Implementation and Use of Entrustable Professional Activities in the Internal Medicine Acting Internship

Abstract

BACKGROUND: The internal medicine acting internship (AI rotation) is a capstone rotation for demonstrating residency readiness, yet grading inflation and rotation variability limit transparent assessment and communication of student skills to residency programs. The Association of American Medical Colleges' Core Entrustable Professional Activities for Entering Residency (EPAs) offer a shared assessment framework, but their implementation in the AI rotation is incompletely characterized nationally. OBJECTIVE: To describe national usage of EPAs in the AI rotation, identify which EPAs are emphasized, and examine associations between EPA use and assessment/grading practices. DESIGN: Cross-sectional electronic survey of AI rotation course directors (January 2023) with selected comparison to prior medicine core clerkship benchmarks. PARTICIPANTS: Course directors at LCME-accredited US schools (71/140; response rate 50.7%). MAIN MEASURES: We evaluated the presence of EPA-focused teaching and assessment in the AI rotation, as well as the correlation of EPA incorporation with institutional practices surrounding student assessment and evaluation. KEY RESULTS: Most institutions (57%) reported EPA incorporation into the AI rotation. Higher complexity EPAs such as EPA 4 (entering/discussing orders), EPA 8 (patient handover), and EPA 10 (urgent/emergent care) were more frequently assessed in the AI rotation than in the core clerkship, although assessment rates for these EPAs remained below 50%. EPA incorporation was correlated with the use of required workplace-based assessments and competency-based rubrics but showed no association with the use of narrative comments in evaluation (p = 0.76), institutional grading structure (p = 0.57), use of grading committees (p = 0.41), perceived grade inflation (p = 0.47), or inclusion of grade distributions in the MSPE (p = 0.23). Reported gaps included limited instruction and formative assessment for EPA 8 and EPA 10. CONCLUSION: Despite growing adoption, EPA incorporation during the AI rotation remains heterogeneous. Greater intentional incorporation of EPAs to align with acting intern responsibilities represents an opportunity to improve the UME-GME transition.

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