Importance of context in entrustable professional activities on surgical undergraduate medical education

Objective: The aim of this study was to emphasize the importance of integrating the context to the construction of the specific Entrustable Professional Activities (EPA) for Undergraduate Medical Education (UME). Design: Mixed study with three phases: 1) Exploratory, we searched context with focus groups technique. 2) Construction, we analyzed academic program of our faculty and the national epidemiology. Therefore, we selected the contents and generated each EPA with its milestones and competence levels. 3) Implementation, we conformed a formative assessment tool which was tested at surgery rotation. Setting: We worked with 10 public and private health institutions of secondary and tertiary health care levels which were used as clinical settings for surgery rotation of fifth year medicine course at the Faculty of Medicine of Universidad Nacional Autónoma de México in Mexico City. Participants: In exploratory focus groups, were involved 10 surgeons and 12 medical students. At implementation 64 students participated and 25 gave feedback. All participants were involved voluntary for this study. Results: We constructed eleven surgery specific EPAs for UME, within specific context of the clinical environment of our faculty. Conclusions: We propose these EPAs because they reflected the most important topics or diseases in our country and as educative developers we support the idea that our graduates should be able to attend the population needs of health.


Introduction
The competency based education is a global trend for medical education and other disciplines, the Accreditation Council for Graduate Medical Education (ACGME) in the Outcome Project (Swing, 2007) identified six domains of general competencies for the medical education. Years later ACGME developed the "Milestone Project" (Nasca, Philibert, Brigham, & Flynn, 2012) for the postgraduate medical programs, these milestones contain behavioral descriptors for the competencies of each specialty or subspecialty. A milestone is "a point along a continuum of a competency or subcompetency: milestones are clearly described and are usually specialty specific" (Klink, Holmboe, & Carraccio, 2015). Later the concept of Entrustable Professional Activities (EPA) was described by Ten Cate(O. Ten Cate, 2005), to integrate the competencies by linking them with a specific clinical event, and allow their assessment.
The tendency of developing EPAs for medical students, at the beginning was exclusive for residents of different specialties, but also it is useful and could be applied for Undergraduate Medical Education (UME). Chen et al (Chen, van den Broek, & ten , proposed three types of EPA for UME; core basic EPAs, core specialtyspecific EPAs and individual elective EPAs. Ten Cate explained EPAs are "units of professional practice, defined as tasks or responsibilities to be entrusted to the unsupervised execution" (O. Ten Cate, 2005). For UME, we cannot expect the full entrustment for unsupervised activities. Therefore, we reviewed the Dreyfus model of skill acquisition (Dreyfus & Dreyfus, 1980), we identified that students can reach the "competent" performance level when they achieve the MD degree. The EPAs' use in UME serves to: encourage the students to achieve certain performance level in the clinical competences, increase their motivation, promote an objective assessment at the workplace.
Thus, we consider the opportunity to develop EPAs for early years of medical training to support the continuum of medical education. In a previous study Hamui et al propose the methodology for the development of core specialtyspecific EPA (Hamui-Sutton et al., 2017), in this article we describe the General Surgery (GS) specific EPAs at UME. To develop a EPA the context is important, Ten Cate specifies EPAs' attributes, one of them is "are part of essential professional work in given context" (O. Ten Cate, 2005). The context has many variables: health care system, institutional culture, clinical settings, operative program, academic program, educational organization, hidden curriculum, epidemiology, among others. We contextualized the general surgery specific EPAs for UME in Mexican context. The aim of this study focus on context relevance and its variables for constructing EPAs and the use of analyzing the context to adoption of EPAs by other institution or country for UME.

Methods
A mixed method study was performed with three phases: 1) Exploratory, 2) Construction, 3) Implementation, with different settings, we will describe each one in the next paragraphs.

Exploratory
This was a qualitative phase, in individual sessions were four focus groups performed with medical students (12) and professors (10), the sessions were audio-recorded and literally transcribed to categorize and classified the testimonies with a priori construct, using grounded theory.

Construction
Gutiérrez-Barreto S, Durán-Pérez V, Flores-Morones F, Esqueda-Nuñez R, Sánchez-Mojica C, Hamui-Sutton A MedEdPublish https://doi.org/10.15694/mep.2018.0000109.1 Page | 3 The triangulation of the information was the next step to construct the EPA we use the next documents: analysis of the previous focus groups, academic program for the fifth-year, hospital's program of surgical clerkship (operative program) and the university program (Facultad de Medicina, 2009), ACGME core competencies and surgery milestones, our national epidemiological profile, and the Dreyfus (Dreyfus, 2004) first three levels. The work team were integrated by three medical education experts, one surgeon and two medical students, who initially developed five EPA. For the validation of content, we used a modified Delphi technique (Varela-Ruiz, Díaz-Bravo, & García-Durán, 2012) with six surgeons of five different hospitals and the comments generated made the team members reconstruct the five EPA to eight.

Implementation
For the implementation, we used a printed version of the eight EPA for students in 10 hospitals and for two months we visit each week in the surgery rotation, for any doubts and for data collect. In the final week, we gather all the printed EPA and perform a qualitative and quantitate assessment of the quality of the content and the usability in their hospitals with the professors and students. Once with all the data analyzed we reconstructed the EPA and finally ended with 11 for the surgery rotation.
Contextual variables in addition to those mentioned above were used in each phase such as the clinical settings for surgical clerkship: Consulting Room (CR), Emergency Room (ER), Hospitalization (H) and Operating Room (OR), the competence of the ACGME that is developed during the realization of the EPA this data set is shown in the appendix.
This work is registered with number 033-2013 before the Ethics and Investigation Committee of the UNAM Medicine School. Consent was obtained from participants. This work has been developed in 2016 and the delay of publication is becaouse the lack of time.

Results
For all the construction of the eleven EPA-specific, we consider the Bloom taxonomy, the Dreyfus model, the national Guideline for clinical practice. The  Considering the place where EPA can be developed and assessed the milestones could be a guide for the student and the clinical professor because this could determinate the type of patient or disease and the level of competence that could be achieved in a specific environment. If we suggest the clinical settings to evaluate the EPA this can contribute to increase the number of assessments and feedbacks.

Discussion
The use of the focus groups works to know the reality in which the students and the clinical professors are placed and thus to realize a construction of EPA more attached to the possible reality. Chen et al used this first phase to know the relevance and adequacy of the levels of competence appropriate to the context in which students develop (Chen, McNamara, et al., 2015).
Epidemiology is an aspect that can be considered to know the relevance of diseases that are considered in each EPA it becomes relevant if you want to adopt or appropriate in other places where morbidity and mortality are different.
The interaction of these contextual variables for the application in real clinical situations allows to adapt the EPA to achieve a level of competence suitable for the students considering all variables making possible for their daily use.
We raise these variables in a specific context, however they are only some of which can be considered when

Conclusions
This specific -EPA for UME in surgery service could be applied in other contexts, for medical students at the same grade, but considering the faculty academic program topics, clinical settings, focus groups and the epidemiology of the diseases of the place where it could be used.