changing-for-the-right-reasons

Even though the Entrustable Professional Activity (EPA) concept offers a practical approach to assess competence in the real-world, the change still required time to get used to. Clin Asst Prof Andrew Ong, who is the PD of Gastroenterology and Consultant in Gastroenterology & Hepatology at SGH, shares why he transited to EPA when the change was resisted by the majority.

"EPAs were introduced in full force by MOH in the last couple of years, with Group A specialties taking the first plunge. Like many PDs, I was miffed at the paperwork and logistics needed to navigate for a major change like this. And there will be many of such changes with our separation from ACGME-I and into APMES. However, I am also a strong believer that change and uncertainty brings with it opportunities.

Why did I decide to change to EPAs way before anyone did?

The SingHealth Gastroenterology programme started its EPA transition as early as 2020, two years before MOH transited programmes into it. I was often asked, “why did you decide to do it when no one else was doing it?”

The answer? Serendipity coupled with a desire to improve. A colleague was unavailable to attend the MOH workshop on EPAs in 2018, so I was given the opportunity to participate instead. Although I was then the Associate Programme Director (APD) of Internal Medicine, I was seated at the wrong table with the Gastroenterology folks, and ended up working together to write the EPAs for Gastroenterology, not knowing that I would implement EPAs years in Gastroenterology later!

However, the impetus of change was not entirely just due to a national directive, but because I saw huge gaps within the assessment culture of our residency programmes. The Clinical Competency Committee (CCC) system was not running as it should, with focus often on the problematic residents and not on the growth of all residents. Prospective direct observations were not happening, and most assessments were untimely retrospective checkbox ticking exercises. While EPAs are not perfect, I saw it as an opportunity to rebuild an assessment system with the right principles and culture.

Therefore, when I took over the SingHealth Gastroenterology Programme in January 2020, I already had a plan to "renovate" the assessment system. On hindsight, I must have been mad to do this in my first six months as a PD when most of the core faculty were more senior than me, and have been around much longer than I have. But I was so sure of the vision I had for this, that I deep dived into understanding change management strategies, so that I could convince them.

The journey of changing for the right reasons

The journey was not easy from the beginning, and it still isn't. Changing something as complex as an assessment culture takes time, perseverance, and sheer passion. The problem had to be dealt on multiple fronts. The assessment culture in our residency system was not ideal for many reasons: Busy faculty, Busy residents, Cumbersome forms, Poor workflows etc. As I tackled these things individually, I came to realise that the introduction of EPAs was an opportunity to start from scratch and do things the right way. Residency has been in SingHealth for more than 10 years, but much of what is done has become muscle memory based on inherited systems without questioning into why we do what we do.

We change for our trainees

There were times when I saw my assessment being done the old way of retrospective checkbox ticking, nonetheless I have also noticed changes within the programme. I see assessors doing direct observation of procedures in a more structured way, I see clinic supervisions guided by assessment forms, and I see trainees sourcing for assessment to make themselves better. Recently, when trainees called me to discuss a case for a blue letter or take over, they would also ask "Can I use these cases for an EPA assessment?". I have also noticed that assessors are giving highly detailed feedback around the EPA. It warms my heart even more to see them make the changes to get better at using the EPA framework.

My view on the EPA transition has shifted somewhat. I was once naive and thought that an assessment culture can be revamped with the right push. It is obviously more difficult than that, but I still think that it is very possible given time. My focus now is on using these EPA assessments for learning. I want to ensure that regardless of the quality of assessment done on the ground, the residents drive their own learning and understand how to use these assessments to improve. Our residents are all quick-witted; they just need the right push in the right direction with the right tools. EPAs seem to have the potential to do that if done in the right way.

At the end of the day, many PDs may ask themselves: Was it worth it? Was it worth the effort I put in to change my assessment system?

One may argue that there is no choice since the transition into EPAs is driven by MOH, but most of us know that what we do extends beyond this bureaucracy. What we do makes a difference in the long run. And for assessment culture, we may only see the start of it before we hand over to our successors.

Ultimately, no assessment system is perfect, and our changes may still revert to a checkbox ticking exercise for many of our assessors. But even if all we did was to change 20% of our faculty, and we did help our trainees get better in a more structured manner, then I would say without batting an eyelid, that it truly was worth it."

Changing for the Right Reasons