Constructing Approaches to Entrustable Professional Activity Development that Deliver Valid Descriptions of Professional Practice.

Issue: Entrustable Professional Activities (EPAs) describe the core tasks health professionals must be competent performing prior to promotion and/or moving into unsupervised practice. When used for learner assessment, they serve as gateways to increased responsibility and autonomy. It follows that identifying and describing EPAs is a high-stakes form of work analysis aiming to describe the core work of a profession. However, hasty creation and adoption of EPAs without rigorous attention to content threatens the quality of judgments subsequently made from using EPA-based assessment tools. There is a clear need for approaches to identify validity evidence for EPAs themselves prior to their deployment in workplace-based assessment. Evidence: For EPAs to realize their potential in health professions education, they must first be constructed to reflect accurately the work of that profession or specialty. If the EPAs fail to do so, they cannot predict a graduate's readiness for or future performance in professional practice. Evaluating the methods used for identification, description, and adoption of EPAs through a construct validity lens helps give leaders and stakeholders of EPA development confidence that the EPAs constructed are, in fact, an accurate representation of the profession's work. Implications: Application of a construct validity lens to EPA development impacts all five commonly followed steps in EPA development: selection of experts; identification of candidate EPAs; iterative revisions; evaluation of proposed EPAs; and formal adoption of EPAs into curricula. It allows curricular developers to avoid pitfalls, bias, and common mistakes. Further, construct validity evidence for EPA development provides assurance that the EPAs adopted are appropriate for use in workplace-based assessment and entrustment decision-making.

Clarifying essential terminology in entrustment.

With the rapid uptake of entrustable professional activties and entrustment decision-making as an approach in undergraduate and graduate education in medicine and other health professions, there is a risk of confusion in the use of new terminologies. The authors seek to clarify the use of many words related to the concept of entrustment, based on existing literature, with the aim to establish logical consistency in their use. The list of proposed definitions includes independence, autonomy, supervision, unsupervised practice, oversight, general and task-specific trustworthiness, trust, entrust(ment), entrustable professional activity, entrustment decision, entrustability, entrustment-supervision scale, retrospective and prospective entrustment-supervision scales, and entrustment-based discussion. The authors conclude that a shared understanding of the language around entrustment is critical to strengthen bridges among stages of training and practice, such as undergraduate medical education, graduate medical education, and continuing professional development. Shared language and understanding provide the foundation for consistency in interpretation and implementation across the educational continuum.

Approaches of anatomy teaching for seriously resource-deprived countries: A literature review.

Background: Teaching anatomy is an important but expensive part of the medical curriculum, potentially more than many countries can afford. In the search for efficient methods, cost-effectiveness is of utmost importance for such countries. The aim of this contribution is to provide a review of the literature on anatomy teaching methods, evaluating these for feasibility in resource-deprived countries. Methods: A literature review was carried out to identify distinct approaches to anatomy teaching published in the period 2000-2014, using the databases of PubMed, Wiley Online Library, Elsevier, HINARI, Springer, and ERIC. The approaches found were compared against their conceptual, operational, technical, and economic feasibility and Mayer's principles of effective instruction. Results: Our search yielded 432 papers that met the inclusion criteria. We identified 14 methods of teaching anatomy. Based on their conceptual feasibility, dissection and technology enhanced learning approaches appeared to have more benefits than others. Dissection has, besides benefits, many specific drawbacks. Lectures and peer teaching showed better technical and economic feasibility. Educational platforms, radiological imaging, and lectures showed the highest operational feasibility. Dissection and surgery were found to be less feasible with regard to operational, technical, and economic characteristics. Discussion: Based on our findings, the most important recommendations for anatomy teaching in seriously resource-deprived countries include a combination of complementary strategies in 3 different moments, lecturing at the beginning, using virtual learning environment (for self-study), and at the end, using demonstration through prosected specimens and radiological imaging. This provides reasonable insights in anatomy through both dead and living human bodies and their virtual representations.

How clinical supervisors develop trust in their trainees: a qualitative study.

CONTEXT: Clinical supervisors oversee trainees' performance while granting them increasing opportunities to work independently. Although the factors contributing to supervisors' trust in their trainees to conduct clinical work have been identified, how the development of trust is shaped by these factors remains less clear. OBJECTIVES: This study was designed to determine how supervisors develop and experience trust in resident (postgraduate years 2 and 3) trainees in the clinical workplace. METHODS: Internal medicine in-patient supervisors at two institutions were interviewed about the meaning and experience of developing trust in resident trainees. Transcribed data were coded and analysed using a phenomenographic approach. RESULTS: Forty-three supervisors participated. Supervisors characterised the meaning of trust from the perspectives of trainee competence and leadership or from their own perspective of needing to provide more or less supervision. Supervisors initially considered trust to be usually independent of prior knowledge of the resident, and then used sources of information about trust to develop their judgements of trust. Sources, which incorporated inference, included supervisors' comparisons with a standard, direct observation of the trainee as a team leader or care provider, and stakeholder input from team members, patients and families. Barriers against and accelerators to trust formation related to the resident, supervisor, resident-supervisor relationship, context and task. Trust formation had implications for supervisors' roles, residents' increasingly independent provision of care, and team functioning. CONCLUSIONS: From a general starting point, supervisors develop trust in residents informed by observation, inference and information gathered from the team and patients. Judgements of trust yield outcomes defined by supervisors' changing roles, the increasingly independent provision of care by residents, and team functioning. The implications of these findings for graded resident autonomy aligned with learning needs can inform the design of training environments to enable readiness for unsupervised practice.

How Reliable are Single-Question Workplace-Based Assessments in Surgery?

OBJECTIVE: Workplace-based assessments (WBAs) play an important role in the assessment of surgical trainees. Because these assessment tools are utilized by a multitude of faculty, inter-rater reliability is important to consider when interpreting WBA data. Although there is evidence supporting the validity of many of these tools, inter-reliability evidence is lacking. This study aimed to evaluate the inter-rater reliability of multiple operative WBA tools utilized in general surgery residency. DESIGN: General surgery residents and teaching faculty were recorded during 6 general surgery operations. Nine faculty raters each reviewed 6 videos and rated each resident on performance (using the Society for Improving Medical Professional Learning, or SIMPL, Performance Scale as well as the operative performance rating system (OPRS) Scale), entrustment (using the ten Cate Entrustment-Supervision Scale), and autonomy (using the Zwisch Scale). The ratings were reviewed for inter-rater reliability using percent agreement and intraclass correlations. PARTICIPANTS: Nine faculty members viewed the videos and assigned ratings for multiple WBAs. RESULTS: Absolute intraclass correlation coefficients for each scale ranged from 0.33 to 0.47. CONCLUSIONS: All single-item WBA scales had low to moderate inter-rater reliability. While rater training may improve inter-rater reliability for single observations, many observations by many raters are needed to reliably assess trainee performance in the workplace.

Contradictions and Opportunities: Reconciling Professional Identity Formation and Competency-Based Medical Education.

The widespread adoption of Competency-Based Medical Education (CBME) has resulted in a more explicit focus on learners' abilities to effectively demonstrate achievement of the competencies required for safe and unsupervised practice. While CBME implementation has yielded many benefits, by focusing explicitly on what learners are doing, curricula may be unintentionally overlooking who learners are becoming (i.e., the formation of their professional identities). Integrating professional identity formation (PIF) into curricula has the potential to positively influence professionalism, well-being, and inclusivity; however, issues related to the definition, assessment, and operationalization of PIF have made it difficult to embed this curricular imperative into CBME. This paper aims to outline a path towards the reconciliation of PIF and CBME to better support the development of physicians that are best suited to meet the needs of society. To begin to reconcile CBME and PIF, this paper defines three contradictions that must and can be resolved, namely: (1) CBME attends to behavioral outcomes whereas PIF attends to developmental processes; (2) CBME emphasizes standardization whereas PIF emphasizes individualization; (3) CBME organizes assessment around observed competence whereas the assessment of PIF is inherently more holistic. Subsequently, the authors identify curricular opportunities to address these contradictions, such as incorporating process-based outcomes into curricula, recognizing the individualized and contextualized nature of competence, and incorporating guided self-assessment into coaching and mentorship programs. In addition, the authors highlight future research directions related to each contradiction with the goal of reconciling 'doing' and 'being' in medical education.

Medical Residents' Informal Learning from Pharmacists in the Clinical Workplace.

Workplace-based interactions between residents and pharmacists, though relatively underexplored, might contribute substantially to learning. This international study sought to investigate the affordances residents use for informal learning about medications, their interactions with pharmacists and patterns of resident-pharmacist engagement, as well as residents' perceived impact of these interactions on their learning. Contextual differences between US and Dutch residency training and electronic health record (EHR) may impact informal learning about medications. We conducted a cross-sectional, online, 25-item survey study, including closed-format and open-response questions among current resident physicians (post-graduate years 1-6, from a variety of residency programs n = 803) from the University of California San Francisco, the University of Minnesota, and the University Medical Center Utrecht. Responses from 173 residents in both countries revealed that these physician trainees were afforded opportunities to engage in a wide variety of pharmacotherapy-related activities but engaged differently with social and environmental resources for support. Residents from the United States (US) utilized pharmacists and Up-To-Date, whereas Dutch residents preferentially utilized the online Dutch medication information site and EHR-embedded medication resources. US residents interacted with pharmacists significantly more frequently than Dutch residents. Pharmacists provided residents with a wide range of useful information, much of which is integrated into the medication resources in the Dutch EHR-based decision-support system. While US residents reported overwhelmingly that informal interactions with pharmacists contribute to their learning about medications, Dutch residents' responses did not confirm this. Intentionally designing residents' training to include opportunities for interactions with pharmacists could potentially positively impact residents' informal workplace learning. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-023-01784-1.

Protocol for an extended scoping review on the use of virtual nominal group technique in research.

INTRODUCTION: Consensus group methods such as the Nominal Group Technique (NGT) and Delphi method are commonly used in research to elicit and synthesize expert opinions when evidence is lacking. Traditionally, the NGT involves a face-to-face interaction. However, due to the COVID-19 pandemic, many in-person meetings have moved to online settings. It is unclear to what extent the NGT has been undertaken in virtual settings. The overarching aim of this scoping review is to explore the use of the virtual NGT in research. Our specific objectives are to answer the following questions: To what extent has the NGT been used virtually? What modifications were made to accommodate this online format? What advantages and disadvantages were noted by authors in comparison with the face-to-face mode of the technique? MATERIALS AND METHODS: This scoping review will follow the steps outlined by Arksey and O'Malley and the PRISMA-ScR guidelines. Several pilot searches were completed to refine inclusion and exclusion criteria. Media Synchronicity Theory will provide a conceptual framework to inform the research, including data extraction and summarizing results. As an additional extension to the literature review, online interviews with corresponding authors will be conducted to gather further information.

How can Entrustable Professional Activities serve the quality of health care provision through licensing and certification?

This paper about Entrustable Professional Activities (EPAs) was solicited to support the discussion about the future of licensing within the Medical Council of Canada. EPAs, units of professional practice to be entrusted to learners or professionals once they have shown to possess sufficient competence, were proposed in 2005 to operationalize competency-based postgraduate medical education and have become widely popular for various health professions education programs in many countries. EPAs break the breadth of competence for license down to units of practice that can be overseen, assessed, monitored, documented, and entrusted. EPAs together may constitute an individual's portfolio of qualifications, and define a scope of practice. A medical license and a specialty certification can then be defined as the required combination of EPAs for which one is qualified at any specific moment in time. That 'snapshot' could change over time and reflect the professional development of the individual, both in their competence and in their privileges to practice. Micro-credentialing and digital badges might become an adequate option to show-case one's scope of practice at any time and operationalize the idea of a dynamic portfolio of EPAs.

Cet article sur les activités professionnelles confiables (APC) a été sollicité pour alimenter la discussion sur l'avenir du titre de licencié au sein du Conseil médical du Canada. En 2005, il a été proposé de se servir des APC, unités de pratique professionnelle qui peuvent être confiées aux apprenants ou aux professionnels une fois qu'ils ont démontré avoir le niveau de compétence nécessaire, pour opérationnaliser la formation médicale postdoctorale basée sur les compétences; depuis, elles sont devenues courantes dans les programmes de formation aux professions de la santé dans de nombreux pays.Les APC décomposent l'étendue des compétences pour l'obtention d'une licence en unités de pratique qui peuvent être supervisées, évaluées, contrôlées, documentées et confiées. Ensemble, les APC peuvent constituer le portfolio de qualifications d'un individu et définir un champ d'exercice. Le titre de licencié et le certificat de spécialité peuvent alors être définis comme représentant la combinaison d'APC qu'une personne est qualifiée à exercer à un moment donné. Ce «cliché instantané¼ peut changer au fil du temps, reflétant le développement professionnel de la personne, tant sur le plan de ses compétences que de ses privilèges d'exercice. Les micro-titres de compétences et le badge numérique pourraient devenir une option adéquate pour présenter à tout moment le champ de pratique d'un médecin et rendre opérationnelle l'idée d'un portfolio dynamique d'APC.

True Entrustment Decisions Regarding Entrustable Professional Activities Happen in the Workplace, not in the Classroom Setting.

Entrustable Professional Activities (EPAs) are workplace responsibilities that directly impact patient care. The use of EPAs allows pharmacy faculty and preceptors to provide learners with feedback and assessment in the clinical setting. Because they focus assessment on a learner's execution of professional activities which requires integration of the respective competencies, EPAs help provide a more holistic picture of a learner's performance. Using EPAs to backwards design classroom learning for those competencies is highly encouraged, but instructors cannot or should not assess performance and make entrustment decisions using EPAs in the classroom setting for several reasons: a learner's classroom performance usually does not predict clinical performance very well, assessment of EPAs require direct observation of the learner performing the EPAs, EPA assessment requires multiple observations of the learner with different patients with varying level of acuity, and most importantly, EPA assessment must result in a decision to trust the learner to perform the clinical activity with limited supervision. By ensuring all entrustment decisions are made in a clinical or experiential setting, students will receive an accurate assessment and benchmark of their performance that will lead them one step closer to becoming independent practitioners.

Effect of the new Bologna bachelor degree on career considerations of medical students in one medical school.

BACKGROUND: The bachelor-master (BaMa) structure was introduced in medical schools in The Netherlands since 2003 and in Utrecht University in 2006. AIM: The aim of this study was to determine whether conferring a bachelor degree at the end of 3 years of medical school influences the career considerations of the students. METHODS: Two cohorts (BaMa and pre-BaMa) of medical students at Utrecht University were approached to fill out questionnaires in 2008 and 2009, about their career plans and whether a bachelor degree would affect these plans. RESULTS: In 2008, two-thirds of the students in both cohorts indicated that they considered a temporary stop. In 2009, the BaMa cohort showed substantially less interest in such a stop than the pre-BaMa cohort. Very few students considered a permanent stop. Comparison of third year pre-BaMa students (2008 cohort) with third year BaMa students (2009 cohort) revealed adjusted odds ratios of 2.34 (95% CI 1.34-4.09) for a temporary stop and 1.33 (95% CI 0.51-3.42) for a definitive stop. CONCLUSION: Awarding a bachelor degree in the BaMa structure does not encourage students to interrupt or discontinue their medical study, to transfer to another master programme or to transfer to another medical school.

Competency-based continuing professional development.

Competence is traditionally viewed as the attainment of a static set of attributes rather than a dynamic process in which physicians continuously use their practice experiences to "progress in competence" toward the attainment of expertise. A competency-based continuing professional development (CPD) model is premised on a set of learning competencies that include the ability to (a) use practice information to identify learning priorities and to develop and monitor CPD plans; (b) access information sources for innovations in development and new evidence that may potentially be integrated into practice; (c) establish a personal knowledge management system to store and retrieve evidence and to select and manage learning projects; (d) construct questions, search for evidence, and record and track conclusions for practice; and (e) use tools and processes to measure competence and performance and develop action plans to enhance practice. Competency-based CPD emphasizes self-directed learning processes and promotes the role of assessment as a professional expectation and obligation. Various approaches to defining general competencies for practice require the creation of specific performance metrics to be meaningful and relevant to the lifelong learning strategies of physicians. This paper describes the assumptions, advantages, and challenges of establishing a CPD system focused on competencies that improve physician performance and the quality and safety of patient care. Implications for competency-based CPD are discussed from an individual and organizational perspective, and a model to bridge the transition from residency to practice is explored.

Competency-based medical education in postgraduate medical education.

With the introduction of Tomorrow's Doctors in 1993, medical education began the transition from a time- and process-based system to a competency-based training framework. Implementing competency-based training in postgraduate medical education poses many challenges but ultimately requires a demonstration that the learner is truly competent to progress in training or to the next phase of a professional career. Making this transition requires change at virtually all levels of postgraduate training. Key components of this change include the development of valid and reliable assessment tools such as work-based assessment using direct observation, frequent formative feedback, and learner self-directed assessment; active involvement of the learner in the educational process; and intensive faculty development that addresses curricular design and the assessment of competency.

Competency-based medical education: theory to practice.

Although competency-based medical education (CBME) has attracted renewed interest in recent years among educators and policy-makers in the health care professions, there is little agreement on many aspects of this paradigm. We convened a unique partnership - the International CBME Collaborators - to examine conceptual issues and current debates in CBME. We engaged in a multi-stage group process and held a consensus conference with the aim of reviewing the scholarly literature of competency-based medical education, identifying controversies in need of clarification, proposing definitions and concepts that could be useful to educators across many jurisdictions, and exploring future directions for this approach to preparing health professionals. In this paper, we describe the evolution of CBME from the outcomes movement in the 20th century to a renewed approach that, focused on accountability and curricular outcomes and organized around competencies, promotes greater learner-centredness and de-emphasizes time-based curricular design. In this paradigm, competence and related terms are redefined to emphasize their multi-dimensional, dynamic, developmental, and contextual nature. CBME therefore has significant implications for the planning of medical curricula and will have an important impact in reshaping the enterprise of medical education. We elaborate on this emerging CBME approach and its related concepts, and invite medical educators everywhere to enter into further dialogue about the promise and the potential perils of competency-based medical curricula for the 21st century.

A Mobile Learning Module to Support Interprofessional Knowledge Construction in the Health Professions.

Objective. To develop and evaluate a mobile learning module to support knowledge construction between medical and pharmacy students through structured dialogue prompts. Methods. Rheumatologists and pharmacists collaboratively developed a two-week, case-based, asynchronous interprofessional learning module that was delivered via a mobile app and focused on collaborative medication management of a complex case involving a patient with systemic lupus erythematosus. The clinical case evolved over three phases: diagnosis, initial treatment, and medication-related complications. Dialogue prompts were incorporated in each phase as a mechanism to support knowledge construction among learners. Pharmacy and medical student pairs were randomized to receive either high guidance or low guidance prompts for collaborative learning. The student pairs worked together, asynchronously, online, to develop three collaborative care plans. The evaluation of the learning module to support knowledge construction included: analysis of text-based dialogue coded for knowledge construction phases; the accuracy and completeness of the three collaborative care plans; and quantitative and qualitative participant feedback. Results. Sixteen pairs of medical and pharmacy students (n=32) participated. Pairs who received high guidance engaged in all phases of knowledge construction more often than pairs who received low guidance. Guidance phase did not differentially impact collaborative care plan scores. Ninety-eight percent of students agreed or strongly agreed that the module improved their clinical reasoning, interprofessional communication, and knowledge of systemic lupus erythematosus. Conclusion. The knowledge construction framework can guide the design and evaluation of educational interventions such as a mobile learning module to support knowledge construction among health professionals.

Learning Challenges, Teaching Strategies, and Cognitive Load: Insights From the Experience of Seasoned Endoscopy Teachers.

PURPOSE: Learners of medical procedures must develop, refine, and apply schemas for both cognitive and psychomotor constructs, which may strain working memory capacity. Procedures with limitations in visual and tactile information may add risk of cognitive overload. The authors sought to elucidate how experienced procedural teachers perceived learners' challenges and their own teaching strategies in the exemplar setting of gastrointestinal endoscopy. METHOD: The authors interviewed 22 experienced endoscopy teachers in the United States, Canada, and the Netherlands between May 2016 and March 2019 and performed thematic analysis using template analysis method. Interviews addressed learner challenges and teaching strategies from the teacher participants' perspectives. Cognitive load theory informed data interpretation and analysis. RESULTS: Participants described taking steps to "diagnose" trainee ability and identify struggling trainees. They described learning challenges related to trainees (performance over mastery goal orientation, low self-efficacy, lack of awareness), tasks (psychomotor challenges, mental model development, tactile understanding), teachers (teacher-trainee relationship, inadequate teaching, teaching variability), and settings (internal/external distractions, systems issues). Participants described employing strategies that could match intrinsic load to learners' levels (teaching along developmental continuum, motor instruction, technical assistance/takeover), minimize extraneous load (optimize environment, systems solutions, emotional support, define expectations), and optimize germane load (promote mastery, teach schemas, stop and focus). CONCLUSIONS: Participants provided insight into possible challenges while learning complex medical procedures with limitations in sensory channels, as well as teaching strategies that may address these challenges at individual and systems levels. Using cognitive load theory, the authors provide recommendations for procedural teachers.

Envisioning a True Continuum of Competency-Based Medical Education, Training, and Practice.

The existing structure of physician education has developed in siloed stages, with consecutive degrees and certifications and progressively longer training programs. As further fragmentation of health care and training systems will not improve the quality of care and education, the authors argue that a new vision of education, training, and practice as a continuum is needed.They advocate for a model of competency-based medical education that merges with competency-based medical practice. In this system, education and training will result in individual, dynamic portfolios of valid entrustable professional activities (EPAs) for which physicians are certified. Physicians can maintain and renew that entrustment as long as the EPAs remain within their scope of practice. Entrustment occurs initially during training but is then granted for new activities as physicians' careers evolve.This model accounts for the need to keep pace with changes in population health needs and expectations of competence over time. It de-emphasizes the divides between the stages of training and views the continuum from undergraduate medical education until retirement as a whole. Key obligations of self-regulating medical professionals include both the reception and the provision of supervision from and for others, respectively. Learning must be embedded in practice to address expectations regarding new knowledge and skills as they evolve with scientific and technological advances.Entrusting physicians to deliver effective and safe care, based on their performance of the requisite EPAs without supervision, should ensure that they provide high-value, quality care to patients.

Reflections From the Rearview Mirror: Internal Medicine Physicians' Reactions to Clinical Feedback After Transitions of Responsibility.

PURPOSE: Learning from practice is important for continuous improvement of practice. Yet little is known about how physicians assimilate clinical feedback and use it to refine their diagnostic approaches. This study described physicians' reactions to learning that their provisional diagnosis was either consistent or inconsistent with the subsequent diagnosis, identified emotional responses to those findings, and explored potential consequences for future practices. METHOD: In 2016-2017, 22 internal medicine hospitalist and resident physicians at Oregon Health & Science University completed semistructured interviews. Critical incident prompts elicited cases of patient care transitions before the diagnosis was known. Interview questions explored participants' subsequent follow-up. Matrix analysis of case elements, emotional reactions, and perceived practice changes was used to compare patterns of responses between cases of confirming versus disconfirming clinical feedback. RESULTS: Participants described 51 cases. When clinical feedback confirmed provisional diagnoses (17 cases), participants recalled positive emotions, judged their performance as sufficient, and generally reinforced current approaches. When clinical feedback was disconfirming (34 cases), participants' emotional reactions were mostly negative, frequently tempered with rationalizations, and often associated with perceptions of having made a mistake. Perceived changes in practice mostly involved nonspecific strategies such as "trusting my intuition" and "broadening the differential," although some described case-specific strategies that could be applied in similar contexts in the future. CONCLUSIONS: Internists' experiences with posttransition clinical feedback are emotionally charged. Internists' reflections on clinical feedback experiences suggest they are primed to adapt practices for the future, although the usefulness of those adaptations for improving practice is less clear.

A primer on entrustable professional activities.

Entrustable professional activities (EPAs) have become a popular topic within competency-based medical education programs in many countries and hundreds of publications within only a few years. This paper was written to introduce the ins and outs of EPAs. After a brief historical overview, the rational of EPAs, as a bridge between a competency framework and daily clinical practice, is explained. Next, entrustment decision-making as a form of assessment is elaborated and framework of levels of supervision is presented. For readers interested to apply the concept in practice a stepwise approach to curriculum development is proposed. The paper concludes with an overview of the state of the art of working with EPAs in across disciplines, professions and countries.

The History of Medical Education in Europe and the United States, With Respect to Time and Proficiency.

In this article, the authors present a historic overview of the development of medical education in the United States and Europe (in particular the Netherlands), as it relates to the issues of time (duration of the course) and proficiency (performance requirements and examinations). This overview is necessarily limited and based largely on post hoc interpretation, as historic data on time frames are not well documented and the issue of competence has only recently been addressed.During times when there were few, if any, formal regulations, physicians were primarily "learned gentlemen" in command of few effective practical skills, and the duration of education and the competencies acquired by the end of a course simply did not appear to be issues of any interest to universities or state authorities. Though uniform criteria gradually developed for undergraduate medical education, postgraduate specialty training remained, before accreditation organizations set regulations, at the discretion of individual institutions and medical societies. This resulted in large variability in training time and acquired competencies between residency programs, which were often judged on the basis of opaque or questionable criteria. Considering the high costs of health care today and the increasing demand for patient safety and educational efficiency, continuing historic models of nonstandardized practices will no longer be feasible. Efforts to constrain, restructure, and individualize training time and licensing tracks to optimize training for safe care, both in the United States and Europe, are needed.