Background

The institutions try to improve or develop the competencies of medical teachers in their current responsibilities and continuously upgrade and redefine their competencies (1). A medical teacher has a wide range of roles and responsibilities that vary from a medical teacher to a trainer and finally a clinical specialist (2). Most medical teachers receive limited training to prepare them to provide effective teaching and clinical supervision (3). It has been observed that they often deal with problems in effectively carrying out their academic responsibilities due to the lack of training (4-6). Furthermore, evidence shows that medical teachers have insufficiently prepared across traditional competencies of medical knowledge, clinical skills, professionalism, and newer competencies of evidence-based practice, quality improvement, interdisciplinary teamwork, and systems to perform their functions effectively (7). Indeed, attaining a qualified medical teacher has been associated with developing many roles, leadership positions, and responsibilities in medical education (1). However, if they see proper educational programs in this regard, they will definitely become better teachers (3).

Entrustable professional activities (EPAs) are units of professional activities, i.e., tasks or responsibilities that can be implemented, observed, and measured independently in terms of procedures and outcomes, and when an individual acquires sufficient competencies (1). Fitzgerald (2016) stated that educational methods, curriculum development, teaching community, evaluation, and leadership skills are competencies of medical teachers required for achieving EPA-based competence (2). Iqbal et al. (2018) reviewed existing medical teacher education programs that incorporated EPAs in their frameworks to provide further insights into how the EPA concept is adopted (3). Furthermore, according to Iqbal (2019), EPAs can serve as a new framework for planning and implementing structured programs for faculty development and evaluating the skills of small-group facilitators after training (4). Van Dam et al. (2021) used EPAS to improve teaching at the patient’s bedside, including preparation, a safe learning environment, flexible teaching, and patient benefits, and introduced a description of structured EPAs (5). Van Bruggen et al. (2022) developed a set of nine EPAs as a foundation for improving the initial and continuous professional development of university teachers in health professions education (6). It appears that existing frameworks of EPAs for medical teachers are limited. While previous educational environment frameworks have focused on various dimensions such as teaching and learning, few have adequately integrated assessment as a critical component affecting students' perceptions (7). The research highlights a specific decline in positive perceptions of the educational environment during clinical years, which appears to be underexplored in current frameworks. Most existing studies tend to generalize findings across all phases of medical education without delineating the unique challenges and experiences faced by students in clinical settings (8, 9). The development of a holistic educational environment framework that encompasses personal development, teaching methods, assessment, facilities, support systems, and curriculum is rare (10-12). Although they may successfully meet the requirements of a longitudinal training program, they do not clearly describe the activities and competencies required for comprehensive roles for a medical teacher. Indeed, the effort to implement effective faculty development programs for medical teachers to provide effective clinical education with the aim of assessing, training, and reassessing their competencies indicates the necessity of developing a comprehensive, flexible, and context-based framework. This is an entrustable professional activities framework for medical teachers that includes both personal and professional competencies and is needed for a teacher's academic activities. Furthermore, it also helps medical teachers who are looking for ways to increase student achievement, which could serve as a foundation for teaching and qualification competencies and professional opportunities.

Objectives

The current study aims to develop core entrustable professional activities (EPAs) for medical teachers related to more effective clinical education.

Methods

This study was conducted in two phases. The first phase focused on defining an initial set of EPAs. The second phase focused on developing this set via a Nominal Group Technique (NGT) among medical teachers until consensus was reached. The ethics committee of the National Center for Strategic Research in Medical Education approved the protocol for this study (IR.NASRME.REC.1400.505).

Development of initial EPAs: The initial list of EPAs was used using the frameworks suggested in previous studies (13-16), as well as the list of competencies related to the faculty development program (FD) for faculty members for essential competencies of medical education at Kerman University of Medical Sciences (KUMS), and the initial list included 62 activities (Appendix 1).

Study design and setting: This NGT study was conducted on clinical specialties affiliated with the KUMS who were invited to a nominal group technique meeting in 2023.

Participants: In the first phase of the study, a nominal group meeting, 15 clinicians participated. In the study's second phase, which was the voting stage for the qualifications obtained from the first phase, 32 clinicians working at Afzalipour Hospital participated. The criterion for enrollment in the study was at least five years of work experience in clinical education (13, 14).

Data collection: The NGT proposed by Humphrey Morto et al. (2017) with modifications of stage four (voting) was used to identify and reach a consensus about the most important EPAs of medical teachers (13). The participants were provided with instructions about the concept of EPA and related examples during the meeting, and the consent form was also sent in printed form. The NGT meeting was held at one of the KUMS-affiliated hospitals in September 2023 and was managed by a medical education specialist (S.S).

In the first stage, silent idea generation, the purpose and procedures of the meeting, and a brief overview of the EPA concept were presented by one of the authors. a list of initial ideas was provided to participants and shown by a video projector (Appendix 1). Participants were asked to write their ideas independently and silently in response to questions written on the papers given to them. At this stage, participants were not permitted to discuss their answers with others. The participants were expected to determine the EPAs required by medical teachers in clinical education to train competent medical graduates; this step took ten minutes.

In the Round-Robin recording of ideas, The Facilitator invited participants to share the ideas they generated while the facilitator wrote them down. Participants were encouraged to use other participants’ responses to write new ideas that may not have been considered in the previous round. All responses were typed word-by-word in Word Office@2016 (Microsoft Corporation, Redmond, Washington, USA) by a medical education specialist and simultaneously displayed to the participants using a video projector. During these steps, the number of responses was not limited; the participants could list as many activities as they wanted. This step took 30 minutes to complete.

In the group discussion stage, the facilitator briefly discussed each suggested item to clarify the ideas proposed by the team of clinical experts for the initial assessment and consolidate similar responses without any judgment or criticism. Participants discussed verbal explanations or more details about any ideas that colleagues generated, which may not have been clear to them. The facilitator allowed people to participate and discuss all ideas to avoid spending too much time on one idea. In this step, necessary efforts were made to neutralize, and judgment and criticism were avoided. At this stage, new ideas were suggested for discussion and items were combined into categories, but no ideas were eliminated. This step took 40 minutes to complete.

In the ranking of ideas step, participants were asked to prioritize each item. They were then asked to evaluate the importance of each EPA on a five-point scale (unimportant = 1, very important = 5). If the participants did not agree with the ideas, the next idea was discussed. The ideas were sorted based on the score they received from the participants, and the priority list reflected group consensus.

In the Tally of the ranking step, the ideas that received too many and too few votes in the previous step were discussed. The purpose of this step was to finalize ideas for important EPAs for medical teachers. In this step, an agreement was reached on the ideas that should be eliminated, and the ideas that received a good score were evaluated in the next step.

In the final step, the ranking review was completed in the next session because of the workplace of the clinical teachers (participants in the nominal group). Therefore, the classified activities in the form of a questionnaire were presented to the participants of the NGT meeting in person at the Afzalipoor Educational Hospital, and they were asked to evaluate the importance of each EPA. Questionnaires were distributed and collected (Figure 1).

Data analysis: Quantitative and qualitative methods were used to analyze the data collected during the NGT meeting. For qualitative analysis, the first author (S.S) read and reread the narratives and extracted relevant characteristics. Then, another author (A.A) independently reviewed the initial coding procedure. Two authors discussed and agreed on the extracted characteristics. The extracted characteristics were merged based on similarities and then grouped into dimensions using a previously described framework (15). The characteristics of a medical teacher with some examples of the participants’ quotes. The characteristics and dimensions were revised by other authors (M.O and M.I.).

In the quantitative analysis phase, descriptive statistics, including frequency, mean, and standard deviation, were calculated using Microsoft Excel 2016 (Microsoft Corporation, Redmond, Washington) to summarize the raw data collected from the voting phase. The frequency of votes was calculated to report the level of consensus, and the mean values were calculated based on the number of participants as well as a measure of dispersion to report the importance of rating each characteristic.

The consensus was defined as 70% agreement for ratings 4 (important) and 5 (very important) (13). In addition, an existing valid framework (O’Neill’s framework) was used to classify medical teacher activities (15).

Results

Thirty-two specialists in internal medicine, general surgery, obstetrics and gynecology, and dermatology voluntarily participated in the three-hour NGT session (Table 1). A total of 32 participants completed the questionnaire in the voting phase. Moreover, 16 participants (50%) in the NGT meeting and the voting stage were female; internal medicine had the highest clinical teaching experience among the participants.

In the qualitative analysis phase, a total of 62 competencies were classified in the five dimensions as examples of quotes (Table 2). After quantitative analysis, 29 EPAs in the five dimensions were agreed upon by more than 70% of the participants. Most of the activities were identified in the curriculum planning activities (n=11) (Table 3). Further details on the characteristics identified in each of the five dimensions (Table 4).

Discussion

The findings of this research showed five domains and 29 entrustable professional activities for medical teachers. These dimensions were curriculum planning, applying technology enhanced, developing effective communication skills, developing professional activities, and conducting scholarship teaching of learning. Among the strengths of this study is the presentation of a general framework with EPAs that was developed in collaboration with medical educators who were closely familiar with the strengths, challenges and needs of medical teachers. In addition, due to the limited evidence regarding the development of EPAs for medical teachers, this research will help to improve the existing evidence.

Similarly, Srinivasan et al. (2011) identified a set of competencies for effective medical teachers in addition to teaching skills (16). Groupon et al. (2016) used competency-based education and EPAs in the curriculum for the Master’s program in health professions. They used EPAs to determine the duties of medical education professionals in competency classifications such as teaching theory, curriculum development, and evaluation (17). Dewey et al. (2017) also suggested early EPAs such as trainee skill assessment, mentoring, individual or small group instruction, large group instruction, and learner-centered clinical learning and indicated that a faculty member must be assessed for competency in EPAs before beginning their role as a teacher (13). As Rosenbaum (2012) described, medical teachers in any setting need content knowledge, learner-centeredness, professionalism, communication, practice-based reflection, and systems-based practice (18).

The findings from this study show that the EPAs of medical teachers were related to their competencies in using advanced technologies in medical education. Much evidence points to the increasing importance of technology in medical education. Technology can enhance learning by providing interactive and engaging experiences for medical students, as well as improving access to educational resources. the potential benefits of using technology to simulate medical procedures and scenarios, allowing students to gain practical experience in a safe and controlled environment (19). Virtual reality (VR) in medical education can be used to simulate medical procedures and scenarios, allowing students to practice and develop their skills in a realistic environment (20). Gamification can be used to engage students and make learning more enjoyable while also promoting critical thinking and problem-solving skills. the potential benefit of using gamification for medical simulations, is that it allows students to practice decision-making and teamwork in a fun and interactive way (21). Furthermore, many educators may not feel comfortable or confident using new technologies and may require training and support to effectively integrate them into their teaching. the potential benefits of providing a continuum of professional development opportunities for faculty, such as workshops, conferences, and online courses (22). Bray et al. (2020) proposed a systematic approach to faculty development with the desire to be flexible and reach potential participants, and using the existing infrastructure can facilitate the participation of evaluators in the new evaluation culture. Moreover, the interaction between the participants during the training sessions not only promoted their learning but also created cooperation to build a group (23).

Although the available evidence to express the competencies needed by medical professors in new technologies is limited, due to the advancement of technology in medicine, the required competencies of medical teachers have also changed. Suitable strategies for improving it, such as involving stakeholders in the decision-making process, providing clear communication and training, and ensuring that technology is aligned with educational goals and outcomes (24). Medical teachers must have the ability to use new technologies and be able to turn them into practical applications in the education of medical students. In addition, they must have the technical and analytical abilities necessary to evaluate and choose appropriate technologies for teaching students. Additionally, they must have the necessary management skills to implement educational programs using technology.

Furthermore, the findings of the present study indicated that effective communication skills and the role modeling of professional behavior improve the effectiveness of clinical education. Medical educators’ communication skills in clinical education play an important role in creating a positive and safe learning climate for students, leading to a happy and motivating environment for students, which improves student learning. Bremer et al. (2021) reported 5 EPAs for medical educators, including medical consultation, medical procedures, guidance and education, communication and collaboration, and nonclinical activities (25). One of the core activities for medical teachers was curriculum planning, leading to the effectiveness of clinical education. Curriculum planning involves clinical training course planning and implementation, which gives meaning to this field. Furthermore, this study highlighted evaluation and scholarship as one of the aspects of EPAs, improving the effectiveness of clinical education. Boyer (1990) defined universities as knowledge institutions in which knowledge activities (production, management, transfer, and application of knowledge) take place. According to Boyer's definition, university faculty members, as knowledge activists, should provide the four knowledge activities in a proportionate manner (26).

It seems that providing FD programs and EPAs based on medical teachers at levels appropriate to the context and their level of competence in teaching can be a way forward. Medical teachers whose teaching is a reliable aspect of their professional work should be assessed, trained, and periodically reassessed to determine if they maintain their qualifications. In this regard, EPAs have been proposed that will lead to the professional development of medical teachers and provide the best possible education for learners (13). Steinert (2006) states that medical teachers should be trained in areas such as teaching, barriers to successful teaching, competency-based assessment, hidden curriculum, educational technology, and scholarship of teaching and learning (SOTLs) (27). Additionally, in another article, he considers a successful FD program to include professional development, teaching, organizational development, and program evaluation (28). McLean et al. (2008) have pointed to things such as higher education, curriculum, research knowledge, leadership and professional development, and teaching methods (29). Trowbridge & Bates (2008) refers to things such as improving teaching and learning, clinical skills, professional development, performance management techniques, and research skills (30). Eventually, since the present study examined the features of EPAs and the necessary capabilities of medical education for medical teachers, the extracted EPAs can be suitable options for evaluating and FD for medical teachers.

One limitation of this article is its focus on studying in one center and a small number of medical teachers. If it is conducted with the participation of several centers and internationally, better results will be achieved. Second, there was a lack of familiarity among medical teachers with EPAs before conducting this study, which requires providing educational lectures on this topic.

Conclusion

This study advocates for a competency-based medical education (CBME) approach, which includes evaluating specific teaching EPAs to ensure that faculty are adequately prepared to supervise and educate trainees. Moreover, continuous professional development in medical education for faculty emphasizes that updates and evaluations of teaching competence should be part of their ongoing professional journey. By adopting EPAs and a structured competency framework for educators, the quality of teaching and the subsequent learning experiences of trainees can be significantly improved, ultimately benefiting patient care. The paper acknowledges potential barriers to implementing such a framework, including time constraints and the financial implications for institutions, but emphasizes that these challenges can be overcome with proper planning and commitment.