman&view=download&alias=15874-rces003-14&category_slug=junho-2014-pdf&Itemid=30192
http://portal.mec.gov.br/index.php?optio... due to its characteristics, which are knowledge, attitude and skills valorization, attention to students and prioritization of results in order to provide excellence in training in the areas of competence in health care management and health education.

The Royal College of Physicians and Surgeons of Canada, in its CanMEDS (Canadian Medical Education Directions for Specialists) Project, has published important medical education material that groups in seven roles the medical practices that a competent physician must be able to integrate to meet quality and safety to people’s health needs. The document points out key competencies and scope for each function leaving the “medical expert role” as the central and integrative role for the practice of medicine 2929. Frank JR , Snell L , Sherbino J , editors . CanMEDS 2015 physician competency framework [ Internet ]. Ottawa : Royal College of Physicians and Surgeons of Canada ; 2015 [ citado 5 Jun 2019 ]. Disponível em: http://canmeds.royalcollege.ca/uploads/en/framework/CanMEDS%202015%20Framework_EN_Reduced.pdf
http://canmeds.royalcollege.ca/uploads/e... .

It is noted at CBME, that the proximity between classroom education and service-based vocational training is a differential that could ensure dynamism, integration between disciplines, professions and emphasizes the longitudinal and permanent knowledge-building aspect 3030. Frank JR , Snell LS , Cate OT , Holmboe ES , Carraccio C , Swing SR , et al . Competency-based medical education: theory to practice . Med Teach . 2010 ; 32 ( 8 ): 638 - 45 . doi: http://dx.doi.org/10.3109/0142159X.2010.501190 .
http://dx.doi.org/10.3109/0142159X.2010.... .

The reality, is therefore, an indispensable scenario in this curriculum approach, contributes to making it critical, reflective and proactive. However, these potentialities, of the CBME may fade in the face of functional curriculum implementations or contaminated by traditional paradigms and current economic model 2121. Lampert JB . Tendências de mudanças na formação médica no Brasil [ tese ]. Rio de Janeiro : Escola Nacional de Saúde Pública Sérgio Arouca ; 2002 . , 3131. Harden RM . Outcome-based education - the ostrich, the peacock and the beaver . Med Teach . 2007 ; 29 ( 7 ): 666 - 71 . doi: http://dx.doi.org/10.1080/01421590701729948 .
http://dx.doi.org/10.1080/01421590701729... .

Gonczi, in 2013 3232. Gonczi A . Competency-based approaches: linking theory and practice in professional education with particular reference to health education . Educ Philos Theory . 2013 ; 45 ( 12 ): 1290 - 306 . doi: http://dx.doi.org/10.1080/00131857.2013.763590 .
http://dx.doi.org/10.1080/00131857.2013.... , pointed out naive and partial apprehension of the concept of competence, as responsible for reductionist and behaviorist training, compromising its holistic nature, as well as evaluation processes interfering in the theory and practice integration. While Lindsay warns about the risks of naturalization of the term and the “individualist making” caused by the lack of real context 3333. Lingard L . What we see and don’t see when we look at ‘competence’: notes on a god term . Adv Health Sci Educ Theory Pract . 2009 ; 14 ( 5 ): 625 - 8 . doi: http://dx.doi.org/10.1007/s10459-009-9206-y .
http://dx.doi.org/10.1007/s10459-009-920... . The procedural reading of the practices was also identified by other authors who, looking for better results, began to question the way in which competencies were being constructed 1818. Gutiérrez-Barreto S , Durán-Pérez VD , Flores-Morones F , Esqueda-Nuñez RI , Sánchez-Mojica CA , Hamui-Sutton A . Importance of context in entrustable professional activities on surgical undergraduate medical education . Med Ed Publish . 2018 . doi: https://dx.doi.org/10.15694/mep.2018.0000109.1 .
https://dx.doi.org/10.15694/mep.2018.000... , 3030. Frank JR , Snell LS , Cate OT , Holmboe ES , Carraccio C , Swing SR , et al . Competency-based medical education: theory to practice . Med Teach . 2010 ; 32 ( 8 ): 638 - 45 . doi: http://dx.doi.org/10.3109/0142159X.2010.501190 .
http://dx.doi.org/10.3109/0142159X.2010.... , 3232. Gonczi A . Competency-based approaches: linking theory and practice in professional education with particular reference to health education . Educ Philos Theory . 2013 ; 45 ( 12 ): 1290 - 306 . doi: http://dx.doi.org/10.1080/00131857.2013.763590 .
http://dx.doi.org/10.1080/00131857.2013.... and its evaluative approaches 2828. Epstein RM , Hundert EM . Defining and assessing professional competence . JAMA . 2002 ; 287 ( 2 ): 226 - 35 . doi: http://dx.doi.org/10.1001/JAMA.287.2.226 .
http://dx.doi.org/10.1001/JAMA.287.2.226... , 3232. Gonczi A . Competency-based approaches: linking theory and practice in professional education with particular reference to health education . Educ Philos Theory . 2013 ; 45 ( 12 ): 1290 - 306 . doi: http://dx.doi.org/10.1080/00131857.2013.763590 .
http://dx.doi.org/10.1080/00131857.2013.... , 3434. ten Cate O . Entrustability of professional activities and competency-based training . Med Educ . 2005 ; 39 ( 12 ): 1176 - 7 . doi: http://dx.doi.org/10.1111/J.1365-2929.2005.02341.X .
http://dx.doi.org/10.1111/J.1365-2929.20...

35. Zibrowski EM , Singh SI , Goldszmidt MA , Watling CJ , Kenyon CF , Schulz V , et al . The sum of the parts detracts from the intended whole: competencies and in-training assessments . Med Educ . 2009 ; 43 ( 8 ): 741 - 8 . doi: http://dx.doi.org/10.1111/j.1365-2923.2009.03404.x .
http://dx.doi.org/10.1111/j.1365-2923.20...

36. Touchie C , ten Cate O . The promise, perils, problems and progress of competency-based medical education . Med Educ . 2016 ; 50 ( 1 ): 93 - 100 . doi: http://dx.doi.org/10.1111/medu.12839 .
http://dx.doi.org/10.1111/medu.12839...

37. ten Cate O . A primer on entrustable professional activities . Korean J Med Educ . 2018 ; 30 ( 1 ): 1 - 10 . doi: http://dx.doi.org/10.3946/kjme.2018.76 .
http://dx.doi.org/10.3946/kjme.2018.76... - 3838. ten Cate O , Scheele F . Competency-based postgraduate training: can we bridge the gap between theory and clinical practice? Acad Med . 2007 ; 82 ( 6 ): 542 - 7 . .

In Brazil, there are challenges for the implementation of dialogic competence. The development of competency grids with knowledge, skills and attitudes separated and disconnected from the context of health care, hinders the integration, appropriation of learning and its action in the face of different health situations 3232. Gonczi A . Competency-based approaches: linking theory and practice in professional education with particular reference to health education . Educ Philos Theory . 2013 ; 45 ( 12 ): 1290 - 306 . doi: http://dx.doi.org/10.1080/00131857.2013.763590 .
http://dx.doi.org/10.1080/00131857.2013....

33. Lingard L . What we see and don’t see when we look at ‘competence’: notes on a god term . Adv Health Sci Educ Theory Pract . 2009 ; 14 ( 5 ): 625 - 8 . doi: http://dx.doi.org/10.1007/s10459-009-9206-y .
http://dx.doi.org/10.1007/s10459-009-920... - 3434. ten Cate O . Entrustability of professional activities and competency-based training . Med Educ . 2005 ; 39 ( 12 ): 1176 - 7 . doi: http://dx.doi.org/10.1111/J.1365-2929.2005.02341.X .
http://dx.doi.org/10.1111/J.1365-2929.20... . Another weak point is the student’s early interaction in the practice setting, contextualized learning 2222. Aguiar AC , Ribeiro ECO . Conceito e avaliação de habilidades e competência na educação médica: percepções atuais dos especialistas . Rev Bras Educ Med . 2010 ; 34 ( 3 ): 371 - 8 . doi: https://dx.doi.org/10.1590/S0100-55022010000300006 .
https://dx.doi.org/10.1590/S0100-5502201... , 3232. Gonczi A . Competency-based approaches: linking theory and practice in professional education with particular reference to health education . Educ Philos Theory . 2013 ; 45 ( 12 ): 1290 - 306 . doi: http://dx.doi.org/10.1080/00131857.2013.763590 .
http://dx.doi.org/10.1080/00131857.2013.... . Difficulties stand out in the implementation of the epidemiological-social theoretical approach, in the establishment of pedagogical models that promote interdisciplinarity, the early insertion of the student in the real scenario, favoring teamwork, building autonomy and their humanist, moral and ethical formation 2222. Aguiar AC , Ribeiro ECO . Conceito e avaliação de habilidades e competência na educação médica: percepções atuais dos especialistas . Rev Bras Educ Med . 2010 ; 34 ( 3 ): 371 - 8 . doi: https://dx.doi.org/10.1590/S0100-55022010000300006 .
https://dx.doi.org/10.1590/S0100-5502201... , 3939. Abdalla IG , Stella RCR , Perim GL , Aguilar-da-Silva RH , Lampert JB , Costa NMSC . Projeto pedagógico e as mudanças na educação médica . Rev Bras Educ Med . 2009 ; 33 Suppl 1 : 44 - 52 . doi: http://dx.doi.org/10.1590/S0100-55022009000500005 .
http://dx.doi.org/10.1590/S0100-55022009...

40. Perim GL , Abdalla IG , Aguilar-da-Silva RH , Lampert JB , Stella RCR , Costa NMSC . Desenvolvimento docente e a formação de médicos . Rev Bras Educ Med . 2009 ; 33 Suppl 1 : 70 - 82 . doi: http://dx.doi.org/10.1590/S0100-55022009000500008 .
http://dx.doi.org/10.1590/S0100-55022009... - 4141. Gontijo ED , Alvim C , Megale L , Melo JRC , Lima MECC . Matriz de competências essenciais para a formação e avaliação de desempenho de estudantes de medicina . Rev Bras Educ Med . 2013 ; 37 ( 4 ): 526 - 39 . doi: http://dx.doi.org/10.1590/S0100-55022013000400008 .
http://dx.doi.org/10.1590/S0100-55022013... .These findings, are exacerbated by the poor local tradition in formative assessment and incipient teacher training programs 1010. Lopes AC . A explosão numérica das escolas médicas brasileiras . Educ Med . 2018 ; 19 Suppl 1 : 19 - 24 . doi: https://dx.doi.org/10.1016/j.edumed.2018.03.004
https://dx.doi.org/10.1016/j.edumed.2018... , 1111. Amaral E , Domingues RCL , Zeferino AMB . Avaliando a competência clínica: o método de avaliação estruturada observacional . Rev Bras Educ Med . 2007 ; 31 ( 3 ): 287 - 90 . doi: https://dx.doi.org/10.1590/S0100-55022007000300011 .
https://dx.doi.org/10.1590/S0100-5502200... , 2121. Lampert JB . Tendências de mudanças na formação médica no Brasil [ tese ]. Rio de Janeiro : Escola Nacional de Saúde Pública Sérgio Arouca ; 2002 . , 2222. Aguiar AC , Ribeiro ECO . Conceito e avaliação de habilidades e competência na educação médica: percepções atuais dos especialistas . Rev Bras Educ Med . 2010 ; 34 ( 3 ): 371 - 8 . doi: https://dx.doi.org/10.1590/S0100-55022010000300006 .
https://dx.doi.org/10.1590/S0100-5502201... , 3939. Abdalla IG , Stella RCR , Perim GL , Aguilar-da-Silva RH , Lampert JB , Costa NMSC . Projeto pedagógico e as mudanças na educação médica . Rev Bras Educ Med . 2009 ; 33 Suppl 1 : 44 - 52 . doi: http://dx.doi.org/10.1590/S0100-55022009000500005 .
http://dx.doi.org/10.1590/S0100-55022009... , 4141. Gontijo ED , Alvim C , Megale L , Melo JRC , Lima MECC . Matriz de competências essenciais para a formação e avaliação de desempenho de estudantes de medicina . Rev Bras Educ Med . 2013 ; 37 ( 4 ): 526 - 39 . doi: http://dx.doi.org/10.1590/S0100-55022013000400008 .
http://dx.doi.org/10.1590/S0100-55022013...

42. Associação Brasileira de Educação Médica . Novas Diretrizes Curriculares Nacionais para a Medicina: avanços e desafios . Cad Abem . 2015 ; 11 : 1 - 67 . - 4343. Domingues RCL , Amaral E , Zeferino AMB , Antonio MAGM , Nadruz W . Competência clínica de aluno de Medicina em estágio clínico: comparação entre métodos de avaliação . Rev Bras Educ Med . 2010 ; 34 ( 1 ): 124 - 31 . doi: http://dx.doi.org/10.1590/S0100-55022010000100015 .
http://dx.doi.org/10.1590/S0100-55022010... .

Since 2005, the concept and application of EPAs, initially proposed for postgraduate studies, has emerged as new and more promising approach in the CBME’s materialization in medical graduation, decoding it, in daily practice, in effective and safe medical care 1515. Chen HC , van den Broek WE , ten Cate O . The case for use of entrustable professional activities in undergraduate medical education . Acad Med . 2015 ; 90 ( 4 ): 431 - 6 . doi: https://dx.doi.org/10.1097/ACM.0000000000000586 .
https://dx.doi.org/10.1097/ACM.000000000... , 3434. ten Cate O . Entrustability of professional activities and competency-based training . Med Educ . 2005 ; 39 ( 12 ): 1176 - 7 . doi: http://dx.doi.org/10.1111/J.1365-2929.2005.02341.X .
http://dx.doi.org/10.1111/J.1365-2929.20... , 3636. Touchie C , ten Cate O . The promise, perils, problems and progress of competency-based medical education . Med Educ . 2016 ; 50 ( 1 ): 93 - 100 . doi: http://dx.doi.org/10.1111/medu.12839 .
http://dx.doi.org/10.1111/medu.12839...

37. ten Cate O . A primer on entrustable professional activities . Korean J Med Educ . 2018 ; 30 ( 1 ): 1 - 10 . doi: http://dx.doi.org/10.3946/kjme.2018.76 .
http://dx.doi.org/10.3946/kjme.2018.76... - 3838. ten Cate O , Scheele F . Competency-based postgraduate training: can we bridge the gap between theory and clinical practice? Acad Med . 2007 ; 82 ( 6 ): 542 - 7 . , 4444. Englander R , Flynn T , Call S , Carraccio C , Cleary L , Fulton TB , et al . Toward defining the foundation of the MD degree: core entrustable professional activities for entering residency . Acad Med . 2016 ; 91 ( 10 ): 1352 - 8 . Doi: http://dx.doi.org/10.1097/ACM.0000000000001204 .
http://dx.doi.org/10.1097/ACM.0000000000... , 4545. Favreau MA , Tewksbury L , Lupi C , Cutrer WB , Jokela JA , Yarris LM , et al . Constructing a shared mental model for faculty development for the core entrustable professional activities for entering residency . Acad Med . 2017 ; 92 ( 6 ): 759 - 64 . doi: http://dx.doi.org/10.1097/ACM.0000000000001511 .
http://dx.doi.org/10.1097/ACM.0000000000... .

In 2014, the Association of American Medical Colleges (AAMC) proposed 13 core EPAs for the achievement of United States (US) competency framework for the medical course and started a pilot study in ten American medical schools that have been adopted this tool and demonstrated the feasibility of its use 1919. Obeso V , Brown D , Aiyer M , Barron B , Bull J , Carter T , et al . Toolkits for the 13 core entrustable professional activities for entering residency . Washington : Association of American Medical Colleges ; 2017 . .

The number of EPAs has varied: the Canadian Association of Faculties of Medicine (AFMC) has recommended, since 2016, to overcome the difficulty in assessing the skills foreseen for national curriculum structures, which part does not refer directly to medical activities, the use of 12 APCs to effect the Canadian CBME 1717. Touchie C , Boucher A , Allen T , Bhanji F , Chan M-K , Clarizia N , et al . AFMC Entrustable Professional Activities for the Transition from Medical School to Residency . Ottawa : Association of Faculties of Medicine of Canada ; 2016 . . In Utrecht, the new CBME is worked through five broad EPAs, while in PROFILES, curriculum guidelines for the Swiss medical course, its fourth chapter presents nine EPAs for medical education in that country 1414. ten Cate O , Graafmans L , Posthumus I , Welink L , van Dijk M . The EPA-based Utrecht undergraduate clinical curriculum: development and implementation . Med Teach . 2018 ; 40 ( 5 ): 506 - 13 . doi: https://dx.doi.org/10.1080/0142159X.2018.1435856 .
https://dx.doi.org/10.1080/0142159X.2018... , 4646. Michaud PA , Jucker-Kupper P , The Profiles Working Group . The “Profiles” document: a modern revision of the objectives of undergraduate medical studies in Switzerland . Swiss Med Wkly . 2016 ; 146 : w14270 . doi: http://dx.doi.org/10.4414/smw.2016.14270 .
http://dx.doi.org/10.4414/smw.2016.14270... .

Study by Meyer et al. 4747. Meyer EG , Chen HC , Uijtdehaage S , Durning SJ , Maggio LA . Scoping review of entrustable professional activities in undergraduate medical education . Acad Med . 2019 ; 94 ( 7 ): 1040 - 9 . doi: http://dx.doi.org/10.1097/ACM.0000000000002735 .
http://dx.doi.org/10.1097/ACM.0000000000... about publications in the literature relating EPAs, medical graduation and evaluation, between 2014 and 2018, located 1089 articles. Of these, 71 were scientific articles. 83.5% of them characterized positively the EPAs. Among the empirical studies (26), the results were positive in 76.7%.

Although with short-term results, two schools in Latin America have successfully adopted EPAs to instrumentalize their CBME as presented at the AMEE (Conference for Medical Education in Europe) Annual Conference 2019 in Vienna 4848. Tapia AER , Maldonado MI , Domínguez LD , Casallas JCG , Jara NP , Diaz MM , et al . Sequencing Entrustable Professional Activities through a whole-task model for instructional design: an early experience in a Latin-American medical school . In: AMEE Annual Conference ; 2019 ; Viena, Austria . Viena : International Association for Medical Education ; 2019 [ citado 5 Jun 2019 ]. Disponível em: https://amee.org/getattachment/Conferences/AMEE-2019/AMEE-2019-APP-Data-PDFs/7H-Short-Communications-Curriculum-Entrustable-Professional-Activities- (EPAs).pdf
https://amee.org/getattachment/Conferenc... , 4949. Dieguez MG , Durante E , Giannasi S , Arceo D , Eder ML , Figari M . Using Entrustable Professional Activities (EPAs) as curriculum organizers in a major medical undergraduate curriculum renewal . In: AMEE Annual Conference ; 2019 ; Viena, Austria . Viena : International Association for Medical Education ; 2019 . [ citado 5 Jun 2019 ]. Disponível em: https://amee.org/getattachment/Conferences/AMEE-2019/AMEE-2019-APP-Data-PDFs/7H-Short-Communications-Curriculum-Entrustable-Professional-Activities- (EPAs).pdf
https://amee.org/getattachment/Conferenc... .

Considering consistent experiences such as those cited, the authors conduct this perspective analysis and present the EPAs as a possible solution for better results in the implementation of CBME and qualified and safe care to the population’s health needs accepting the ability of EPAs to approximate theory and practice 1414. ten Cate O , Graafmans L , Posthumus I , Welink L , van Dijk M . The EPA-based Utrecht undergraduate clinical curriculum: development and implementation . Med Teach . 2018 ; 40 ( 5 ): 506 - 13 . doi: https://dx.doi.org/10.1080/0142159X.2018.1435856 .
https://dx.doi.org/10.1080/0142159X.2018... , 3838. ten Cate O , Scheele F . Competency-based postgraduate training: can we bridge the gap between theory and clinical practice? Acad Med . 2007 ; 82 ( 6 ): 542 - 7 . .

The EPAs are professional practices that should be developed on a daily basis, therefore, in the practice scenarios, under the direct supervision of the teacher, and in immersion with the relations of the care production, interacting with cognitive, technical, humanistic aspects, relational, organizational and management. This is one of the supports used to point it out as a tool aimed at mediating the CBME 1313. ten Cate O , Chen HC , Hoff RG , Peters H , Bok H , van der Schaaf M . Curriculum development for the workplace using Entrustable Professional Activities (EPAs): AMEE Guide No. 99 . Med Teach . 2015 ; 37 ( 11 ): 983 - 1002 . doi: https://dx.doi.org/10.3109/0142159X.2015.1060308 .
https://dx.doi.org/10.3109/0142159X.2015... , 1515. Chen HC , van den Broek WE , ten Cate O . The case for use of entrustable professional activities in undergraduate medical education . Acad Med . 2015 ; 90 ( 4 ): 431 - 6 . doi: https://dx.doi.org/10.1097/ACM.0000000000000586 .
https://dx.doi.org/10.1097/ACM.000000000... , 1616. Lomis K , Amiel JM , Ryan MS , Esposito K , Green M , Stagnaro-Green A , et al . Implementing an entrustable professional activities framework in undergraduate medical education: early lessons from the AAMC Core Entrustable Professional Activities for Entering Residency Pilot . Acad Med . 2017 ; 92 ( 6 ): 765 - 70 . doi: https://dx.doi.org/10.1097/ACM.0000000000001543 .
https://dx.doi.org/10.1097/ACM.000000000... . However, as we detail its concept and application, several elements will be pointed out.

The concept of EPAs is based on single EPAs, which together build the real-life tasks done by a profession. Each EPA represents an activity, or unit of practice, of what the physician should accomplish as a component of his professional duty. ten Cate 3434. ten Cate O . Entrustability of professional activities and competency-based training . Med Educ . 2005 ; 39 ( 12 ): 1176 - 7 . doi: http://dx.doi.org/10.1111/J.1365-2929.2005.02341.X .
http://dx.doi.org/10.1111/J.1365-2929.20... defined that EPAs:

1 are part of essential professional work in a given context; 2 must require adequate knowledge, skills and attitude, generally acquired through training; 3 must lead to recognized output of professional labour; 4 should usually confined to qualified personnel; 5 independently executable; 6 should be executable within a time frame; 7 should be observable and measurable in their process and their outcome, leading to a conclusion (‘well done’ or ‘not well done’); and, 8 should reflect one or more of the competencies to be acquired. (p. 1177)

The EPAs are intimately connected to the context of the clinical work, to the society where it is inserted and to the health needs of the local population. Therefore, EPAs happen in real life, in the world of work, and in coping with the challenges that the day-to-day imposes on the profession exercise 3434. ten Cate O . Entrustability of professional activities and competency-based training . Med Educ . 2005 ; 39 ( 12 ): 1176 - 7 . doi: http://dx.doi.org/10.1111/J.1365-2929.2005.02341.X .
http://dx.doi.org/10.1111/J.1365-2929.20... , 3636. Touchie C , ten Cate O . The promise, perils, problems and progress of competency-based medical education . Med Educ . 2016 ; 50 ( 1 ): 93 - 100 . doi: http://dx.doi.org/10.1111/medu.12839 .
http://dx.doi.org/10.1111/medu.12839...

37. ten Cate O . A primer on entrustable professional activities . Korean J Med Educ . 2018 ; 30 ( 1 ): 1 - 10 . doi: http://dx.doi.org/10.3946/kjme.2018.76 .
http://dx.doi.org/10.3946/kjme.2018.76... - 3838. ten Cate O , Scheele F . Competency-based postgraduate training: can we bridge the gap between theory and clinical practice? Acad Med . 2007 ; 82 ( 6 ): 542 - 7 . .

When considering the reality and dispensation of health care, the development of EPAs allows a holistic look with a wide range of learning opportunities that involve the care of the individual, family and community, the work process, health services, public policies and social commitment 3636. Touchie C , ten Cate O . The promise, perils, problems and progress of competency-based medical education . Med Educ . 2016 ; 50 ( 1 ): 93 - 100 . doi: http://dx.doi.org/10.1111/medu.12839 .
http://dx.doi.org/10.1111/medu.12839... , 5050. ten Cate O , Snell L , Carraccio C . Medical competence: the interplay between individual ability and the health care environment . Med Teach . 2010 ; 32 ( 8 ): 669 - 75 . doi: http://dx.doi.org/10.3109/0142159X.2010.500897 .
http://dx.doi.org/10.3109/0142159X.2010.... .

Now, how does the EPA concept enable a medical student to accomplish a professional task while preserving the patient’s integrity, the effectiveness of the action and the acquisition of knowledge, skills and attitudes in his own learning time process?

In this concept, EPAs have two more important key characteristics in addition representing a professional activity: for its realization is mediated by a trust attribution (entrustment decision) made by the supervisor and the last point is that the EPA practice requires supervisor feedback in form of different levels of supervision 3737. ten Cate O . A primer on entrustable professional activities . Korean J Med Educ . 2018 ; 30 ( 1 ): 1 - 10 . doi: http://dx.doi.org/10.3946/kjme.2018.76 .
http://dx.doi.org/10.3946/kjme.2018.76... .

The entrustment decision considers the capacity of the student to perform procedures and to take decisions independently, but is time-guided, depends of various factors and tends to respect the student learning curve in a constructive friction way. The four important aspects that may influence the decisions are: 1- the conditions of the student; 2- the personality of the supervisor; 3- the environment and circumstances (e.g., the time, place, facilities, team and patient) in which the activities are executed; and 4- the nature and complexity of the activity 5151. Sterkenburg A , Barach P , Kalkman C , Gielen M , ten Cate O . When do supervising physicians decide to entrust residents with unsupervised tasks? Acad Med . 2010 ; 85 ( 9 ): 1408 - 17 . doi: http://dx.doi.org/10.1097/ACM.0b013e3181eab0ec .
http://dx.doi.org/10.1097/ACM.0b013e3181... .

Therefore, while the process will be mediated by the decision-making of the supervisor, in the face of his perceptions on the situation, the patient, the student and when to entrust to the student certain activity, the student will be responsible for his/her decision: if he/she can take it independently or, if and when, he/she shall ask for help 5252. ten Cate O . Entrustment as assessment: recognizing the ability, the right, and the duty to act . J Grad Med Educ . 2016 ; 8 ( 2 ): 261 - 2 . doi: http://dx.doi.org/10.4300/JGME-D-16-00097.1 .
http://dx.doi.org/10.4300/JGME-D-16-0009... , 5353. Carraccio C , Burke AE . Beyond competencies and milestones: adding meaning through context . J Grad Med Educ . 2010 ; 2 ( 3 ): 419 - 22 . doi: http://dx.doi.org/10.4300/JGME-D-10-00127.1 .
http://dx.doi.org/10.4300/JGME-D-10-0012... .

The assessment potential of the EPAs is complemented with the supervisor presence and supervision.

With the entrustment decisions is necessary to reach the supervision level for the EPA practice. ten Cate 3737. ten Cate O . A primer on entrustable professional activities . Korean J Med Educ . 2018 ; 30 ( 1 ): 1 - 10 . doi: http://dx.doi.org/10.3946/kjme.2018.76 .
http://dx.doi.org/10.3946/kjme.2018.76... described five level of supervision:

Level 1: the learner is allowed to be present and observe, not to enact an EPA.

Level 2: the learner is allowed to execute the EPA with direct, pro-active supervision, present in the room.

Level 3: the learner is allowed to carry out the EPA without a supervisor in the room, but quickly available if needed, i.e. with indirect, reactive, supervision.

Level 4: the learner is allowed to work unsupervised.

Level 5: the learner is allowed to provide supervision to more junior learners. (p. 98)

The exercise of EPAs is linked to the close student follow-up by a supervisor along the way and can be evaluated many times and by different supervisors 5050. ten Cate O , Snell L , Carraccio C . Medical competence: the interplay between individual ability and the health care environment . Med Teach . 2010 ; 32 ( 8 ): 669 - 75 . doi: http://dx.doi.org/10.3109/0142159X.2010.500897 .
http://dx.doi.org/10.3109/0142159X.2010.... .

According to ten Cate 3737. ten Cate O . A primer on entrustable professional activities . Korean J Med Educ . 2018 ; 30 ( 1 ): 1 - 10 . doi: http://dx.doi.org/10.3946/kjme.2018.76 .
http://dx.doi.org/10.3946/kjme.2018.76... ,

An essential component of training is the regular transfer of responsibilities, if the situation allows for it. A supervising physician does this when she feels that the skills of the learner at that time match the complexity of the patient, and the risks in doing this are acceptable. These are called “ad- hoc entrustment decisions”. (p. 96-7)

In this relationship, a bonding of trust and accountability is built between students, professors and patients. Thus, during the encounters, we contrast the construction of the evaluation as a unique process where the empathy is another aspect to be appreciated 5454. ten Cate O . Trust, competence, and the supervisor’s role in postgraduate training . BMJ . 2006 ; 333 ( 7571 ): 748 - 51 . doi: http://dx.doi.org/10.1136/bmj.38938.407569.94 .
http://dx.doi.org/10.1136/bmj.38938.4075... .

The use of EPAs over time already established in the training of resident physicians has also demonstrated in the undergraduate courses to promote the qualification of the practice, responsible and safe insertion of the student in the services and promotion of a process of highly sensitive evaluation 1313. ten Cate O , Chen HC , Hoff RG , Peters H , Bok H , van der Schaaf M . Curriculum development for the workplace using Entrustable Professional Activities (EPAs): AMEE Guide No. 99 . Med Teach . 2015 ; 37 ( 11 ): 983 - 1002 . doi: https://dx.doi.org/10.3109/0142159X.2015.1060308 .
https://dx.doi.org/10.3109/0142159X.2015...

14. ten Cate O , Graafmans L , Posthumus I , Welink L , van Dijk M . The EPA-based Utrecht undergraduate clinical curriculum: development and implementation . Med Teach . 2018 ; 40 ( 5 ): 506 - 13 . doi: https://dx.doi.org/10.1080/0142159X.2018.1435856 .
https://dx.doi.org/10.1080/0142159X.2018...

15. Chen HC , van den Broek WE , ten Cate O . The case for use of entrustable professional activities in undergraduate medical education . Acad Med . 2015 ; 90 ( 4 ): 431 - 6 . doi: https://dx.doi.org/10.1097/ACM.0000000000000586 .
https://dx.doi.org/10.1097/ACM.000000000... - 1616. Lomis K , Amiel JM , Ryan MS , Esposito K , Green M , Stagnaro-Green A , et al . Implementing an entrustable professional activities framework in undergraduate medical education: early lessons from the AAMC Core Entrustable Professional Activities for Entering Residency Pilot . Acad Med . 2017 ; 92 ( 6 ): 765 - 70 . doi: https://dx.doi.org/10.1097/ACM.0000000000001543 .
https://dx.doi.org/10.1097/ACM.000000000... , 1919. Obeso V , Brown D , Aiyer M , Barron B , Bull J , Carter T , et al . Toolkits for the 13 core entrustable professional activities for entering residency . Washington : Association of American Medical Colleges ; 2017 . , 3232. Gonczi A . Competency-based approaches: linking theory and practice in professional education with particular reference to health education . Educ Philos Theory . 2013 ; 45 ( 12 ): 1290 - 306 . doi: http://dx.doi.org/10.1080/00131857.2013.763590 .
http://dx.doi.org/10.1080/00131857.2013.... , 3333. Lingard L . What we see and don’t see when we look at ‘competence’: notes on a god term . Adv Health Sci Educ Theory Pract . 2009 ; 14 ( 5 ): 625 - 8 . doi: http://dx.doi.org/10.1007/s10459-009-9206-y .
http://dx.doi.org/10.1007/s10459-009-920... , 4545. Favreau MA , Tewksbury L , Lupi C , Cutrer WB , Jokela JA , Yarris LM , et al . Constructing a shared mental model for faculty development for the core entrustable professional activities for entering residency . Acad Med . 2017 ; 92 ( 6 ): 759 - 64 . doi: http://dx.doi.org/10.1097/ACM.0000000000001511 .
http://dx.doi.org/10.1097/ACM.0000000000... , 5555. The Association of Faculties of Medicine of Canada . Entrustable professional activities for the transition from medical school to residency [ Internet ]. Ottawa : AFMC ; 2016 [ citado 5 Jun 2019 ]. Disponível em: https://afmc.ca/sites/default/files/documents/AFMC_Entrustable_Professional_Activities_EN_0.pdf
https://afmc.ca/sites/default/files/docu... , 5656. Holzhausen Y , Maaz A , Renz A , Bosch J , Peters H . Development of Entrustable Professional Activities for entry into residency at the Charité Berlin . GMS J Med Educ . 2019 ; 36 ( 1 ): Doc5 . doi: http://dx.doi.org/10.3205/zma001213 .
http://dx.doi.org/10.3205/zma001213... It provides the formative, longitudinal approach with continued construction of independence and, the autonomy of the student based on trust, acquisition of skills for the practice exercise and responsibility 5050. ten Cate O , Snell L , Carraccio C . Medical competence: the interplay between individual ability and the health care environment . Med Teach . 2010 ; 32 ( 8 ): 669 - 75 . doi: http://dx.doi.org/10.3109/0142159X.2010.500897 .
http://dx.doi.org/10.3109/0142159X.2010....

51. Sterkenburg A , Barach P , Kalkman C , Gielen M , ten Cate O . When do supervising physicians decide to entrust residents with unsupervised tasks? Acad Med . 2010 ; 85 ( 9 ): 1408 - 17 . doi: http://dx.doi.org/10.1097/ACM.0b013e3181eab0ec .
http://dx.doi.org/10.1097/ACM.0b013e3181...

52. ten Cate O . Entrustment as assessment: recognizing the ability, the right, and the duty to act . J Grad Med Educ . 2016 ; 8 ( 2 ): 261 - 2 . doi: http://dx.doi.org/10.4300/JGME-D-16-00097.1 .
http://dx.doi.org/10.4300/JGME-D-16-0009... - 5353. Carraccio C , Burke AE . Beyond competencies and milestones: adding meaning through context . J Grad Med Educ . 2010 ; 2 ( 3 ): 419 - 22 . doi: http://dx.doi.org/10.4300/JGME-D-10-00127.1 .
http://dx.doi.org/10.4300/JGME-D-10-0012... , 5757. ten Cate O . Nuts and bolts of entrustable professional activities . J Grad Med Educ . 2013 ; 5 ( 1 ): 157 - 8 . doi: http://dx.doi.org/10.4300/JGME-D-12-00380.1 .
http://dx.doi.org/10.4300/JGME-D-12-0038... At this point, the summative characteristic of the EPAs is linked to the moment when the supervision is no longer more required 1919. Obeso V , Brown D , Aiyer M , Barron B , Bull J , Carter T , et al . Toolkits for the 13 core entrustable professional activities for entering residency . Washington : Association of American Medical Colleges ; 2017 . , 3737. ten Cate O . A primer on entrustable professional activities . Korean J Med Educ . 2018 ; 30 ( 1 ): 1 - 10 . doi: http://dx.doi.org/10.3946/kjme.2018.76 .
http://dx.doi.org/10.3946/kjme.2018.76... , 5656. Holzhausen Y , Maaz A , Renz A , Bosch J , Peters H . Development of Entrustable Professional Activities for entry into residency at the Charité Berlin . GMS J Med Educ . 2019 ; 36 ( 1 ): Doc5 . doi: http://dx.doi.org/10.3205/zma001213 .
http://dx.doi.org/10.3205/zma001213... , 5858. Peters H , Holzhausen Y , Boscardin C , ten Cate O , Chen HC . Twelve tips for the implementation of EPAs for assessment and entrustment decisions . Med Teach . 2017 ; 39 ( 8 ): 802 - 7 . doi: http://dx.doi.org/10.1080/0142159X.2017.1331031 .
http://dx.doi.org/10.1080/0142159X.2017.... . However, this condition only persists when the student keeps on doing the activity 3737. ten Cate O . A primer on entrustable professional activities . Korean J Med Educ . 2018 ; 30 ( 1 ): 1 - 10 . doi: http://dx.doi.org/10.3946/kjme.2018.76 .
http://dx.doi.org/10.3946/kjme.2018.76...

The student‘s interaction with the work process is provocative and puts him/her in front of the patient‘s demands and the need for teamwork. It highlights here the potentiality of new and unfamiliar situations for student development 5959. Wijnen-Meijer M , Van der Schaaf M , Booij E , Harendza S , Boscardin C , Van Wijngaarden J , et al . An argument-based approach to the validation of UHTRUST: can we measure how recent graduates can be trusted with unfamiliar tasks? Adv Health Sci Educ Theory Pract. 2013 ; 18 ( 5 ): 1009 - 27 . doi: http://dx.doi.org/10.1007/s10459-013-9444-x .
http://dx.doi.org/10.1007/s10459-013-944...

In this scenario, a recommended practice is the Entrustment-Based Discussion, a conversation between the supervisor and the student about 15 minutes after the completion of an EPA where key aspects related to doing and the context are discussed and re-meaning 6060. ten Cate O , Hoff RG . From case-based to entrustment-based discussions . Clin Teach . 2017 ; 14 ( 6 ): 385 - 9 . doi: http://dx.doi.org/10.1111/tct.12710 .
http://dx.doi.org/10.1111/tct.12710... .

This close proximity between teacher-student-service and patient, the supervisor’s immersion into the praxis, in the real world, creates a positive feedback to the qualification of the teaching and the service for the mutual benefit of both.

Accepting the integration of competencies in the clinical environment as necessary for the medical qualification, we are led to further consider the applicability of the EPAs in the Brazilian medical curriculum 1818. Gutiérrez-Barreto S , Durán-Pérez VD , Flores-Morones F , Esqueda-Nuñez RI , Sánchez-Mojica CA , Hamui-Sutton A . Importance of context in entrustable professional activities on surgical undergraduate medical education . Med Ed Publish . 2018 . doi: https://dx.doi.org/10.15694/mep.2018.0000109.1 .
https://dx.doi.org/10.15694/mep.2018.000... , 5050. ten Cate O , Snell L , Carraccio C . Medical competence: the interplay between individual ability and the health care environment . Med Teach . 2010 ; 32 ( 8 ): 669 - 75 . doi: http://dx.doi.org/10.3109/0142159X.2010.500897 .
http://dx.doi.org/10.3109/0142159X.2010.... . The practical essence of the EPA and its relational aspect makes it represent the real dimension of the medical practice in the context in which it is placed and accredits its mediation of CBME 5656. Holzhausen Y , Maaz A , Renz A , Bosch J , Peters H . Development of Entrustable Professional Activities for entry into residency at the Charité Berlin . GMS J Med Educ . 2019 ; 36 ( 1 ): Doc5 . doi: http://dx.doi.org/10.3205/zma001213 .
http://dx.doi.org/10.3205/zma001213... :

[…] trainees in health care are part of a team and a wider organizational structure. Decisions pertaining to the division of labour in this organization include trainees. Many of these decisions involve entrustment of professional activities, and therefore implicit judgments about competence. These elements force us to view medical training and assessment of competence within the context of the interplay between individual ability and the clinical environment 5050. ten Cate O , Snell L , Carraccio C . Medical competence: the interplay between individual ability and the health care environment . Med Teach . 2010 ; 32 ( 8 ): 669 - 75 . doi: http://dx.doi.org/10.3109/0142159X.2010.500897 .
http://dx.doi.org/10.3109/0142159X.2010.... . (p. 674)

Thus, the design of the EPAs must be constructed from the different realities from which it is inserted, assuring its belonging and results. It is not an adaptation but an effort in the identification and description of professional tasks that meet the needs of the community while advancing in the scientific and humanistic references 5050. ten Cate O , Snell L , Carraccio C . Medical competence: the interplay between individual ability and the health care environment . Med Teach . 2010 ; 32 ( 8 ): 669 - 75 . doi: http://dx.doi.org/10.3109/0142159X.2010.500897 .
http://dx.doi.org/10.3109/0142159X.2010.... .

The full implementation of the EPAs with the team will favor, through critical and dialogic practice, the improvement and constant development of health care 5050. ten Cate O , Snell L , Carraccio C . Medical competence: the interplay between individual ability and the health care environment . Med Teach . 2010 ; 32 ( 8 ): 669 - 75 . doi: http://dx.doi.org/10.3109/0142159X.2010.500897 .
http://dx.doi.org/10.3109/0142159X.2010.... . This reflective culture that goes beyond the walls of the academy, follows the reference of permanent education of the National Policy of Permanent Education in Health (NPPEH) 6161. Brasil . Ministério da Saúde . Política Nacional de Educação Permanente em Saúde . Brasília : Ministério da Saúde ; 2009 . and shall include teachers, students and a multiprofessional team.

In Brazil, the EPAs would contribute to the improvement of the CBME, the evaluation process, and professional training as a whole, in order to improve the health work process itself 6262. Francischetti I , Peters H . Definição de atividades profissionais confiáveis para acesso à residência médica como melhor forma de traduzir para a prática a educação médica baseda em competência [ bolsa exterior-pesquisa ] [ Internet ]. Marília : Faculdade de Medicina de Marília , Berlin : Charité Universitätsmedizin Berlin ; 2019 [ citado 5 Jun 2019 ]. Disponível em: https://bv.fapesp.br/pt/bolsas/184598
https://bv.fapesp.br/pt/bolsas/184598... .

In conclusion, the exposed material supports us to recognize and suggest EPAs as an excellent possibility to decode CBME to practice, to promote a realistic learning, attending the integral care dimension in workplace, with team engagement and under a qualified assessment processes.

The potential of the EPAs, when based on the local/regional reality, goes beyond the professional qualification, aligning them well with the NCG 11. Brasil . Ministério da Educação . Resolução CNE/CES nº 4, de 7 de Novembro de 2001. Institui diretrizes curriculares nacionais do curso de graduação em medicina . Diário Oficial da União [ Internet ]. 9 Nov 2001 [ citado 3 Jun 2019 ]. Disponível em: http://portal.mec.gov.br/cne/arquivos/pdf/CES04.pdf
http://portal.mec.gov.br/cne/arquivos/pd... , 22. Brasil . Ministério da Educação . Resolução CNE/CES nº 3, de 20 de Junho de 2014. Institui diretrizes curriculares nacionais do curso de graduação em medicina e dá outras providências . Diário Oficial da União [ Internet ]. 23 Jun 2014 [ citado 3 Jun 2019 ]. Disponível em: http://portal.mec.gov.br/index.php?option=com_docman&view=download&alias=15874-rces003-14&category_slug=junho-2014-pdf&Itemid=30192
http://portal.mec.gov.br/index.php?optio... and NPPEH 6161. Brasil . Ministério da Saúde . Política Nacional de Educação Permanente em Saúde . Brasília : Ministério da Saúde ; 2009 . and promoting advances in training and services. Nevertheless, care must be taken so that its adoption is not made by transposition incurring reductionism but grounded in the environment where it will be experienced.

Many authors advocate the elaborating of EPAs and guide their construction by providing material for accurate and genuine production 1414. ten Cate O , Graafmans L , Posthumus I , Welink L , van Dijk M . The EPA-based Utrecht undergraduate clinical curriculum: development and implementation . Med Teach . 2018 ; 40 ( 5 ): 506 - 13 . doi: https://dx.doi.org/10.1080/0142159X.2018.1435856 .
https://dx.doi.org/10.1080/0142159X.2018... , 1919. Obeso V , Brown D , Aiyer M , Barron B , Bull J , Carter T , et al . Toolkits for the 13 core entrustable professional activities for entering residency . Washington : Association of American Medical Colleges ; 2017 . , 5050. ten Cate O , Snell L , Carraccio C . Medical competence: the interplay between individual ability and the health care environment . Med Teach . 2010 ; 32 ( 8 ): 669 - 75 . doi: http://dx.doi.org/10.3109/0142159X.2010.500897 .
http://dx.doi.org/10.3109/0142159X.2010.... , 5656. Holzhausen Y , Maaz A , Renz A , Bosch J , Peters H . Development of Entrustable Professional Activities for entry into residency at the Charité Berlin . GMS J Med Educ . 2019 ; 36 ( 1 ): Doc5 . doi: http://dx.doi.org/10.3205/zma001213 .
http://dx.doi.org/10.3205/zma001213... , 5858. Peters H , Holzhausen Y , Boscardin C , ten Cate O , Chen HC . Twelve tips for the implementation of EPAs for assessment and entrustment decisions . Med Teach . 2017 ; 39 ( 8 ): 802 - 7 . doi: http://dx.doi.org/10.1080/0142159X.2017.1331031 .
http://dx.doi.org/10.1080/0142159X.2017.... , 6363. Holzhausen Y , Maaz A , Renz A , Bosch J , Peters H . How to define core entrustable professional activities for entry into residency? BMC Med Educ . 2018 ; 18 ( 1 ): 87 . doi: http://dx.doi.org/10.1186/s12909-018-1159-5 .
http://dx.doi.org/10.1186/s12909-018-115... . So, the time has come for Brazil to develop its own EPAs to better implement CBME, meeting their needs and social reality.

Acknowledgments

Ieda Francischetti expresses her gratitude to Prof. Dr. Harm Peters for the pot-doctorate orientation and opportunity to research at the Dieter Scheffner Center for Medical Education and Educational Research, Charité Universitätsmedizin Berlin, Berlin, Germany.

References

  • 1
    Brasil . Ministério da Educação . Resolução CNE/CES nº 4, de 7 de Novembro de 2001. Institui diretrizes curriculares nacionais do curso de graduação em medicina . Diário Oficial da União [ Internet ]. 9 Nov 2001 [ citado 3 Jun 2019 ]. Disponível em: http://portal.mec.gov.br/cne/arquivos/pdf/CES04.pdf
    » http://portal.mec.gov.br/cne/arquivos/pdf/CES04.pdf
  • 2
    Brasil . Ministério da Educação . Resolução CNE/CES nº 3, de 20 de Junho de 2014. Institui diretrizes curriculares nacionais do curso de graduação em medicina e dá outras providências . Diário Oficial da União [ Internet ]. 23 Jun 2014 [ citado 3 Jun 2019 ]. Disponível em: http://portal.mec.gov.br/index.php?option=com_docman&view=download&alias=15874-rces003-14&category_slug=junho-2014-pdf&Itemid=30192
    » http://portal.mec.gov.br/index.php?option=com_docman&view=download&alias=15874-rces003-14&category_slug=junho-2014-pdf&Itemid=30192
  • 3
    Brasil . Presidência da República . Lei nº 12.871, de 22 de Outubro de 2013. Institui o Programa Mais Médicos, altera as Leis nº 8.745, de 9 de Dezembro de 1993, e nº 6.932, de 7 de Julho de 1981, e dá outras providências . Diário Oficial da União [ Internet ]. 2 Out 2013 [ citado 3 Jun 2019 ]. Disponível em: http://pesquisa.in.gov.br/imprensa/jsp/visualiza/index.jsp?jornal=1&pagina=1&data=23/10/2013
    » http://pesquisa.in.gov.br/imprensa/jsp/visualiza/index.jsp?jornal=1&pagina=1&data=23/10/2013
  • 4
    Oliveira NA , Meirelles RMS , Cury GC , Alves LA . Mudanças curriculares no ensino médico brasileiro: um debate crucial no contexto do Promed . Rev Bras Educ Med 2008 ; 32 ( 3 ): 333 - 46 .
  • 5
    Brasil . Ministério da Saúde . Ministério da Educação . Portaria Interministerial nº 610, de 26 de Março de 2002. Institui o Programa Nacional de Incentivo às Mudanças Curriculares para as Escolas Médicas . Diário Oficial da União [ Internet ]. 1 Abr 2002 [ citado 3 Jun 2019 ]. Disponível em: https://www.jusbrasil.com.br/diarios/496301/pg-75-secao-1-diario-oficial-da-uniao-dou-de-01-04-2002
    » https://www.jusbrasil.com.br/diarios/496301/pg-75-secao-1-diario-oficial-da-uniao-dou-de-01-04-2002
  • 6
    Brasil . Ministério da Saúde . Ministério da Educação . Portaria Interministerial nº 2.101, de 3 de Novembro de 2005. Institui o Programa Nacional de Reorientação da Formação Profissional em Saúde (Pró-Saúde) para os cursos de Medicina, Enfermagem e Odontologia . Diário Oficial da União [ Internet ]. 3 Nov 2005 . [ citado 3 Jun 2019 ]. Disponível em: http://www.lex.com.br/doc_541196_PORTARIA_INTERMINISTERIAL_N_2101_DE_3_DE_NOVEMBRO_DE_2005.aspx
    » http://www.lex.com.br/doc_541196_PORTARIA_INTERMINISTERIAL_N_2101_DE_3_DE_NOVEMBRO_DE_2005.aspx
  • 7
    Brasil . Ministério da Saúde . Programa Nacional de Reorientação da Formação Profissional em Saúde (Pró-Saúde): objetivos, implementação e desenvolvimento potencial [ Internet ]. Brasília : Ministério da Saúde ; 2009 [ citado 3 Jun 2019 ]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/programa_nacional_reorientacao_profissional_saude.pdf
    » http://bvsms.saude.gov.br/bvs/publicacoes/programa_nacional_reorientacao_profissional_saude.pdf
  • 8
    Scheffer M , coordenador . Demografia médica no Brasil 2018 . São Paulo : Faculdade de Medicina, Universidade de São Paulo ; 2018 .
  • 9
    Escolas Médicas do Brasil . Estatísticas nacionais [ Internet ]. 2007 [ citado 3 Jun 2019 ]. Disponível em: https://www.escolasmedicas.com.br/estatisticas-nacionais.php
    » https://www.escolasmedicas.com.br/estatisticas-nacionais.php
  • 10
    Lopes AC . A explosão numérica das escolas médicas brasileiras . Educ Med . 2018 ; 19 Suppl 1 : 19 - 24 . doi: https://dx.doi.org/10.1016/j.edumed.2018.03.004
    » https://dx.doi.org/10.1016/j.edumed.2018.03.004
  • 11
    Amaral E , Domingues RCL , Zeferino AMB . Avaliando a competência clínica: o método de avaliação estruturada observacional . Rev Bras Educ Med . 2007 ; 31 ( 3 ): 287 - 90 . doi: https://dx.doi.org/10.1590/S0100-55022007000300011 .
    » https://dx.doi.org/10.1590/S0100-55022007000300011
  • 12
    Braccialli LAD , Oliveira MAC . Desafios na formação médica: a contribuição da avaliação . Rev Bras Educ Med . 2012 ; 36 ( 2 ): 280 - 8 . doi: https://dx.doi.org/10.1590/S0100-55022012000400018 .
    » https://dx.doi.org/10.1590/S0100-55022012000400018
  • 13
    ten Cate O , Chen HC , Hoff RG , Peters H , Bok H , van der Schaaf M . Curriculum development for the workplace using Entrustable Professional Activities (EPAs): AMEE Guide No. 99 . Med Teach . 2015 ; 37 ( 11 ): 983 - 1002 . doi: https://dx.doi.org/10.3109/0142159X.2015.1060308 .
    » https://dx.doi.org/10.3109/0142159X.2015.1060308
  • 14
    ten Cate O , Graafmans L , Posthumus I , Welink L , van Dijk M . The EPA-based Utrecht undergraduate clinical curriculum: development and implementation . Med Teach . 2018 ; 40 ( 5 ): 506 - 13 . doi: https://dx.doi.org/10.1080/0142159X.2018.1435856 .
    » https://dx.doi.org/10.1080/0142159X.2018.1435856
  • 15
    Chen HC , van den Broek WE , ten Cate O . The case for use of entrustable professional activities in undergraduate medical education . Acad Med . 2015 ; 90 ( 4 ): 431 - 6 . doi: https://dx.doi.org/10.1097/ACM.0000000000000586 .
    » https://dx.doi.org/10.1097/ACM.0000000000000586
  • 16
    Lomis K , Amiel JM , Ryan MS , Esposito K , Green M , Stagnaro-Green A , et al . Implementing an entrustable professional activities framework in undergraduate medical education: early lessons from the AAMC Core Entrustable Professional Activities for Entering Residency Pilot . Acad Med . 2017 ; 92 ( 6 ): 765 - 70 . doi: https://dx.doi.org/10.1097/ACM.0000000000001543 .
    » https://dx.doi.org/10.1097/ACM.0000000000001543
  • 17
    Touchie C , Boucher A , Allen T , Bhanji F , Chan M-K , Clarizia N , et al . AFMC Entrustable Professional Activities for the Transition from Medical School to Residency . Ottawa : Association of Faculties of Medicine of Canada ; 2016 .
  • 18
    Gutiérrez-Barreto S , Durán-Pérez VD , Flores-Morones F , Esqueda-Nuñez RI , Sánchez-Mojica CA , Hamui-Sutton A . Importance of context in entrustable professional activities on surgical undergraduate medical education . Med Ed Publish . 2018 . doi: https://dx.doi.org/10.15694/mep.2018.0000109.1 .
    » https://dx.doi.org/10.15694/mep.2018.0000109.1
  • 19
    Obeso V , Brown D , Aiyer M , Barron B , Bull J , Carter T , et al . Toolkits for the 13 core entrustable professional activities for entering residency . Washington : Association of American Medical Colleges ; 2017 .
  • 20
    Carraccio C , Wolfsthal SD , Englander R , Ferentz K , Martin C . Shifting paradigms: from Flexner to competencies . Acad Med . 2002 ; 77 ( 5 ): 361 - 7 .
  • 21
    Lampert JB . Tendências de mudanças na formação médica no Brasil [ tese ]. Rio de Janeiro : Escola Nacional de Saúde Pública Sérgio Arouca ; 2002 .
  • 22
    Aguiar AC , Ribeiro ECO . Conceito e avaliação de habilidades e competência na educação médica: percepções atuais dos especialistas . Rev Bras Educ Med . 2010 ; 34 ( 3 ): 371 - 8 . doi: https://dx.doi.org/10.1590/S0100-55022010000300006 .
    » https://dx.doi.org/10.1590/S0100-55022010000300006
  • 23
    Sá P , Paixão F . Contributos para a clarificação do conceito de competência numa perspetiva integrada e sistémica . Rev Port Educ . 2013 ; 26 ( 1 ): 87 - 114 .
  • 24
    Moreira MA . Aprendizagem significativa . Brasília : Editora UnB ; 1999 .
  • 25
    Lima VV . Competência: distintas abordagens e implicações na formação de profissionais de saúde . Interface (Botucatu) . 2005 ; 9 ( 17 ): 369 - 79 . doi: http://dx.doi.org/10.1590/S1414-32832005000200012 .
    » http://dx.doi.org/10.1590/S1414-32832005000200012
  • 26
    Tsuji H , Aguilar-da-Silva RH . Currículo integrado por Competências Profissionais: reflexão sobre o trabalho desenvolvido na Faculdade de Medicina de Marília (Famema) [ Internet ]. Marília : Famema ; 2006 [ citado 17 Set 2019 ]. Disponível em: http://gestaouniversitaria.com.br/artigos/curriculo-integrado-por-competencias-profissionais
    » http://gestaouniversitaria.com.br/artigos/curriculo-integrado-por-competencias-profissionais
  • 27
    Perrenoud P . Avaliação: da excelência à regulação das aprendizagens: entre duas lógicas . Porto Alegre : Artmed ; 1999 .
  • 28
    Epstein RM , Hundert EM . Defining and assessing professional competence . JAMA . 2002 ; 287 ( 2 ): 226 - 35 . doi: http://dx.doi.org/10.1001/JAMA.287.2.226 .
    » http://dx.doi.org/10.1001/JAMA.287.2.226
  • 29
    Frank JR , Snell L , Sherbino J , editors . CanMEDS 2015 physician competency framework [ Internet ]. Ottawa : Royal College of Physicians and Surgeons of Canada ; 2015 [ citado 5 Jun 2019 ]. Disponível em: http://canmeds.royalcollege.ca/uploads/en/framework/CanMEDS%202015%20Framework_EN_Reduced.pdf
    » http://canmeds.royalcollege.ca/uploads/en/framework/CanMEDS%202015%20Framework_EN_Reduced.pdf
  • 30
    Frank JR , Snell LS , Cate OT , Holmboe ES , Carraccio C , Swing SR , et al . Competency-based medical education: theory to practice . Med Teach . 2010 ; 32 ( 8 ): 638 - 45 . doi: http://dx.doi.org/10.3109/0142159X.2010.501190 .
    » http://dx.doi.org/10.3109/0142159X.2010.501190
  • 31
    Harden RM . Outcome-based education - the ostrich, the peacock and the beaver . Med Teach . 2007 ; 29 ( 7 ): 666 - 71 . doi: http://dx.doi.org/10.1080/01421590701729948 .
    » http://dx.doi.org/10.1080/01421590701729948
  • 32
    Gonczi A . Competency-based approaches: linking theory and practice in professional education with particular reference to health education . Educ Philos Theory . 2013 ; 45 ( 12 ): 1290 - 306 . doi: http://dx.doi.org/10.1080/00131857.2013.763590 .
    » http://dx.doi.org/10.1080/00131857.2013.763590
  • 33
    Lingard L . What we see and don’t see when we look at ‘competence’: notes on a god term . Adv Health Sci Educ Theory Pract . 2009 ; 14 ( 5 ): 625 - 8 . doi: http://dx.doi.org/10.1007/s10459-009-9206-y .
    » http://dx.doi.org/10.1007/s10459-009-9206-y
  • 34
    ten Cate O . Entrustability of professional activities and competency-based training . Med Educ . 2005 ; 39 ( 12 ): 1176 - 7 . doi: http://dx.doi.org/10.1111/J.1365-2929.2005.02341.X .
    » http://dx.doi.org/10.1111/J.1365-2929.2005.02341.X
  • 35
    Zibrowski EM , Singh SI , Goldszmidt MA , Watling CJ , Kenyon CF , Schulz V , et al . The sum of the parts detracts from the intended whole: competencies and in-training assessments . Med Educ . 2009 ; 43 ( 8 ): 741 - 8 . doi: http://dx.doi.org/10.1111/j.1365-2923.2009.03404.x .
    » http://dx.doi.org/10.1111/j.1365-2923.2009.03404.x
  • 36
    Touchie C , ten Cate O . The promise, perils, problems and progress of competency-based medical education . Med Educ . 2016 ; 50 ( 1 ): 93 - 100 . doi: http://dx.doi.org/10.1111/medu.12839 .
    » http://dx.doi.org/10.1111/medu.12839
  • 37
    ten Cate O . A primer on entrustable professional activities . Korean J Med Educ . 2018 ; 30 ( 1 ): 1 - 10 . doi: http://dx.doi.org/10.3946/kjme.2018.76 .
    » http://dx.doi.org/10.3946/kjme.2018.76
  • 38
    ten Cate O , Scheele F . Competency-based postgraduate training: can we bridge the gap between theory and clinical practice? Acad Med . 2007 ; 82 ( 6 ): 542 - 7 .
  • 39
    Abdalla IG , Stella RCR , Perim GL , Aguilar-da-Silva RH , Lampert JB , Costa NMSC . Projeto pedagógico e as mudanças na educação médica . Rev Bras Educ Med . 2009 ; 33 Suppl 1 : 44 - 52 . doi: http://dx.doi.org/10.1590/S0100-55022009000500005 .
    » http://dx.doi.org/10.1590/S0100-55022009000500005
  • 40
    Perim GL , Abdalla IG , Aguilar-da-Silva RH , Lampert JB , Stella RCR , Costa NMSC . Desenvolvimento docente e a formação de médicos . Rev Bras Educ Med . 2009 ; 33 Suppl 1 : 70 - 82 . doi: http://dx.doi.org/10.1590/S0100-55022009000500008 .
    » http://dx.doi.org/10.1590/S0100-55022009000500008
  • 41
    Gontijo ED , Alvim C , Megale L , Melo JRC , Lima MECC . Matriz de competências essenciais para a formação e avaliação de desempenho de estudantes de medicina . Rev Bras Educ Med . 2013 ; 37 ( 4 ): 526 - 39 . doi: http://dx.doi.org/10.1590/S0100-55022013000400008 .
    » http://dx.doi.org/10.1590/S0100-55022013000400008
  • 42
    Associação Brasileira de Educação Médica . Novas Diretrizes Curriculares Nacionais para a Medicina: avanços e desafios . Cad Abem . 2015 ; 11 : 1 - 67 .
  • 43
    Domingues RCL , Amaral E , Zeferino AMB , Antonio MAGM , Nadruz W . Competência clínica de aluno de Medicina em estágio clínico: comparação entre métodos de avaliação . Rev Bras Educ Med . 2010 ; 34 ( 1 ): 124 - 31 . doi: http://dx.doi.org/10.1590/S0100-55022010000100015 .
    » http://dx.doi.org/10.1590/S0100-55022010000100015
  • 44
    Englander R , Flynn T , Call S , Carraccio C , Cleary L , Fulton TB , et al . Toward defining the foundation of the MD degree: core entrustable professional activities for entering residency . Acad Med . 2016 ; 91 ( 10 ): 1352 - 8 . Doi: http://dx.doi.org/10.1097/ACM.0000000000001204 .
    » http://dx.doi.org/10.1097/ACM.0000000000001204
  • 45
    Favreau MA , Tewksbury L , Lupi C , Cutrer WB , Jokela JA , Yarris LM , et al . Constructing a shared mental model for faculty development for the core entrustable professional activities for entering residency . Acad Med . 2017 ; 92 ( 6 ): 759 - 64 . doi: http://dx.doi.org/10.1097/ACM.0000000000001511 .
    » http://dx.doi.org/10.1097/ACM.0000000000001511
  • 46
    Michaud PA , Jucker-Kupper P , The Profiles Working Group . The “Profiles” document: a modern revision of the objectives of undergraduate medical studies in Switzerland . Swiss Med Wkly . 2016 ; 146 : w14270 . doi: http://dx.doi.org/10.4414/smw.2016.14270 .
    » http://dx.doi.org/10.4414/smw.2016.14270
  • 47
    Meyer EG , Chen HC , Uijtdehaage S , Durning SJ , Maggio LA . Scoping review of entrustable professional activities in undergraduate medical education . Acad Med . 2019 ; 94 ( 7 ): 1040 - 9 . doi: http://dx.doi.org/10.1097/ACM.0000000000002735 .
    » http://dx.doi.org/10.1097/ACM.0000000000002735
  • 48
    Tapia AER , Maldonado MI , Domínguez LD , Casallas JCG , Jara NP , Diaz MM , et al . Sequencing Entrustable Professional Activities through a whole-task model for instructional design: an early experience in a Latin-American medical school . In: AMEE Annual Conference ; 2019 ; Viena, Austria . Viena : International Association for Medical Education ; 2019 [ citado 5 Jun 2019 ]. Disponível em: https://amee.org/getattachment/Conferences/AMEE-2019/AMEE-2019-APP-Data-PDFs/7H-Short-Communications-Curriculum-Entrustable-Professional-Activities- (EPAs).pdf
    » https://amee.org/getattachment/Conferences/AMEE-2019/AMEE-2019-APP-Data-PDFs/7H-Short-Communications-Curriculum-Entrustable-Professional-Activities- (EPAs).pdf
  • 49
    Dieguez MG , Durante E , Giannasi S , Arceo D , Eder ML , Figari M . Using Entrustable Professional Activities (EPAs) as curriculum organizers in a major medical undergraduate curriculum renewal . In: AMEE Annual Conference ; 2019 ; Viena, Austria . Viena : International Association for Medical Education ; 2019 . [ citado 5 Jun 2019 ]. Disponível em: https://amee.org/getattachment/Conferences/AMEE-2019/AMEE-2019-APP-Data-PDFs/7H-Short-Communications-Curriculum-Entrustable-Professional-Activities- (EPAs).pdf
    » https://amee.org/getattachment/Conferences/AMEE-2019/AMEE-2019-APP-Data-PDFs/7H-Short-Communications-Curriculum-Entrustable-Professional-Activities- (EPAs).pdf
  • 50
    ten Cate O , Snell L , Carraccio C . Medical competence: the interplay between individual ability and the health care environment . Med Teach . 2010 ; 32 ( 8 ): 669 - 75 . doi: http://dx.doi.org/10.3109/0142159X.2010.500897 .
    » http://dx.doi.org/10.3109/0142159X.2010.500897
  • 51
    Sterkenburg A , Barach P , Kalkman C , Gielen M , ten Cate O . When do supervising physicians decide to entrust residents with unsupervised tasks? Acad Med . 2010 ; 85 ( 9 ): 1408 - 17 . doi: http://dx.doi.org/10.1097/ACM.0b013e3181eab0ec .
    » http://dx.doi.org/10.1097/ACM.0b013e3181eab0ec
  • 52
    ten Cate O . Entrustment as assessment: recognizing the ability, the right, and the duty to act . J Grad Med Educ . 2016 ; 8 ( 2 ): 261 - 2 . doi: http://dx.doi.org/10.4300/JGME-D-16-00097.1 .
    » http://dx.doi.org/10.4300/JGME-D-16-00097.1
  • 53
    Carraccio C , Burke AE . Beyond competencies and milestones: adding meaning through context . J Grad Med Educ . 2010 ; 2 ( 3 ): 419 - 22 . doi: http://dx.doi.org/10.4300/JGME-D-10-00127.1 .
    » http://dx.doi.org/10.4300/JGME-D-10-00127.1
  • 54
    ten Cate O . Trust, competence, and the supervisor’s role in postgraduate training . BMJ . 2006 ; 333 ( 7571 ): 748 - 51 . doi: http://dx.doi.org/10.1136/bmj.38938.407569.94 .
    » http://dx.doi.org/10.1136/bmj.38938.407569.94
  • 55
    The Association of Faculties of Medicine of Canada . Entrustable professional activities for the transition from medical school to residency [ Internet ]. Ottawa : AFMC ; 2016 [ citado 5 Jun 2019 ]. Disponível em: https://afmc.ca/sites/default/files/documents/AFMC_Entrustable_Professional_Activities_EN_0.pdf
    » https://afmc.ca/sites/default/files/documents/AFMC_Entrustable_Professional_Activities_EN_0.pdf
  • 56
    Holzhausen Y , Maaz A , Renz A , Bosch J , Peters H . Development of Entrustable Professional Activities for entry into residency at the Charité Berlin . GMS J Med Educ . 2019 ; 36 ( 1 ): Doc5 . doi: http://dx.doi.org/10.3205/zma001213 .
    » http://dx.doi.org/10.3205/zma001213
  • 57
    ten Cate O . Nuts and bolts of entrustable professional activities . J Grad Med Educ . 2013 ; 5 ( 1 ): 157 - 8 . doi: http://dx.doi.org/10.4300/JGME-D-12-00380.1 .
    » http://dx.doi.org/10.4300/JGME-D-12-00380.1
  • 58
    Peters H , Holzhausen Y , Boscardin C , ten Cate O , Chen HC . Twelve tips for the implementation of EPAs for assessment and entrustment decisions . Med Teach . 2017 ; 39 ( 8 ): 802 - 7 . doi: http://dx.doi.org/10.1080/0142159X.2017.1331031 .
    » http://dx.doi.org/10.1080/0142159X.2017.1331031
  • 59
    Wijnen-Meijer M , Van der Schaaf M , Booij E , Harendza S , Boscardin C , Van Wijngaarden J , et al . An argument-based approach to the validation of UHTRUST: can we measure how recent graduates can be trusted with unfamiliar tasks? Adv Health Sci Educ Theory Pract. 2013 ; 18 ( 5 ): 1009 - 27 . doi: http://dx.doi.org/10.1007/s10459-013-9444-x .
    » http://dx.doi.org/10.1007/s10459-013-9444-x
  • 60
    ten Cate O , Hoff RG . From case-based to entrustment-based discussions . Clin Teach . 2017 ; 14 ( 6 ): 385 - 9 . doi: http://dx.doi.org/10.1111/tct.12710 .
    » http://dx.doi.org/10.1111/tct.12710
  • 61
    Brasil . Ministério da Saúde . Política Nacional de Educação Permanente em Saúde . Brasília : Ministério da Saúde ; 2009 .
  • 62
    Francischetti I , Peters H . Definição de atividades profissionais confiáveis para acesso à residência médica como melhor forma de traduzir para a prática a educação médica baseda em competência [ bolsa exterior-pesquisa ] [ Internet ]. Marília : Faculdade de Medicina de Marília , Berlin : Charité Universitätsmedizin Berlin ; 2019 [ citado 5 Jun 2019 ]. Disponível em: https://bv.fapesp.br/pt/bolsas/184598
    » https://bv.fapesp.br/pt/bolsas/184598
  • 63
    Holzhausen Y , Maaz A , Renz A , Bosch J , Peters H . How to define core entrustable professional activities for entry into residency? BMC Med Educ . 2018 ; 18 ( 1 ): 87 . doi: http://dx.doi.org/10.1186/s12909-018-1159-5 .
    » http://dx.doi.org/10.1186/s12909-018-1159-5

  • *
    This article received financial support from the Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), from the research project under process number 2018 / 26011-2.

Publication Dates

  • Publication in this collection
    16 Mar 2020
  • Date of issue
    2020

History

  • Received
    23 July 2019
  • Accepted
    26 Nov 2019
Creative Common - by 4.0
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
UNESP Botucatu - SP - Brazil
E-mail: intface@fmb.unesp.br
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