EPAs, Competencies, Subcompetencies, and Milestones

Entrustable Professional Activities for Family Medicine

What Are EPAs?
As part of the strategic planning process of Family Medicine for America’s Health, entrustable professional activities (EPAs) were developed for the discipline of family medicine relating to residency completion. Evidence for improved health outcomes, healthcare system efficiency, and equity in care were used to develop these EPAs.

EPAs are broad categories of activities that define the essential professional work of a discipline. With regard to residency training, EPAs define the expectations for the education of family physicians. EPAs integrate all of the core competencies, subcompetencies, and their specific milestones.

EPAs define the knowledge, skills, attitudes and behaviors that each family medicine resident physician must master. Additionally, physicians in osteopathic designated residencies will incorporate the utilization of osteopathic principles and practice in their overall evaluation and treatment of patients. Each resident physician must be able to perform each activity without supervision before graduation from a family medicine residency training program. Family Medicine educators must ensure that systems of assessment align with the expectations of the future activities of the trainees.

For Family Medicine, the EPAs collectively define a type of care that the residency graduate can be trusted to deliver to the public. It is understood that some graduates of family medicine residency programs will not practice the breadth described in these EPAs. Through such comprehensive training, the goal for the discipline is for more family physicians, rather than fewer, and for the majority of family physicians, rather than some, to practice this breadth.

Entrustable Professional Activities for Family Medicine:

1. Provide a usual source of comprehensive, longitudinal medical care for people of all ages.
2. Care for patients and families in multiple settings.
3. Provide first-contact access to care for health issues and medical problems.
4. Provide preventive care that improves wellness, modifies risk factors for illness and injury, and detects illness in early, treatable stages.
5. Provide care that speeds recovery from illness and improves function.
6. Evaluate and manage undifferentiated symptoms and complex conditions.
7. Diagnose and manage chronic medical conditions and multiple co-morbidities.
8. Diagnose and manage mental health conditions.
9. Diagnose and manage acute illness and injury.
10. Perform common procedures in the outpatient or inpatient setting.
11. Manage prenatal, labor, delivery and post-partum care.
12. Manage end-of-life and palliative care.
13. Manage inpatient care, discharge planning, transitions of care.
14. Manage care for patients with medical emergencies.
15. Develop trusting relationships and sustained partnerships with patients, families and communities.
16. Use data to optimize the care of individuals, families and populations.
17. In the context of culture and health beliefs of patients and families, use the best science to set mutual health goals and provide services most likely to benefit health.
18. Advocate for patients, families and communities to optimize health care equity and minimize health outcome disparities.
19. Provide leadership within interprofessional health care teams.
20. Coordinate care and evaluate specialty consultation as the condition of the patient requires.

Sources

1. The 7 essential functions of primary care that improve outcomes and access, and lower costs. (Starfield 2004-2005)
2. The Joint Principles of the Patient-Centered Medical Home (2007)
3. The benefits of implementing PCMH (PCPCC 2010, 2012)
4. The clinical epidemiology definition of the three levels of prevention
5. The role definition of the family physician FFM 2.0

See the Entrustable Professional Activities page within the Residency Accreditation Toolkit for additional FAQs about EPAs. 

ACGME Competencies

"The Accreditation Council for Graduate Medical Education US’ graduate medical education programs foster resident physicians’ development of competencies in six domains and collect performance data that reliably and accurately depicts residents’ ability to care for patients and to work effectively in healthcare delivery systems."¹

Patient Care
Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.

Medical Knowledge
Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care.

Practice-Based Learning and Improvement
Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning.

Interpersonal and Communication Skills
Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals.

Professionalism
Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.

Systems-Based Practice
Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.

See the Milestones & Resident Assessment page within the Residency Accreditation Toolkit for additional FAQs about Competencies.

1. Swing SR. 2007. The ACGME outcomes project: Retrospective and prospective. Med Teach 29(7):648–654.

ACGME Milestones

Each subcompetency has five Milestone levels, which represent the resident education process and graduation into independent practice. According to the ACGME, the definition of each level is as follows:

• Level 1: The resident demonstrates some of the behaviors or skills that would be expected of someone with some education in family medicine
• Level 2: The resident demonstrates increased achievement of expected behaviors or skills.
• Level 3: The resident continues to advance with further achievement of behaviors or skills, and has achieved most of the milestones expected for residency graduation.
• Level 4: The resident has achieved all of the milestones expected for residency graduation.
• Level 5: Describes an "expert resident" who has performed at a level beyond expectations.

See the Milestones & Resident Assessment page within the Residency Accreditation Toolkit for additional guidance about assessments using ACGME Milestones.