Equity, diversity, and inclusion in entrustable professional activities based assessment

Improving equity, diversity and inclusion (EDI) within health profession education is a global priority. In this issue of Medical Education, Lam et al.¹ review EDI literature in postgraduate medical education (PGME) focusing on how discrimination is conceptualised and addressed. They find that while learner representation and gender inequities are recognised, systemic racism and power dynamics are often overlooked, limiting the effectiveness of current reforms. They emphasise the need for critical, intersectional approaches and re-examining educational processes to truly advance equity in learning environments for marginalised groups.

One educational process to re-examine is workplace-based assessment (WBA), a significant challenge in advancing EDI within PGME. Since the introduction of Competency-Based Medical Education (CBME), WBA has been increasingly adopted for competence assessments and workplace learning.² WBA is inherently subjective, influenced by individual judgement and existing workplace structures and hierarchies and thus susceptible to racism and inequity through implicit and explicit biases in direct observation, performance interpretations, coaching and feedback and supervisor–trainee power dynamics. The lack of diverse perspectives and inadequate supervisor training on EDI principles can exacerbate inequities in assessments, disadvantaging marginalised trainees. Yet, CBME principles can help advance EDI by centring the trainee and providing individualised resources to navigate barriers and ensure fair learning and assessment opportunities.³

One approach that has gained significant attention over recent years in aligning WBA with CBME is the use of Entrustable Professional Activities (EPAs). EPAs are units of professional practice, defined as tasks entrusted to trainees for unsupervised execution once they demonstrate sufficient competence.⁴ Assessment through EPAs involves entrustment decision-making, which requires evaluating a trainee's competence and determining their readiness to take on more responsibility or autonomy with less supervision. Whether EPAs can reduce bias in WBA is a complex and multifaceted question. While entrustment decision-making offers a new rating approach, it is not immune to bias and could potentially introduce new biases related to how supervisors conceptualise or experience trust. For instance, studies comparing traditional proficiency scales with entrustment–supervision scales have shown that the latter offer more reliable performance estimates with less inter-rater variability, suggesting that entrustment could be less influenced by performance-irrelevant trainee characteristics.^{5, 6} However, considerable variability in supervisors' willingness to grant trust has been reported.⁷

One advantage offered by the EPA model is its explicit delineation of the five factors influencing WBA and entrustment decisions.⁸ Knowing these factors, listed below, is a first step towards inspection, reflection, and remediation; however, opportunities to address bias, racism, and inequity need to be embraced.

In conclusion, while EPAs may offer a promising approach for improving equity in assessment in health profession education due to their explicit focus on the factors influencing WBA, success relies on intentional implementation. Regardless of any assessment model used, deliberate and conscious efforts are pivotal to ensuring that assessments are fair, comprehensive and reflective of the diverse competencies needed in practice. As new educational and assessment methods emerge, we must seek out and seize opportunities to address and mitigate the effects of racism and bias by adopting the critical and intersectional approaches that Lam et al. propose.¹ Their review highlights the ongoing work required and the importance of continually refining and adapting our processes to genuinely advance equity in health profession education.

Marije P. Hennus: Conceptualization; writing—original draft. H. Carrie Chen: Conceptualization; writing—original draft.