EPAs for the Ambulatory Internist in Translation: Findings from a Canadian Multi-Center Survey

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Rupal Shah
Lindsay Melvin
Rodrigo B Cavalcanti



Increased demand for outpatient care has made defining the role of ambulatory general internists an educational priority. Canadian residency programs are transitioning towards competency-based education, where learning goals are articulated as entrustable professional activities (EPAs). Engaging frontline internists in the validation of context-specific EPAs is important for implementation.


This study describes a consensus approach for developing EPAs for ambulatory general internal medicine (GIM) training and results of a Canada-wide survey seeking feedback from academic internists.


In 2016, we reviewed Royal College of Physicians and Surgeons of Canada GIM accreditation documents, and systematic literature search results for internal medicine ambulatory training objectives, to draft EPAs. EPAs were revised via expert consensus at the University of Toronto. A survey was distributed to Canadian academic internists to determine level of agreement on proposed EPAs. Consensus was defined as greater than 80% inter-rater agreement. Open-ended questions explored reasons for disagreements, which were reviewed independently by authors and iteratively organized into categories.


Eight EPAs were generated. Survey response rate was 24.9% (63/253). Consensus was achieved on all EPAs except obstetrical medicine (49/63, 77.8%). Reasons for disagreements reflected variable understanding of EPA concepts by respondents. Where understood well, disagreements fell into 3 main categories: (1) further training required, (2) not within internal medicine scope, and (3) implementation barriers.


Frontline academic physicians are pivotal in validating proposed EPAs. Disagreements were either content or concept related and recognizing these diverse perspectives can help clinician-educators predict and prepare for challenges with EPA implementation.

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