Identifying entrustable professional activities for postgraduation in psychiatry: What should a psychiatrist be able to do?

Background: Competency-based medical education (CBME) has been the mandate by regulatory bodies of medical education in India, and implementation is an evolving process. This study aimed to identify and propose a set of entrustable professional activities (EPAs) for a master's degree in psychiatry. An attempt has been made to present it in the form of a portfolio. Methodology: Faculty experts in psychiatry went through phases of review to select appropriate EPAs for postgraduate residents from divergent thinking to development of portfolio.
Results: One hundred and sixty-seven EPAs were identified and are presented. These were divided according to expertise required. Of these, 54% were considered vital, 30% essential, and 16% desirable.
Conclusion: It is envisaged that the use of EPAs and portfolios will be instrumental in implementation and success of CBME in psychiatry. It is expected that medical universities will incorporate them in their curricula. It is also expected that data will be generated to identify challenges, which shall guide future refinement of the EPAs. Copyright:

A postgraduate student resident in psychiatry has to undergo formative and summative assessments during their course of 3 years. The National Medical Commission (NMC) PG curriculum decrees that summative assessment in psychiatry includes four theory papers, practical examination, and viva voce.[1] Despite this thorough assessment plan, doubt sometimes remains in the mind of examiners about whether the resident will be able to work independently in the community or if he/she can be trusted to deliver. This raises the question about whether the current assessment and certification process are aligned to provide this trust.

NMC in 2020 promulgated guidelines for competency-based postgraduate training for master's degree (MD) in psychiatry. The document has a well-defined syllabus and curriculum. The guidelines elucidate specific learning objectives covering cognitive, affective, and psychomotor domains.[1] The National Board of Examinations has also formulated guidelines for competency-based training program for DNB psychiatry.[2] However, the desired outcomes have not been defined clearly in these guidelines. It becomes imperative to find a method to ascertain the ability of a specialist in psychiatry to perform a professional activity. Any outcome-based education needs these answers. Therefore, there is a requirement to find the path to gain the trust for each professional activity in postgraduate training in psychiatry.

An entrustable professional activity (EPA) is defined as “task or responsibility to be entrusted to the unsupervised execution by a trainee once he or she has attained sufficient specific competence.”[3] The outcomes and processes in the EPAs should be such that they can be easily observed, assessed, and implemented for a particular competency. Arranging these EPAs as graded tasks of increasing mastery forms the basis of a comprehensive postgraduation competency-based medical education (CBME) program. These are objective ability statements, which will be able to assess comprehensive theoretical knowledge and practical skills. The stages in the development of competencies specific to each EPA are called milestones. They are the intervening steps required to fulfill a particular EPA. A similar approach has been used by many CBME-based curricula around the world. Prominent among them were the Accreditation Council for Graduate Medical Education and the Canadian Medical Education Directions for Specialists.[45] The advantages of defining EPAs include measuring real-time performance, allowing trainee to evaluate their learning against expectations listed in milestone, and encouraging curriculum planners to focus on both process and outcome.[6] Hence, though a curriculum for MD in psychiatry exists in India, outcome-based EPAs have not been elucidated in the guidelines. Hence, it is essential to define EPAs and milestones in order to help residents achieve desired competencies.

Most postgraduate disciplines including psychiatry require the learner to acquire higher-order skills as they work through the years of postgraduation training. Most of such skill acquisition occurs as part of on-the-job training. There is a need that this learning be validated and documented. One means of doing so is the use of educational portfolios, which is a validated tool for documenting learning.[7] A portfolio has an advantage over logbooks which is another such tool in terms of being a reflective learning tool.

The present study aims to identify and enumerate EPAs for a learner of masters in medicine in the discipline of psychiatry in the Indian context. In order to provide a clear understanding to all involved in education system, EPAs may be further documented in the form of a portfolio along with milestones.

METHODOLOGY

This study was conducted at the Armed Forces Medical College, Pune. Three professors in the subject, two senior residents, and three final-year residents constituted the study group. They were tasked to identify EPAs for the PG curriculum in psychiatry. For the sake of classification, the entire subject curriculum was divided into sections and segments. Subsequently, four phases were followed in the study to develop the EPAs. The study methodology is outlined in Figure 1. The competency to qualify as an EPA was defined by Olle Ten Cate in 2005.[3] He described the following criteria to make it an effective measure of competence:

Figure 1

Flowchart of methodology

An EPA should be suitable for entrustment. It should be executed independently by a learner within a definite time frame, it should be observable by an expert, and both process and outcome should be measurable

It should preferably be a specialty-related real-life patient care situation that requires specialized knowledge, attitude, and skills to be able to perform by an expert

The EPA should lead directly to one or more of the competencies that are required to be attained at the end of the program.

The constituents and attributes of an EPA were explained to members of the study group accordingly.

Phase 1: Divergent thinking

All the study group members were asked their opinion regarding the list of abilities required to be an effective psychiatrist in one of the two situations. The situations were hypothesized as either working as a stand-alone psychiatrist in a peripheral hospital or working in a tertiary care hospital as a member of a larger team. The inputs were solicited as categories developed and in the form of job requirements. The process continued for over a month, with each member working individually. For this phase, the study group members were asked to give as many suggestions as possible. Finally, an online database was created to collate and compile the inputs of the participants. Subsequently, the group worked together over multiple brainstorming sessions and discussed shortlisting of EPAs.

Phase 2: Convergent thinking

In further discussions, overlaps between statements were removed, and the draft EPAs were formulated. Brainstorming was done during these meetings to critically evaluate the collated data. Efforts were made to merge and reclassify the identified EPAs to refine them further. All doubts and conflicts regarding adopting or dropping a statement were resolved by simple consensus. The whole process was conducted in an unblended fashion in a single room. Other subject experts like clinical psychologists and medical education experts were also consulted on an “as-needed basis.”

Phase 3: Deconstruction

This phase involved a more focused approach, with each EPA being discussed in detail. EPAs were classified as “vital,” “essential,” or “desirable” based on the consensus of the study group. Bearing in mind the expectations out of a newly graduated psychiatrist, the expected expertise of each EPA was classified as “knows,” “knows how,” “shows,” “shows how,” and “does.” Wherever possible, the EPAs were further divided into smaller tangible and recordable milestones. The milestones were defined as smaller steps to achieve an EPA that could be observed and assessed during residency. For each milestone, an expected level of expertise was also identified. All members of the group participated in the process barring two senior members. These two participants acted as internal peer reviewers in the subsequent phase.

Phase 4: Internal peer review and corrections

This phase dealt with the creation of a portfolio. Draft portfolio was peer-reviewed by members of the study group. Both the internal peer reviewers went through each EPA separately. They suggested changes as appropriate. After incorporation of the suggested changes, the second round of internal review was done. The portfolio was finalized after two rounds of internal review.

Phase 5: Framework of developing the portfolio

To further enhance the EPAs and milestones, a framework was required. We used the template developed by Datta et al. to populate the EPAs and milestones.[8] The main ingredients of this template are EPAs and milestones. This portfolio was designed to meet the needs of an outcome-based curriculum. A Google Sheets (electronic spreadsheet program) was used for compilation of content and development of the portfolio. We used an open-source mail merge tool to create the individual pages of portfolio. Physical copies were used for the process of peer review in a bid to ensure more diligent scrutiny.

RESULTS

The study was conducted from July to November 2020. The study group to begin with went through the syllabus and identified broad sections and segments for classifying the EPAs. Eleven broad groups and 57 segments were identified. The classification is shown in Table 1. A total of 567 EPA statements were generated during the first phase (divergent thinking). Three hundred and forty-five EPA statements remained after merging/removing duplicates. EPAs were further refined and narrowed down to 207 during the group discussion phase. Merging and reassignment of EPAs as appropriate was carried out during this phase. Skills that could be acquired as part of another EPA were then removed. Wherever a deficiency was found, a separate EPA was added to make the learning outcomes more explicit. Subsequently, the EPAs were classified according to the expertise and level. For a number of EPAs, specific milestones were defined in addition. It was attempted to define the milestones in some measurable terms so that they can be assessed objectively during either a formative assessment or at workplace-based assessment. Each milestone had its defined expected expertise. As brought out in the methodology, the draft template underwent two cycles of peer review. Corrections were made wherever deemed appropriate. An attempt was made to keep the milestones focussed yet flexible, so as to cater for local adaptations. In the final portfolio, 167 EPAs were incorporated. The portfolio of each EPA is provided as Supplementary Material 1. Portfolio sample with milestones is depicted in Table 2. The breakup of the EPAs is depicted in Figure 2. Out of the total EPAs, 54% were considered vital, 30% essential, and 16% desirable [Figure 3]. List of Vital EPAs is provided as Supplementary Material 2.

Table 1

List of sections and segments

Section	Segment
General psychiatry
1.1	General psychiatry skills
1.2	Psychiatric emergencies
1.3	Psychoeducation skills
1.4	Psychological assessment
1.5	Research and publications
1.6	Others
Neuropsychiatry
2.1	Neurological examination
2.2	Psychiatric aspects of neurological illnesses
2.3	Neurological investigations
2.4	Others
Psychiatric aspects of medical disorders
3.1	Psychiatric aspects of medical disorders
3.2	Psychiatric aspects of transplantation
3.3	Psychiatric aspects of palliative care
3.4	Others
Adult psychiatry
4.1	Substance use disorders
4.2	Schizophrenia and other psychotic disorders
4.3	Mood disorders
4.4	Anxiety disorders including OCD
4.5	Stress, somatoform, and dissociative disorders
4.6	Sexual disorders including GID
4.7	Personality disorders
4.8	Sleep disorders
4.9	Culture bound syndromes and other disorders
Child and adolescent psychiatric disorders
5.1	Psychosocial aspects of normal childhood
5.2	Adolescent development
5.3	Intellectual disability
5.4	Autism spectrum disorders
5.5	Hyperkinetic and conduct disorders
5.6	Others
Geriatric psychiatry
6.1	Mild cognitive impairment and dementia
6.2	Psychiatric disorders in elderly
6.3	Psychosocial aspects of old age
6.4	End-of-life issues and others
Treatments
7.1	Psychopharmacology
7.2	Psychotherapy
7.3	Other therapies
7.4	Others
Community psychiatry
8.1	Mental health policies
8.2	Outreach activities and school mental health
8.3	Psychosocial rehabilitation
8.4	Others
Forensic psychiatry and ethics
9.1	Legal framework and legislations
9.2	Criminal responsibility and psychiatrist as a witness
9.3	Testamentary capacity and disability certification
9.4	Medical negligence
9.5	Professional ethics and etiquettes
9.6	Ethics in psychiatry and others
Special population and situations
10.1	Psychiatric considerations in women
10.2	Psychiatric considerations in LGBTQ
10.3	Psychiatric considerations in immigrants
10.4	Psychiatric considerations in disaster management
10.5	Psychiatric considerations in immigrants and others
Psychiatrist as a leader and administrator
11.1	Management of outpatient department
11.2	Management of psychiatry ward
11.3	Procurement of drugs and equipment
11.4	Others

OCD – Obsessive-compulsive disorder, GID – Gender identity disorders, LGBTQ-Lesbian, Gay, Bisexual, Transgender and Queer

Table 2

Sample portfolio page showing various elements pertaining to single entrustable professional activities

Competency No: 4	Segment:General Psychiatry skills			To be completed by: Phase 1
Competency: Ability to elicit psychopathology and perform mental status examination
Expected level: Vital Expected Domain expertise: Does
Teaching Learning Experiences: Clinical case presentation, Ward round, Apprenticeship, Group discussion
Assessment: WPBA, MEQ, Viva voce, Case Presentation, OSCE
S No	Milestone (Instructor to initial with date in the box once he/she is satisfied with the level achieved)	Knows	Knows how	Shows	Shows how	Does
1	Demonstrates knowledge of psychiatric symptomatology
2	Demonstrates knowledge of mental status examination
3	Takes informed consent
4	Establishes rapport and therapeutic alliance
5	Elicits comprehensive history to reach provisional diagnosis
6	Performs mental status examination eliciting signs of psychopathology
7	Assesses cognition, insight, and judgement to add to formulation of diagnosis
8
9
10
Reflections of student (What have you learned and its implications on your professional development):
Feedback by facilitator:

Figure 2

Section-wise entrustable professional activities

Figure 3

VED analysis of entrustable professional activities

Supplementary Material 2

List of Vital EPAs

Section	Entrustable Professional Activities
	General Psychiatry	Ability to establish therapist-patient relationship ensuring gender sensitivity, confidentiality and boundaries
		Ability to take informed consent
		Ability to demonstrate components of psychiatric history taking
		Ability to elicit psychopathology and perform mental status examination
		Ability to perform cognitive assessment
		Ability to make a diagnostic and cultural formulation
		Ability to perform risk assessment
		Ability to define mental health and to utilize the concept of normalcy in counselling
		Ability to clinically evaluate, make differential diagnoses and manage a suicidal patient
		Ability to clinically evaluate, investigate, make differential diagnosis and manage a case of Delirium
		Ability to clinically evaluate, make differential diagnoses and manage a case of violent and aggressive patients
		Ability to clinically evaluate, make differential diagnoses and manage Psychotropic drug related emergencies (Neuroleptic Malignant Syndrome, Serotonin syndrome, etc.)
		Ability to impart psychoeducation to a patient having psychiatric illness.
		Ability to impart psychoeducation to a caregiver of a patient having psychiatric illness
		Ability to perform common psychodiagnostic tests
		Ability to administer common psychiatric rating scales
		Ability to plan and conduct research
		Ability to perform grief counselling
	Neuropsychiatry	Ability to perform neurological examination and give a 4 tier diagnosis in a case of neuropsychiatric syndrome
		Ability to clinically evaluate the psychiatric symptoms occurring in patient with Neurological illnesses (Head injury, Epilepsy, Movement disorder, Stroke, etc)
		Ability to formulate and execute a management plan for psychiatric symptoms occurring in patient with Neurological illnesses (Head injury, Epilepsy, Movement disorder, Stroke, etc)
		Ability to perform and interpret EEG
		Ability to order, analyse and utilise Neuroimaging findings
	Psychiatric aspects of medical disorders	Psychiatric aspects of medical disorders
		Ability to clinically evaluate the psychiatric symptoms in patient with Endocrine disorders
		Ability to formulate and execute a management plan for psychiatric symptoms in patient with Endocrine disorders
		Ability to clinically evaluate the psychiatric symptoms in patient with Cancer
		Ability to formulate and execute a management plan for psychiatric symptoms in patient with Cancer
		Ability to perform psychiatric assessment in a potential organ donor & recipient
		Ability to elicit history, perform examination, prepare differential diagnosis and investigate a case of Alcohol Use disorder
		Ability to formulate and execute a management plan for a case of Alcohol Use disorder
		Ability to clinically evaluate, investigate, make differential diagnosis and manage a case of Delirium Tremens
		Ability to establish therapist-patient relationship ensuring gender sensitivity, confidentiality and boundaries
		Ability to take informed consent
		Ability to demonstrate components of psychiatric history taking
		Ability to elicit psychopathology and perform mental status examination
		Ability to perform cognitive assessment
		Ability to make a diagnostic and cultural formulation
		Ability to perform risk assessment
		Ability to define mental health and to utilize the concept of normalcy in counselling
		Ability to clinically evaluate, make differential diagnoses and manage a suicidal patient
		Ability to clinically evaluate, investigate, make differential diagnosis and manage a case of Delirium
		Ability to clinically evaluate, make differential diagnoses and manage a case of violent and aggressive patients
		Ability to clinically evaluate, make differential diagnoses and manage Psychotropic drug related emergencies (Neuroleptic Malignant Syndrome, Serotonin syndrome, etc.)
		Ability to impart psychoeducation to a patient having psychiatric illness.
		Ability to impart psychoeducation to a caregiver of a patient having psychiatric illness
		Ability to perform common psychodiagnostic tests
		Ability to administer common psychiatric rating scales
		Ability to plan and conduct research
		Ability to perform grief counselling
	Neuropsychiatry	Ability to perform neurological examination and give a 4 tier diagnosis in a case of neuropsychiatric syndrome
		Ability to clinically evaluate the psychiatric symptoms occurring in patient with Neurological illnesses (Head injury, Epilepsy, Movement disorder, Stroke, etc)
		Ability to formulate and execute a management plan for psychiatric symptoms occurringin patient with Neurological illnesses (Head injury, Epilepsy, Movement disorder, Stroke, etc)
		Ability to perform and interpret EEG
		Ability to order, analyse and utilise Neuroimaging findings
	Psychiatric aspects of medical disorders	Psychiatric aspects of medical disorders
		Ability to clinically evaluate the psychiatric symptoms in patient with Endocrine disorders
		Ability to formulate and execute a management plan for psychiatric symptoms in patient with Endocrine disorders
		Ability to clinically evaluate the psychiatric symptoms in patient with Cancer
		Ability to formulate and execute a management plan for psychiatric symptoms in patient with Cancer
		Ability to perform psychiatric assessment in a potential organ donor & recipient
	Adult Psychiatry	Ability to elicit history, perform examination, prepare differential diagnosis and investigate a case of Alcohol Use disorder
		Ability to formulate and execute a management plan for a case of Alcohol Use disorder
		Ability to clinically evaluate, investigate, make differential diagnosis and manage a case of Delirium Tremens
		Ability to elicit history, perform examination, prepare differential diagnosis and investigate a case of Opioid Use disorder
		Ability to formulate and execute a management plan for a case of Opioid Use disorder
		Ability to elicit history, perform examination, prepare differential diagnosis and investigate a case of Cannabis Use Disorders
		Ability to formulate and execute a management plan for a case of Cannabis Use Disorders
		Ability to elicit history, perform examination, prepare differential diagnosis and investigate a case of Tobacco Use Disorders
		Ability to formulate and execute a management plan for a case of Tobacco Use Disorders
		Ability to elicit history, perform examination, prepare differential diagnosis and investigate a case of disorders related to use of other psychoactive substancesAbility to formulate and execute a management plan for a case of disorders related to use of other psychoactive substances
		Ability to elicit history, perform examination, prepare differential diagnosis and investigate a case of Schizophrenia
		Ability to formulate and execute a management plan for a case of Schizophrenia Ability to elicit history, perform examination, prepare differential diagnosis and investigate a case of Delusional disorder
		Ability to formulate and execute a management plan for a case of Delusional Disorder
		Ability to elicit history, perform examination, prepare differential diagnosis and investigate a case of Acute and Transient Psychotic disorder
		Ability to formulate and execute a management plan for a case of Acute and Transient Psychotic disorder
		Ability to elicit history, perform examination, prepare differential diagnosis and investigate a case of Depressive Episode
		Ability to formulate and execute a management plan for a case of Depressive Episode
		Ability to elicit history, perform examination, prepare differential diagnosis and investigate a case of Mania/hypomania
		Ability to formulate and execute a management plan for a case of Mania/hypomania
		Ability to elicit history, perform examination, prepare differential diagnosis and investigate a case of Bipolar Affective Disorder
		Ability to formulate and execute a management plan for a case of Bipolar Affective Disorder
		Ability to elicit history, perform examination, prepare differential diagnosis and investigate a case of Panic Disorder
		Ability to formulate and execute a management plan for a case of Panic Disorder
		Ability to elicit history, perform examination, prepare differential diagnosis and investigate a case of Generalised anxiety Disorders
		Ability to formulate and execute a management plan for a case of Generalised anxiety Disorders
		Ability to elicit history, perform examination, prepare differential diagnosis and investigate a case of Phobic anxiety Disorders
		Ability to formulate and execute a management plan for a case of Phobic anxiety Disorders
		Ability to elicit history, perform examination, prepare differential diagnosis and investigate a case of Obsessive Compulsive Disorders
		Ability to formulate and execute a management plan for a case of Obsessive Compulsive Disorders
		Ability to elicit history, perform examination, prepare differential diagnosis and investigate a case of Post Traumatic Stress Disorder
		Ability to formulate and execute a management plan for a case of Post Traumatic Stress Disorder
		Ability to elicit history, perform examination, prepare differential diagnosis and investigate a case of Adjustment disorder
		Ability to formulate and execute a management plan for a case of Adjustment disorder
		Ability to elicit history, perform examination, prepare differential diagnosis and investigate a case of Somatoform Disorders
		Ability to formulate and execute a management plan for a case of Somatoform Disorders
		Ability to elicit history, perform examination, prepare differential diagnosis and investigate a case of Sexual dysfunction, not caused by organic disorder or disease
		Ability to formulate and execute a management plan for a case of Sexual dysfunction, not caused by organic disorder or disease
	Child & Adolescent Psychiatric Disorders	Ability to identify and manage psychosocial issues related to normal childhood and adolescent development (School refusal, Social anxiety, Sibling rivalry, etc.)
		Ability to elicit history, perform examination, prepare differential diagnosis and investigate a case of Intellectual Disability
		Ability to formulate and execute a management plan for a case of Intellectual Disability
		Ability to elicit history, perform examination, prepare differential diagnosis and investigate a case of Autism Spectrum Disorder
		Ability to formulate and execute a management plan for a case of Autism Spectrum Disorder
		Ability to elicit history, perform examination, prepare differential diagnosis and investigate a case of Hyperkinetic Disorder
		Ability to formulate and execute a management plan for a case of Hyperkinetic Disorder
	Geriatric Psychiatry	Ability to clinically evaluate a case of Mild Cognitive Impairment & Dementia occurring in an elderly patient.
		Ability to formulate and execute a management plan for a case of Mild Cognitive Impairment & Dementia occurring in an elderly patient.
		Ability to elicit history, perform examination, prepare differential diagnosis and investigate a case of psychiatric disorders in elderly
		Ability to formulate and execute a management plan for a psychiatric disorders in elderly
		Ability to prescribe antidepressants as per guidelines ensuring dose titration, adherence & monitoring adverse effects
		Ability to prescribe antipsychotics as per guidelines ensuring dose titration, adherence & monitoring adverse effects
		Ability to prescribe mood-stabilizers as per guidelines ensuring dose titration, adherence & Monitoring adverse effects
		Ability to prescribe sedative & hypnotics as per guidelines ensuring dose titration, adherence & monitoring adverse effects
		Ability to prescribe anticraving medications as per guidelines ensuring dose titration, adherence & monitoring adverse effects
		Ability to prescribe drugs used in childhood psychiatric disorders as per guidelines ensuring dose titration, adherence & monitoring adverse effects
		Ability to prescribe drugs used in geriatric psychiatric disorders as per guidelines ensuring dose titration, adherence & monitoring adverse effects
		Ability to prescribe other drugs used in psychiatric disorders as per guidelines (Anticholinergics, etc.)
		Ability to prescribe psychotropics in psychiatric patients with hepatic and renal impairment as per guidelines ensuring dose titration, adherence & monitoring adverse effects
		Ability to perform Brief intervention
		Ability to perform Behaviour therapy
		Ability to perform Motivational Enhancement Therapy
		Ability to perform Group therapy
		Ability to perform Family therapy
		Ability to perform ECT
	Community Psychiatry	Ability to execute National Mental Health Policies
		Ability to formulate and execute community mental health outreach programs
		Advice administration in executing School mental health program
		Ability to formulate and execute a management plan for psycho-social rehabilitation for Persons with Mental Illness
	Forensic Psychiatry & Ethics	Ability to function within the ambit of relevant mental health act (MHCA-2017)
		Ability to perform assessment and documentation as per prevailing legislation (NDPS, POCSO, JJ Act)
		Ability to perform assessment for disability certification (RPwD Act 2016)
		Ability to assess Criminal Responsibility on referral
		Ability to opine as expert witness
		Ability to assess testamentary capacity
		Ability to prevent Medical Negligence
		Ability to function appropriately maintaining professional ethics and etiquette
		Ability to conduct research within the framework of bio-ethics
		Ability to clinically evaluate and manage psychiatric symptoms during pregnancy
	Special Populatior	Ability to clinically evaluate and manage psychiatric symptoms during lactation

DISCUSSION

CBME is currently the most desirable medical education framework worldwide. However, despite the many advantages, implementation has been challenging. To operationalize CBME, EPAs were introduced. In fact, EPAs form the core of CBME. Medical educators are required to define the various EPAs and their scope which corresponds to their workplace-based learning settings. In addition, there is a need to develop reliable and adequate assessment frameworks. In India, regulatory agencies have mandated a CBME-based curriculum. However, they have not defined any specific curriculum or a corresponding assessment framework, thereby essentially putting the onus of implementation on the medical colleges and universities. Current teaching and learning that happens in most medical colleges across the country lacks a defined structure. Moreover, there are few objective assessment methods available. Clearly defined EPAs can be instrumental in this regard. They will help both the learner and the educator to have a clear understanding of the nature of skill expected from a trainee. This can facilitate focussed and objective learning. Since the EPAs are expected to cover the breadth of specialty, it will help the learners master skills that may be overlooked for various reasons during the course. Further, in such a setting, the use of portfolios can add quality to learning. Remarks and inputs in the portfolio can add to self-directed learning.[9]

Researchers in the field of medical education are working on developing comprehensive set of EPAs. Some have focused on developing educational stage-specific EPAs. Almost all medical specialties have seen a surge in this area of study. Even though there is an overlap in clinical skills across specialties, the “specialty-specific” teaching and learning content requires focused work in the field by domain experts. In the field of psychiatry, research in the area of EPAs has shown a steady increase in the number of publications starting in the first decade of the 21st century. The quality of studies has also shown improvement over the years as reported in a systematic review on EPAs in psychiatry published in 2019.[10]

Number of entrustable professional activities identified

After an iterative process, we identified a total of 167 EPAs. We identified a greater number of EPAs than reported by most studies done to identify EPAs in psychiatry. In 2014, the Executive Council of the American Association of Directors of Psychiatric Residency Training created the EPAs for Psychiatry Task Force. Members of the task force developed essential and representative EPAs using a rigorous, multistage process. This comprehensive process yielded 13 end-of-training EPAs which is markedly less than the number identified by us.[11] Similarly, other studies in the field conducted in the USA and Australia/New Zealand have reported EPAs in the range of 1–18. We, however, feel that this number of EPAs though simplistic is too restrictive and may not cover all the varied aspects of learning. A comprehensive coverage of all the competencies would need more EPAs. It makes the EPAs more specific and reduces overlap. Hence, the 167 EPAs identified are comprehensive and more representative of the final goal of a CBME curriculum in psychiatry postgraduation. We could not find any Indian studies mentioning EPAs in psychiatry. It is worth mentioning that the present EPAs are just a beginning. It will require further refinement with inputs based on practical application from different institutes and experts.

Section-wise distribution of entrustable professional activities

EPAs identified were classified based on various sections of the syllabus. They were divided into 11 broad groups and 57 different sections representative of all aspects of syllabus. A similar method was followed by Datta et al. in the development of EPAs for ENT.[9]

VED analysis

The identified EPAs were further subdivided into vital, essential, and desirable based on shared understanding of relative importance in real-life independent clinical practice. This means of classifying entities on the merit of importance has been used in the hospital medical store procurements. Drugs considered vital are those that are lifesaving medications and are given utmost priority in procurement. Stores which are not lifesaving but are required for common illnesses and are prescribed on a regular basis are included in essential category. The last category of drugs, i.e. desirable, is infrequently used and is not lifesaving. These generally include medications for rare disorders. The classification of EPAs will help the students and teachers to devote proportionate time and resources to a specific EPA. However, this may be required to be tailored to the specific needs of different institutes. Institutes may choose to shuffle the EPAs into different categories of vital, essential, and desirable according to their specific needs. The purpose of making different levels of EPAs was to help faculty and students identify areas requiring greater investment of time and resources.

The enumeration of milestones for each EPA needs special mention. It is imperative that developed EPAs be deconstructed into discrete assessable milestones. This has been shown in an example [Table 2]. As already mentioned, this needs to be less prescriptive and medical educators need to adapt them considering their needs and feasibility.

Implications

The development of EPAs has several important implications. Foremost, they can become part of a portfolio in medical education. Concurrently, they will be benchmarks for a student to achieve proficiency in the subject. They can be used as guides by teachers and students alike to set clear goals. It is pertinent to mention the EPAs have a hierarchy of importance and some EPAs may not be as important as others. Hence, it is important that students focus more on vital EPAs and achieve desirable EPAs if time and facility permits. Our intent of making three levels was to allow for a degree of flexibility considering variation between institutes in terms of resources and clientele-specific requirements. There is a possible risk of some EPAs being overlooked in tertiary care teaching hospitals. However, such a tendency should be guarded against and steps taken to ensure the achievement of all vital EPAs.

Furthermore, it will help subject experts and policymakers to identify vital areas of skill and expertise, which otherwise are less represented in the present curriculum. This has implications in refinement and development of a holistic syllabus. This may also be a window of opportunity for the medical educators to identify deficiencies in resources and infrastructure required for providing adequate training. Furthermore, appropriate interdepartmental collaborations including rotations and cross attachments can be planned to enhance experience and output of training. An example might be EPAs related to assessment and management of neuropsychiatric disorders where an overlap exists between neurology and psychiatry.

Limitations

The aim of the present study was to develop a list of comprehensive EPAs in psychiatry by subject experts with involvement of students in training. There are, however, certain limitations which need to be highlighted. The EPAs developed were internally peer-reviewed but have not been tested. A long follow-up is required to assess the improvement in objectively defined outcomes of training. Further, this list of EPAs involved experts from a single institution which might have led to some bias. However, we wish to add that this list is not the final word on the subject. We hope that different institutions across the nation add them to their curriculum and report results after use. The list can be taken up for refinement and updation over time. We believe that this is one vital early step as identification of EPAs is the most fundamental requirement of development in this area. This step does not intend to be an education intervention in its current form and is proposed to be used as a guide for developing portfolios. In future, we plan to develop an electronic version of the portfolio.

The International Association for Medical Education in Europe guide no. 140 published in 2020 gives recommendations as to how an EPA should be elucidated into eight sections.[12] Although a detailed breakdown of EPAs based on the recommendations is possible. However, we have restricted ourselves as the primary objective of the study was to make a comprehensive list of EPAs.

CONCLUSION

CBME is the most desirable medical education framework worldwide and EPAs lie at its core. National medical education regulators have provided guidelines for CBME, but detailed description of requisite skills in a psychiatry postgraduate trainee after 3 years of training is currently lacking. An attempt has been made to clearly define such skills in the form of EPAs. The use of these identified EPAs has been proposed for development of portfolios. To bring in more objectivity and ease of assessment, explicit milestones have also been defined. It is envisaged that the use of EPAs and portfolios will be instrumental in implementation and success of CBME in the discipline of psychiatry. It is also hoped that medical colleges will incorporate the same in their curricula and data will be generated to identify the challenges which shall guide future refinement of the EPAs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Supplementary Material 1: Portfolio of each EPA.

Competency No: 1 Segment: General Psychiatry skills To be completed by: Phase 1

Competency : Ability to establish therapist-patient relationship ensuring gender sensitivity, confidentiality and boundaries

Expected level : Vital Expected Domain expertise: Does

Teaching Learning Experiences : Clinical case presentation, Ward round, Apprenticeship, Group discussion

Assessment : MEQ, Viva voce, Case Presentation, OSCE

Reflections of student (What have you learned and its implications on your professional development):

Feedback by facilitator :

Competency No: 1 Segment: Neurological examination To be completed by: Phase 1

Competency : Ability to perform neurological examination and give a 4 tier diagnosis in a case of neuropsychiatric syndrome

Expected level : Vital Expected Domain expertise: Does

Teaching Learning Experiences : Clinical case presentation, ward round, apprenticeship, group discussion

Assessment : Viva voce, Case Presentation, OSCE

Reflections of student (What have you learned and its implications on your professional development):

Feedback by facilitator :

Competency No: 1 Segment: Psychiatric aspects of medical disorders To be completed by: Phase 2

Competency : Ability to clinically evaluate the psychiatric symptoms in patient with Endocrine disorders

Expected level : Vital Expected Domain expertise: Shows

Teaching Learning Experiences : Clinical case presentation, ward round, apprenticeship, group discussion

Assessment : MEQ, Viva voce, Case Presentation, OSCE

Reflections of student (What have you learned and its implications on your professional development):

Feedback by facilitator :

Competency No: 1 Segment: Substance use disorders To be completed by: Phase 2

Competency : Ability to elicit history, perform examination, prepare differential diagnosis and investigate a case of Alcohol Use disorder

Expected level : Vital Expected Domain expertise : Does

Teaching Learning Experiences : Clinical case presentation, ward round, apprenticeship, group discussion

Assessment : MCQ, MEQ, Viva voce, Case Presentation, OSCE

Reflections of student (What have you learned and its implications on your professional development):

Feedback by facilitator :

Competency No: 1 Segment: Psychosocial aspects of normal childhood and adolescent development To be completed by: Phase 2

Competency : Ability to identify and manage psychosocial issues related to normal childhood and adolescent development (School refusal, Social anxiety, Sibling rivalry, etc.)

Expected level : Vital Expected Domain expertise: Does

Teaching Learning Experiences : Clinical case presentation, ward round, apprenticeship, group discussion

Assessment : MEQ, Viva voce, Case Presentation, OSCE

Reflections of student (What have you learned and its implications on your professional development):

Feedback by facilitator :

Competency No: 1 Segment: Mild Cognitive Impairment & Dementia To be completed by: Phase 2

Competency : Ability to clinically evaluate a case of Mild Cognitive Impairment & Dementia occurring in an elderly patient.

Expected level : Vital Expected Domain expertise: Does

Teaching Learning Experiences : Clinical case presentation, ward round, apprenticeship, group discussion

Assessment : MEQ, Viva voce, Case Presentation, OSCE

Reflections of student (What have you learned and its implications on your professional development):

Feedback by facilitator :

Competency No: 1 Segment: Psychopharmacology To be completed by: Phase 2

Competency : Ability to prescribe antidepressants as per guidelines ensuring dose titration, adherence & monitoring adverse effects

Expected level : Vital Expected Domain expertise: Does

Teaching Learning Experiences : Clinical case presentation, ward round, apprenticeship, group discussion

Assessment : MEQ, Viva voce, Case Presentation, OSCE

Reflections of student (What have you learned and its implications on your professional development):

Feedback by facilitator :

Competency No: 1 Segment: Mental Health Policies To be completed by: Phase 3

Competency : Ability to execute National Mental Health Policies

Expected level : Vital Expected Domain expertise: Shows How

Teaching Learning Experiences : Tutorials, DOAP session

Assessment : Educational seminar, MEQ, Viva-voce

Reflections of student (What have you learned and its implications on your professional development):

Feedback by facilitator :

Competency No: 1 Segment: Legal framework & Legislation To be completed by: Phase 3

Competency : Ability to function within the ambit of relevant mental health act (MHCA-2017)

Expected level : Vital Expected Domain expertise: Shows How

Teaching Learning Experiences : Case Based Learning, Tutorials, DOAP session

Assessment : WPBA, OSCE, CBL, MEQ

Reflections of student (What have you learned and its implications on your professional development):

Feedback by facilitator :

Competency No: 1 Segment: Psychiatric considerations in women To be completed by: Phase 2

Competency: Ability to clinically evaluate and manage psychiatric symptoms during pregnancy

Expected level : Vital Expected Domain expertise: Does

Teaching Learning Experiences : Clinical case presentation, ward round, apprenticeship, group discussion

Assessment : MEQ, Viva voce, Case Presentation, OSCE

Reflections of student (What have you learned and its implications on your professional development):

Feedback by facilitator :

Competency No: 1 Segment: Management of Out-Patient Department To be completed by: Phase 3

Competency : Ability to supervise day to day working of OPD including documentation

Expected level : Essential Expected Domain expertise: Shows How

Teaching Learning Experiences : Appernticeship assessment

Assessment : WPBA/Project wor

Reflections of student (What have you learned and its implications on your professional development):

Feedback by facilitator :

Supplementary Material 2: List of Vital EPAs

S no	Milestone (Instructor to initial with date in the box once he/she is satisfied with the level achieved)	Knows	Knows How	Shows	Shows how	Does
1	Demonstrates knowledge of empathy, rapport and therapeutic alliance in psychiatry
2	Demonstrates knowledge of confidentiality, gender sensitivity and boundary issues in psychiatry
3	Conducts interview maintaining confidentiality, gender sensitivity and therapist-patient boundary
4	Communicates with empathetic non-judgemental responsiveness to patient
5	Uses a variety of validation techniques to build rapport
6	Documents and maintains clinical records ensuring confidentiality
7
8
9
10

S no	Milestone (Instructor to initial with date in the box once he/she is satisfied with the level achieved)	Knows	Knows How	Shows	Shows how	Does
1	Demonstrates knowledge of Neurological examination
2	Obtains informed consent
3	documents management plan with pharmacological, non-pharmacological, somatic and rehabilitation components
4	Performs clinical examination including detailed neurological examination
5	Formulates the case and presents 4-tier diagnosis including etiological differential diagnoses
6	Documents findings in clinical records
7	Communicates assessment to patient and caregivers
8	Incorporates findings in management plan
9
10

S no	Milestone (Instructor to initial with date in the box once he/she is satisfied with the level achieved)	Knows	Knows How	Shows	Shows how	Does
1	Elicits appropriate history to diagnose psychiatric symptoms in patient with Endocrine disorders
2	Does physical and mental status examination
3	Formulate differential diagnosis
4	Demonstrate knowledge of diagnostic criteria as per ICD-10 / DSM-5
5	Order appropriate investigations and interpret them
6	Documents clinical findings
7
8
9
10

S no	Milestone (Instructor to initial with date in the box once he/she is satisfied with the level achieved)	Knows	Knows How	Shows	Shows how	Does
1	Elicits history of intoxicaition, harmful use, dependence in a patient of Alcohol Use disorder
2	Elicit withdrawal features in a suspected case of Alcohol Use Disorder
3	Formulate differential diagnosis in a case of Alcohol Use Disorder
4	Demonstrate knowledge of diagnostic criteria as per ICD-10 / DSM-5
5	Order appropriate investigations and interpret them
6	Documents clinical findings
7
8
9
10

S no	Milestone (Instructor to initial with date in the box once he/she is satisfied with the level achieved)	Knows	Knows How	Shows	Shows how	Does
1	Demonstrates knowledge of psychosocial issues related to normal childhood and adolescent development
2	Elicits history from parent and child about psychosocial issues
3	Carries out physical and mental status examination
4	Formulates differential diagnoses keeping in view of developmental stage
5	Orders appropriate investigations and interprets them
6	Documents clinical findings and management plan
7	Performs psychotherapeutic interventions appropriate to developmental stage
8	Counsels family members regarding understanding of psychosocial issues related to normal childhood and adolescent development
9
10

S no	Milestone (Instructor to initial with date in the box once he/she is satisfied with the level achieved)	Knows	Knows How	Shows	Shows how	Does
1	Elicits appropriate history to diagnose a case of Mild Cognitive Impairment & Dementia occurring in an elderly patient.
2	Does physical and mental status examination
3	Formulate differential diagnosis
4	Demonstrate knowledge of diagnostic criteria as per ICD-10 / DSM-5
5	Order appropriate investigations and interpret them
6	Documents clinical findings
7
8
9
10

Table

S no	Milestone (Instructor to initial with date in the box once he/she is satisfied with the level achieved)	Knows	Knows How	Shows	Shows how	Does
1	Demonstrates knowledge of indications, contraindications and side effects of anti-depressants and counsells patients
2	Demonstrates knowledge of pharmacodynamics and pharmacokinetics of anti-depressants
3	Takes informed consent and utilises shared decision making
4	Analyse the clinical situation for appropriate choice of drug
5	Assesses potentially harmful or beneficial drug-drug interactions
6	Documents prescriptions accurately in the patient’s medical record with using generic names, correct doses, duration after ascertaining
7	Assesses and monitor adherence to therapy
8	Assesses and monitor response to therapy
9
10

S no	Milestone (Instructor to initial with date in the box once he/she is satisfied with the level achieved)	Knows	Knows How	Shows	Shows how	Does
1	Demonstrates knowledge of components (goals, guidelines and functionaries) of National Mental Health Program and District Mental Health Program.
2	Demonstrates knowledge of components of National Mental Health Policy.
3	Executes duties and responsibilities of Psychiatrist under NMHP and DMHP.
4	Conducts training of medical officers and para-medical staff in execution of NMHP/DMHP
5	Follows procedures for indenting, prescribing and issuing medications and equipment.
6	Adheres to guidelines for utilisation of allotted funds.
7	Maintains documents and records.
8
9
10

S no	Milestone (Instructor to initial with date in the box once he/she is satisfied with the level achieved)	Knows	Knows How	Shows	Shows how	Does
1	Demonstrates knowledge of the provisions of relevant mental health act (MHCA 2017)
2	Performs capacity assessment of patient
3	Takes informed consent from patient or nominated representative depending on the type of admission
4	Processes independent/supported admission using appropriate forms
5	Communicates effectively with the patient and nominated representative
6	Communicates effectively with mental health authorities and mental health review boards
7	Documents findings and maintains records
8	Processes procedure of discharge
9
10

S no	Milestone (Instructor to initial with date in the box once he/she is satisfied with the level achieved)	Knows	Knows How	Shows	Shows how	Does
1	Clinically evaluates and screens a pregnant woman presenting with psychiatric symptoms.
2	Psycho-educates a pregnant woman and her caregivers about stress management, relaxation techniques and need for referral/ specialist care.
3	Performs risk-benefit analysis for selecting medications (dose and duration) for treatment of psychiatric symptoms with respect to safety and efficacy in first, second or third trimester of pregnancy.
4	Psycho-educates psychiatric patients of child-bearing age regarding effect of pregnancy on psychiatric illness and vice versa.
5	Psycho-educates female psychiatric patients who are planning pregnancy regarding potential effects of psychiatric medication on pregnancy and vice versa
6	Counsels pregnant psychiatric patients regarding symptom-monitoring, indicators of relapse and need for regular follow-up.
7
8
9
10

Table

S no	Milestone (Instructor to initial with date in the box once he/she is satisfied with the level achieved)	Knows	Knows How	Shows	Shows how	Does
1	Checks general cleanliness and area maintenance of the OPD
2	Checks availability of various documents and investigation forms
3	Checks the equipment in the OPD is working
4	Checks if all the required registers are present and being filled up regularly
5	Scrutinize feedback register of the OPD and recommends action to be taken
6
7
8
9
10