Identifying emergency medicine program directors' expectations of competence upon entry into residency: Bridging the distance from the Association of American Medical Colleges Core Entrustable Professional Activities.

Background: Residency program directors (PDs) frequently describe students as unprepared for the patient care responsibilities expected of them upon entry into residency. The Association of American Medical Colleges (AAMC) developed the Core Entrustable Professional Activities (Core EPAs) to address this concern by defining 13 tasks students should be able to do with minimal supervision upon graduation. However, the Core EPAs remain difficult for PDs to use due to their breadth and lack of granularity. Methods: Using Delphi consensus methodology, we identified granular observable practice activities (OPAs) that PDs expect of entering interns derived from the Core EPAs. Twelve emergency medicine education experts drafted OPAs based on the Core EPAs and their associated core functions described in one-page schematics. A separate group of 12 PDs underwent three rounds of voting, and consensus for inclusion was set at 70%. Thematic analysis of comments discussing votes was performed using an inductive approach. Results: A total of 321 OPAs were drafted and 127 adopted as expectations for entering interns based on the Core EPAs. The adopted OPAs were all general expectations; none were specialty-specific. Four main themes were identified from the comments: Schools are not responsible for specialty-specific training, PDs do not fully trust schools' assessments, supervision expectations of graduates should be lowered for higher-order EPAs, and the context in which the student performs a task and its associated complexity matter greatly in entrustment decisions. Conclusions: PDs agree with the generalist focus of the AAMC Core EPAs and feel strongly that specialty training should be left to residency programs. They also have mechanisms in place to verify entrustment within their local context. Transparency in assessment and summative entrustment processes in UME may unify expectations. Finally, the granularity of OPAs may aid in a post-Match handover to further operationalize the EPAs and optimize the UME-to-GME transition.