Exploring Interprofessional Development of Entrustable Professional Activities For Pediatric Intensive Care Fellows: A Proof-of-Concept Study.

Phenomenon: Entrustable professional activities (EPAs) delineate major professional activities that an individual in a given specialty must be "entrusted" to perform, ultimately without supervision, to provide quality patient care. Until now, most EPA frameworks have been developed by professionals within the same specialty. As safe, effective, and sustainable health care ultimately depends on interprofessional collaboration, we hypothesized that members of interprofessional teams might have clear and possibly additional insight into which activities are essential to the professional work of a medical specialist. Approach: We recently employed a national modified Delphi study to develop and validate a set of EPAs for Dutch pediatric intensive care fellows. In this proof-of-concept study, we explored what pediatric intensive care physicians' non-physician team members (physician assistants, nurse practitioners, and nurses) constitute as essential professional activities for PICU physicians and how they regarded the newly developed set of nine EPAs. We compared their judgments with the PICU physicians' opinions. Findings: This study shows that non-physician team members share a mental model with physicians about which EPAs are indispensable for pediatric intensive care physicians. Despite this agreement however, descriptions of EPAs are not always clear for non-physician team members who have to work with them on a daily basis. Insights: Ambiguity as to what an EPA entails when qualifying a trainee can have implications for patient safety and trainees themselves. Input from non-physician team members may add to the clarity of EPA descriptions. This finding supports the involvement of non-physician team members in the developmental process of EPAs for (sub)specialty training programs.

The entrustable professional activities of laparoscopic surgery: moving toward an integrated training model.

BACKGROUND: Entrustable Professional Activities (EPAs) provide the opportunity to integrate multiple competencies into meaningful units that facilitate curriculum development and assessment design. As part of the process of reviewing and enhancing the Fundamentals of Laparoscopic of Surgery (FLS) program, we used the concept of EPAs to create a framework of reference that articulates a contemporary definition of Laparoscopic Surgery (LS). METHODS: The framework of reference of LS was created with data gathered from a literature review and during series of educational retreats with subject matter experts (SMEs). Various activities were implemented during these retreats to develop the LS EPAs, their constitutive competencies, and related observable behaviors. RESULTS: Ten EPAs and associated competency descriptors (articulated as observable behaviors) specific to LS were identified. In addition, knowledge areas were associated to each EPA. DISCUSSION: A comprehensive list of EPAs for LS were identified. These EPAs will be used in the development and update of the FLS program. Further, they can be used to guide the development of curriculum, clinical teaching, and assessment in any surgical program with a laparoscopic training component. They are applicable to any level of training by defining the expected observable behaviors associated with a given level of expertise. These fundamental aspects of LS provide a common framework of reference across different surgical specialties.

How much is enough? Proposing achievement thresholds for core EPAs of graduating medical students in Canada.

PURPOSE: The transition towards Competency-Based Medical Education at the Cumming School of Medicine was accelerated by the reduced clinical time caused by the COVID-19 pandemic. The purpose of this study was to define a standard protocol for setting Entrustable Professional Activity (EPA) achievement thresholds and examine their feasibility within the clinical clerkship. METHODS: Achievement thresholds for each of the 12 AFMC EPAs for graduating Canadian medical students were set by using sequential rounds of revision by three consecutive groups of stakeholders and evaluation experts. Structured communication was guided by a modified Delphi technique. The feasibility/consequence models of these EPAs were then assessed by tracking their completion by the graduating class of 2021. RESULTS: The threshold-setting process resulted in set EPA achievement levels ranging from 1 to 8 across the 12 AFMC EPAs. Estimates were stable after the first round for 9 of 12 EPAs. 96.27% of EPAs were successfully completed by clerkship students despite the shortened clinical period. Feasibility was predicted by the slowing rate of EPA accumulation overtime during the clerkship. CONCLUSION: The process described led to consensus on EPA achievement thresholds. Successful completion of the assigned thresholds was feasible within the shortened clerkship.[Box: see text].

An innovative interprofessional dental clinical learning environment using entrustable professional activities.

INTRODUCTION: Changes in society, new public demands for dental care and contemporary educational insights have influenced dental education worldwide and demand a renewed perspective. Following this perspective, an innovative interprofessional dental Master curriculum was developed at Radboud University Nijmegen in the Netherlands. EDUCATIONAL PRINCIPLES: The curriculum is based on five contemporary educational principles and the core of the curriculum consists of a Student Run Dental Clinic that is fully run by students under professional supervision. THE NEW CURRICULUM: In the Student Run Dental Clinic, Master dental students and Bachelor oral hygiene students are responsible for the care of approximately 750 patients. The students work within the same clinic for 3 years and patients receive oral health care from the same students over a long period. The clinic is a longitudinal cross-disciplinary clinic with different dental subdisciplines. Entrustable professional activities (also known as EPAs), to our knowledge not yet widely used in dental education, were introduced to facilitate learning and assessment. Fourteen EPAs have been developed to stimulate interprofessional education and learning. Of these, five EPAs are identical for the dental and oral hygiene curriculum, leading to extended interprofessional education and learning in the Student Run Dental Clinic. DISCUSSION: Preliminary results show that EPAs are generally well received by supervisors and students. CONCLUSION: To monitor and investigate the exact effect of the interventions and underlying mechanisms, a research programme on interprofessional learning, practice-based learning and EPAs and entrustment in dental education was recently set up.

Feasibility, and validity aspects of Entrustable Professional Activity (EPA)-based assessment in general practice training.

INTRODUCTION: Entrustable Professional Activities (EPAs) are developed to support the practical application of competency frameworks in postgraduate medical education (PGME) programmes. EPAs are used for the assessment of the trainees' competence development, which takes place by means of an entrustment decision, aiming to stimulate learning and independent practice in trainees. In this pilot study, we explore the feasibility and validity of EPA-based assessment in a General Practice (GP) training programme. METHODS: We used questionnaires to evaluate trainers' and trainees' experiences with the use of six EPAs for trainee learning, assessment and independent practice at the Out-of-Hours GP Center. Data were analysed quantitatively and qualitatively. Additionally, we examined the inter-item correlation between scores on EPA-based assessment and competency-based assessment using Spearman's Rho. RESULTS: EPA-based assessment provided opportunities for giving concrete feedback and substantiating competency-based assessment. No consistent correlation between EPA-based assessment and competency-based assessment could be detected. Only later in the course of the training programme a correlation was found between the EPA scores and the degree of independence of trainees. DISCUSSION: Results of this pilot study confirm the theories behind EPAs, as well as earlier research on EPAs in the workplace regarding trainee learning, assessment and independent practice. An important limitation of this study was the COVID-19 pandemic, as it influenced the results through reduced inclusion and follow-up, and through the impact on the workplace and trainee learning possibilities. Further research is needed to determine how EPAs support independent practice of trainees, as well as the assessment of trainee competency development.

Evolving Librarian Engagement in Undergraduate Medical Education Student Research and Scholarship.

Undergraduate Medical Education (UME) program curriculum redesign at Oregon Health & Science University (OHSU) in the early 2010s resulted in incorporation of a long-term research project-called "Scholarly Projects"-into the UME experience. Since 2014, OHSU librarians have participated in curricular support for Scholarly Projects, focusing on helping students develop skills in searching and information management at a moment when the students are starting their projects. This library participation has developed over time and continues to change in response to ongoing librarian reflection on student engagement with the material.

Entrustable professional activity 7: opportunities to collaborate on evidence-based medicine teaching and assessment of medical students.

BACKGROUND: This study was conducted to examine gaps and opportunities for involvement of librarians in medical education and patient care as well as improve the teaching and assessment of Entrustable Professional Activity 7 (EPA 7) -- the ability to form clinical questions and retrieve evidence to advance patient care. METHODS: The Association of Academic Health Sciences Libraries (AAHSL) Competency-Based Medical Education Task Force surveyed all AAHSL member libraries in October 2016 on health sciences librarian awareness and involvement in teaching and assessing EPA 7. RESULTS: The survey response rate was 54% (88/164 member libraries). While 90% (n = 76) of respondents were regularly engaged in teaching or assessing aspects of EPA 7 only 34 (39%) were involved explicitly in a Core EPA 7 project, 44% (15/34) of these projects were librarian initiated. CONCLUSIONS: Involvement in teaching and assessment of EPA 7 is an untapped opportunity for librarians to collaborate in medical education and patient care. Although librarians are already deeply involved in teaching and assessment of EPA 7 related knowledge, skills, and behaviors, further librarian collaboration can help bolster the planning or updating of existing curricula and assessments of this entrustable professional activity.

Trainers' and trainees' expectations of entrustable professional activities (EPAs) in a primary care training programme.

Introducing Entrustable Professional Activities (EPAs) into primary care postgraduate medical education (PGME) programmes may be challenging, due to the general nature of primary care medicine, but trainers and trainees both stand to benefit from their use. We investigated the expectations of trainers and trainees in a primary care PGME programme regarding the use of EPAs. We held two focus group discussions with trainers and four with trainees from the Dutch General Practice training programme, to explore their views on the use of EPAs in their training programme. Focus group discussions were audio-recorded and transcribed verbatim. The transcripts were analysed using conventional content analysis. Trainers and trainees felt that the large number of EPAs in the training programme, and the general way they are formulated, made them unsuitable for use in formal assessments. However, they felt that EPAs can be a useful aid to trainee learning. EPAs may help trainers to give trainees specific feedback on their performance. While the use of the classic EPA method in primary care PGME programmes may be challenging, EPAs in such programmes might be more suitable as design and learning tools than as a tool for formal assessment.

Entrustment of the on-call senior medical resident role: implications for patient safety and collective care.

BACKGROUND: The on-call responsibilities of a senior medicine resident (SMR) may include the admission transition of patient care on medical teaching teams (MTT), supervision of junior trainees, and ensuring patient safety. In many institutions, there is no standardised assessment of SMR competency prior to granting these on-call responsibilities in internal medicine. In order to fulfill competency based medical education requirements, training programs need to develop assessment approaches to make and defend such entrustment decisions. The purpose of this study is to understand the clinical activities and outcomes of the on-call SMR role and provide training programs with a rigorous model for entrustment decisions for this role. METHODS: This four phase study utilizes a constructivist grounded theory approach to collect and analyse the following data sets: case study, focus groups, literature synthesis of supervisory practices and return-of-findings focus groups. The study was conducted in two Academic Health Sciences Centres in Ontario, Canada. The case study included ten attending physicians, 13 SMRs, 19 first year residents and 14 medical students. The focus groups included 19 SMRs. The later, return-of-findings focus groups included ten SMRs. RESULTS: Five core on-call supervisory tasks (overseeing ongoing patient care, briefing, case review, documentation and preparing for handover) were identified, as well as a range of practices associated with these tasks. We also identified challenges that influenced the extent to which SMRs were able to effectively perform the core tasks. At times, these challenges led to omissions of the core tasks and potentially compromised patient safety and the admission transition of care. CONCLUSION: By identifying the core supervisory tasks and associated practices, we were able to identify the competencies for the on-call SMR role. Our findings can further be used by training programs for assessment and for making entrustment decisions.

The Changing World of Psychiatric Education: Challenges and Opportunities.

This special section of the journal focuses on the expanding horizons, challenges, and opportunities for the psychiatric educators. In the six papers that comprise this special section, the authors have covered a broad range of topics in both undergraduate medical education and graduate medical education including topics such as accreditation, technology, how providers can locate education resources, how trainees are taught about professionalism in the digital age, telepsychiatry, manualized psychotherapy treatments, and cultural competence. We hope that psychiatric educators, and others interested in this field, will find these papers helpful.

What's new in graduate medical education?

The development of new graduate medical education programmes provides both opportunities and challenges. Efforts to address physician workforce shortages as well as a realisation that curricula need to be updated to adjust to our rapidly changing healthcare environment have resulted in more educators considering the "how to" and "what's new" of programme development. Understanding the Next Accreditation System, an accreditation system introduced by the Accreditation Council of Graduate Medical Education in 2012, is critical to the success of new as well as existing residency and fellowship programmes. Although many educators are aware of the general rational for the Next Accreditation System, an in-depth understanding of the meaning of Next Accreditation System is necessary from an experiential and theoretical perspective to be able to successfully launch new programmes and moves towards accreditation. A new paediatric categorical residency programme and a new paediatric surgical programme were developed at our institution immediately following the implementation of Next Accreditation System. We provide a series of insights and perspectives based on our experience relative to what priorities we saw outlined from both the programmatic and the institutional perspective to have our graduate medical education programmes reviewed for accreditation. During this discussion, the following objectives are outlined: to overview the Next Accreditation System as a framework and priorities, to discuss the opportunities and challenges that may exist in developing new programmes, and to discuss future directions in the evaluation of trainees and assessment of training competency. Although challenges are outlined, we hope to relay the continued excitement and opportunities that exist relative to enhancing training curricula for future graduate medical education programme builders.

Assessing achievement in nephrology training: using clinic chart audits to quantitatively screen competency.

BACKGROUND: Entrustable professional activities (EPAs) are complex tasks representing vital physician functions in multiple competencies, used to demonstrate trainee development along milestones. Managing a nephrology outpatient clinic has been proposed as an EPA for nephrology fellowship training. STUDY DESIGN: Retrospective cohort study of nephrology fellow outpatient clinic performance using a previously validated chart audit tool. SETTING & PARTICIPANTS: Outpatient encounter chart audits for training years 2008-2009 through 2012-2013, corresponding to participation in the Nephrology In-Training Examination (ITE). A median of 7 auditors (attending nephrologists) audited a mean of 1,686±408 (SD) charts per year. 18 fellows were audited; 12, in both of their training years. PREDICTORS: Proportion of chart audit and quality indicator deficiencies. OUTCOMES: Longitudinal deficiency and ITE performance. MEASUREMENTS & RESULTS: Among fellows audited in both their training years, chart audit deficiencies were fewer in the second versus the first year (5.4%±2.0% vs 17.3%±7.0%; P<0.001) and declined between the first and second halves of the first year (22.2%±6.4% vs 12.3%±9.5%; P=0.002). Most deficiencies were omission errors, regardless of training year. Quality indicator deficiencies for hypertension and chronic kidney disease-associated anemia recognition and management were fewer during the second year (P<0.001). Yearly audit deficiencies ≥5% were associated with an ITE score less than the 25th percentile for second-year fellows (P=0.03), with no significant association for first-year fellows. Auditor-reported deficiencies declined between the first and second halves of the year (17.0% vs 11.1%; P<0.001), with a stable positive/neutral comment rate (17.3% vs 17.8%; P=0.6), suggesting that the decline was not due to auditor fatigue. LIMITATIONS: Retrospective design and small trainee numbers. CONCLUSIONS: Managing a nephrology outpatient clinic is an EPA. The chart audit tool was used to assess longitudinal fellow performance in managing a nephrology outpatient clinic. Failure to progress may be quantitatively identified and remediated. The tool identifies deficiencies in all 6 competencies, not just medical knowledge, the primary focus of the ITE and the nephrology subspecialty board examination.

Multifaceted Strategy That Improves Students' Achievement of Entrustable Professional Activities Across Advanced Pharmacy Practice Experiences.

OBJECTIVE: To outline an approach to help students achieve Entrustable Professional Activities (EPAs) entrustment during a sequence of Advanced Pharmacy Practice Experiences (APPEs) by implementing longitudinal monitoring and individualized intervention and remediation strategies. METHODS: Using the recommended EPAs within the core APPEs (acute care, ambulatory care, community, institutional), students were expected to achieve entrustment on all EPAs by graduation. A longitudinal monitoring approach, using an "EPA report card," was implemented to continuously identify students at risk of not meeting the EPA requirement of "Level 3" entrustment (perform with reactive supervision). Individualized interventions, including proactive outreach and in-sequence remediation, were incorporated into the APPE core and elective sequence to help ensure all students were entrusted by the end of APPEs without requiring further end-of-year remediation to graduate. RESULTS: For the graduating classes of 2023 and 2024, 12% (8 of 69) and 16% (12 of 75) students, respectively, were identified as at risk of not meeting EPA entrustment. Proactive outreach, in-sequence remediation, or a combination of both strategies, were used to enhance learning and EPA performance. As a result, all students achieved "Level 3" entrustment on the deficient EPA(s) by the end of the APPE sequence. No student required further end-of-year remediation to graduate. CONCLUSION: Utilizing a multifaceted strategy provided timely, real-world practice opportunities to improve the students' achievement of EPAs across the APPE curriculum and decreased the need for end-of-year remediation and potential graduation delays.

Developing entrustable professional activities for family medicine training in South Africa.

Workplace-based assessment (WPBA) is becoming part of high-stake assessments in specialist training. Entrustable professional activities (EPAs) are a recent addition to WPBA. This is the first South African publication on developing EPAs for postgraduate family medicine training. An EPA is a unit of practice, observable in the workplace, constituting several tasks with underlying knowledge, skills and professional behaviours. Entrustable professional activities allow for entrustable decisions regarding competence in a described work context. A national workgroup representing all nine postgraduate training programmes in South Africa has developed 19 EPAs. This new concept needs change management to understand the theory and practice of EPAs. Family medicine departments with large clinical workloads are small, necessitating navigating logistical issues to develop EPAs. It has unmasked existing workplace learning and assessment challenges.Contribution: This article contributes new thinking to developing EPAs for family medicine in an effort to understand more authentic WPBA nationally.

Qualitative analysis of advanced pharmacy practice experience goals.

INTRODUCTION: This study identified advanced pharmacy practice experience (APPE) activities students wish to pursue via a qualitative analysis of goal setting. It also aimed to understand student goal setting alignment with core Entrustable Professional Activities (EPAs). METHODS: SMART (specific, measurable, achievable, realistic/relevant, time-bound) goal data were reviewed, analyzed, and coded to develop an inductive thematic analysis. Overall frequency of SMART goal coding themes was analyzed using descriptive statistics, along with frequency of themes based on rotation type. Relative percentages of each rotation type were compared. A crosswalk between themes and EPA was created post-coding. RESULTS: Several themes among student SMART APPE goals from one complete academic year were identified (n = 79). A total of 1690 SMART goals were categorized into 22 themes. The top five most frequently utilized themes represent 60.6% of all goals, and included "Assess, Select, Recommend Therapy" (19%); "Patient Communication" (15.4%); "Foundational Knowledge" (12.4%); "Interprofessional Collaboration" (7.9%); and "Workflow, Roles and Responsibilities" (6%). The core EPA Patient Care Provider Domain was most common and accounted for 46.4% of SMART goals. The remainder included Information Master (18.8%); Practice Manager (16.1%); Interprofessional Education Team Member (7.9%); Population Health Promoter (6.6%); and Self-Developer (3.6%). CONCLUSIONS: Our analysis revealed that students set goals in alignment with the profession's primary focus of providing direct patient care however some EPAs were infrequently citied by students in their goal setting process which may mean there is less focus on these important skills.

Autonomy in entrustable professional activities after the COVID-19 pandemic: the perspectives of residents and teachers. / Autonomía en actividades profesionales confiables luego de la pandemia por COVID-19: perspectivas de residentes y docentes.

Introduction. The entrustable professional activities (EPAs) are 13 activities that new medical graduates should be able to perform without direct supervision. Our objective was to assess the perceptions of residents and teachers regarding their autonomy to perform the EPAs 2 years after the onset of the COVID-19 pandemic. Materials and methods. Cross-sectional study of first-year residents of clinical and surgical specialties and their teachers. Electronic, anonymous questionnaires were used. Results. Subjects were 31 residents and 20 teachers. Most residents believed that they were able to perform 8 of the 13 EPAs independently. According to most teachers, residents required direct supervision to perform 11 of the 13 EPAs. Significant differences were observed between residents' and teachers' perceptions in 8 of the 13 EPAs. Conclusion. The perception of autonomy to perform the EPAs in the beginning of the residency program was considerably better among residents than their teachers.

Introducción. Las actividades profesionales confiables (APROC) son 13 actividades que los médicos recién graduados deberían poder realizar sin supervisión directa. Nuestro objetivo fue evaluar la percepción de residentes y docentes acerca de la autonomía para realizar las APROC, luego de 2 años del inicio de la pandemia. Materiales y métodos. Estudio de corte transversal, que incluyó residentes de primer año de especialidades clínicas y quirúrgicas, y sus docentes. Se enviaron cuestionarios electrónicos y anónimos. Resultados. Se incluyeron 31 residentes y 20 docentes. La mayoría de los residentes creía que podía realizar en forma autónoma 8 de las 13 APROC. Para la mayoría de los docentes, los residentes requerían supervisión directa para 11 de las 13 actividades. Se observaron diferencias significativas entre la percepción de residentes y docentes en 8 de las 13 APROC. Conclusión. La percepción de autonomía para realizar las APROC al inicio de la residencia fue considerablemente mayor en residentes que en sus docentes.

Rapid Mobilization of Medical Student Volunteers to Administer Vaccines During the COVID-19 Pandemic.

In December 2020, the first COVID-19 vaccines were approved for emergency use by the U.S. Food and Drug Administration, and vaccination efforts rapidly launched across the country. Concurrently, New York City experienced an increase in COVID-19 hospitalizations. This created an immediate need to inoculate frontline workers in a strained health system that lacked sufficient personnel to meet the demand. In response, New York State permitted medical students with appropriate clinical experience to administer vaccinations. Albert Einstein College of Medicine students rapidly stepped in to administer vaccines and serve as clinic navigators. Student leaders at Einstein collaborated with Montefiore Medical Center to rapidly implement a student vaccination initiative. Medical students underwent virtual and on-site training regarding COVID-19 vaccines and their administration. In January 2021, students began to staff vaccine clinics across the Bronx. By July 2021, 291 out of 830 eligible medical and Medical Scientist Training Program (MSTP) students (35.1%) had volunteered >2400 h. Of the 291 volunteers, 77 (26.5%) worked as vaccinators and administered approximately 2929 COVID-19 vaccines from January to May 2021. We demonstrate success using the concept of Entrustable Professional Activities (EPAs) in the context of training medical students in a specific clinical skill. Our framework resulted in the administration of approximately 2929 COVID-19 vaccines from January to May 2021. The authors believe that this framework can be implemented at peer institutions to alleviate the burden on hospital systems and outpatient clinics vaccinating their communities against COVID-19, or to meet future clinical needs.

Benefits of EPAs at risk? The influence of the workplace environment on the uptake of EPAs in EPA-based curricula.

INTRODUCTION: Entrustable Professional Activities (EPAs) have been applied differently in many postgraduate medical education (PGME) programmes, but the reasons for and the consequences of this variation are not well known. Our objective was to investigate how the uptake of EPAs is influenced by the workplace environment and to what extent the benefits of working with EPAs are at risk when the uptake of EPAs is influenced. This knowledge can be used by curriculum developers who intend to apply EPAs in their curricula. METHOD: For this qualitative study, we selected four PGME programmes: General Practice, Clinical Geriatrics, Obstetrics & Gynaecology, and Radiology & Nuclear Medicine. A document analysis was performed on the national training plans, supported by the AMEE Guide for developing EPA-based curricula and relevant EPA-based literature. Interviews were undertaken with medical specialists who had specific involvement in the development of the curricula. Content analysis was employed and illuminated the possible reasons for variation in the uptake of EPAs. RESULTS: An important part of the variation in the uptake of EPAs can be explained by environmental factors, such as patient population, the role of the physician in the health-care system, and the setup of local medical care institutions where the training programme takes place. The variation in uptake of EPAs is specifically reflected in the number and breadth of the EPAs, and in the way the entrustment decision is executed within the PGME programme. DISCUSSION: Due to variation in uptake of EPAs, the opportunities for trainees to work independently during the training programme might be challenging. EPAs can be implemented in the curriculum of PGME programmes in a meaningful way, but only if the quality of an EPA is assessed, future users are involved in the development, and the key feature of EPAs (the entrustment decision) is retained.

A Study to Analyze Narrative Feedback Record of an Emergency Department.

BACKGROUND: This study adopts the Situation-Behavior-Impact-Action (SBIA) model to examine the compliance of narrative feedback in the Entrustable Professional Activities (EPAs)-based e-Portfolio system for clinical preceptors in the emergency department of a regional teaching hospital, and analyzes the applicability of its application in emergency clinical training to increase the feasibility of improving the quality of clinical preceptors' feedback content. METHODS: Application of data mining technique to analyze 928 data points was recorded by 14 clinical teachers from April 2017 to May 2019. These data points were narrative feedback from workplace direct observation, which was recorded in the EPAs-based e-Portfolio. RESULTS: The majority of the narrative feedback consisted of only one component, behavior observed (53.99%) and action suggestion (17.24%). Some feedback consisted of two to three components; which were behavior observed-action suggestion (20.37%) and situation description-behavior observed- action suggestion (1.29%). Only a few feedbacks consisted of all four components: situation description- behavior observed-possible impact-action suggestion (0.75%). CONCLUSIONS: The current narrative feedback is from the basic appearance of SBIA, but there still got room for improvement. The narrative feedback should be given according to SBIA model in order to provide a comprehensive and constructive learning outcome. The narrative feedback recorded in EPAsbased e-Portfolio provides the delay of feedback effect. Thus, multiple feedbacks from various clinical teachers could make the assessments more concrete and outline the authentic clinical condition of the trainees.

Firsthand Experience in Graduating Three Cohorts of Forensic Pathologists Trained With Competency by Design (CBD) Curriculum.

INTRODUCTION: The University of Toronto experienced graduating three cohorts of forensic pathologists trained with Competency by Design (CBD) curriculum. We achieved this as a result of multiyear development of Entrustable Professional Activities (EPAs), Required Training Experience (RTEs), and Specialty Competency Requirements (SCRs) by the Royal College of Physicians and Surgeons of Canada's Forensic Pathology Speciality Committee, the Ontario Forensic Pathology Service, and the University of Toronto. METHOD: Our academic year is comprised of 13 blocks. We divided the 13-block period into 4 stages to map all the EPAs and RTEs. The first stage, Transition to Discipline, is 1 block, the second stage, Foundation of Discipline, consists of 3 blocks; the third stage, Core of Discipline, consists of 6 blocks, and the final fourth stage, Transition to Practice, consists of 3 blocks. Board-certified faculty members in Forensic Pathology with more than five years of experience supervised the trainees. We graduated 5 Canadian and 4 international trainees at the end of the third cycle of CBD-based training program. CONCLUSION: Using the Royal College Speciality Committee blueprint, the University of Toronto started in 2016 planning the CBD curriculum in the forensic pathology training program. By the end of June 2021, we graduated nine trainees from our CBD-based Forensic Pathology training program. We are training the fourth cohort, and they will be graduating at the end of June 2022. This article aims to share our firsthand experiencing in CBD training in forensic pathology.