Our rationale for the study

Postgraduate medical education (PGME) programs are transitioning to competency-based medical education (CBME). CBME promises greater accountability, flexibility, and learner-centeredness (Frank, Mungroo, et al., 2010). It is meant to support residents’ growth.

CBME is structured around residents’ development of the competencies required to fulfill patients’ needs (Frank, Snell, et al., 2010). Competencies can be defined as the observable, measurable, and assessable abilities that residents apply to clinical tasks (Frank, Snell, & Sherbino, 2015). CBME goes hand in hand with continuous and longitudinal assessment for and of learning. Collated assessment data should inform residents about their progress and path towards advancement in the curriculum. The same data should enable faculty to support residents’ development of competencies (Holmboe, Sherbino, Englander, Snell, & Frank, 2017). However, residents and faculty may find competencies too abstract to work with (Carraccio & Burke, 2010).

Ten Cate and Scheele (2007) have introduced Entrustable Professional Activities (EPAs) to connect competencies to everyday clinical practice. EPAs are the essential clinical tasks of a specialty that can be progressively entrusted to residents as they demonstrate increasing readiness to practice unsupervised (ten Cate et al., 2015). The full description of an EPA defines the scope of the task and the requirements for high-stakes entrustment: residents can therefore build their own path to entrustment (ten Cate & Taylor, 2020). It has been postulated that implementing frameworks of EPAs allows for residents to achieve entrustment of increasingly complex tasks and to take on more and more responsibility within clinical teams, which should support residents’ growth (ten Cate et al., 2011). However, evidence suggests that this is not happening.

Since the implementation of EPAs in PGME programs, studies have shown that residents do not perceive their work towards achievement of entrustment as an opportunity for growth (Brandfield Day, Miles, Ginsburg, & Melvin, 2020; Hall et al., 2020; Martin, Sibbald, Vegas, Russel, & Govaerts, 2020). In addition, faculty perceive that the system predetermines entrustment (Melvin, Rassos, Stroud, & Ginsburg, 2020), which suggests that faculty may be unable to support residents’ growth.

These findings leave the question of how EPAs can promote residents’ growth unanswered. Tackling this gap in knowledge is crucial as CMBE could result in demotivation if implemented incorrectly (Leung, 2002).

Self-Determination Theory (SDT) provides a useful lens to tackle this gap in knowledge. SDT a theory of human motivation that is concerned with our tendency to move towards growth (Ryan & Deci, 2000). It posits that autonomously motivated individuals are more likely to achieve growth. Autonomous motivation is a combination of intrinsic motivation (i.e., doing something for its inherent satisfaction) and identified regulation and integrated regulation of extrinsic motivation (i.e., doing something because we understand the importance of rules made by others and doing something because we connect the rules to our own values, respectively) (ten Cate, Kusurkar, & Williams, 2011). Autonomous motivation is nurtured when our basic psychological needs for autonomy, competence, and relatedness are met. It is linked to better performance, improved well-being, and a stronger commitment to lifelong learning (Kusurkar, ten Cate, van Asperen, & Croiset, 2011; van der Burgt et al., 2018).

Therefore, we propose to study how EPAs promote autonomy, competence, and relatedness to build a conceptual understanding of how EPAs can support residents' development into competent physicians.

Julien-Carl Phaneuf, on behalf of the research team

January 25, 2022


Branfield Day, L., Miles, A., Ginsburg, S., & Melvin, L. (2020). Resident Perceptions of Assessment and Feedback in Competency-Based Medical Education: A Focus Group Study of One Internal Medicine Residency Program. Academic Medicine, 95(11), 1712–1717.

Carraccio, C., & Burke, A. E. (2010). Beyond Competencies and Milestones: Adding Meaning Through Context. Journal of Graduate Medical Education, 2(3), 419–422.

Frank, J. R., Mungroo, R., Ahmad, Y., Wang, M., Rossi, S. D., & Horsley, T. (2010). Toward a definition of competency-based education in medicine: A systematic review of published definitions. Medical Teacher, 32(8), 631–637.

Frank, J. R., Snell, L., & Sherbino, J. (2015). CanMEDS 2015 Physician Competency Framework. Ottawa: Royal College of Physicians and Surgeons of Canada. Retrieved January 18, 2021, from

Frank, J. R., Snell, L. S., ten Cate, O., Holmboe, E. S., Carraccio, C., Swing, S. R., Harris, P., Glasgow, N. J., Campbell, C., Dath, D., Harden, R. M., Iobst, W., Long, D. M., Mungroo, R., Richardson, D. L., Sherbino, J., Silver, I., Taber, S., Talbot, M., & Harris, K. A. (2010). Competency-based medical education: Theory to practice. Medical Teacher, 32(8), 638–645.

Hall, A. K., Frank, J., van Melle, E., Cheung, W. J., Oswald, A., Cooke, L. J., Dalseg, T., Skutovich, A., Brzezina, S., Gorman, L., & Taber, S. (2020). Competence by Design (CBD) Implementation Pulse Check: Spring 2020. Retrieved November 15, 2020, from

Holmboe, E. S., Sherbino, J., Englander, R., Snell, L., & Frank, J. R. (2017). A call to action: The controversy of and rationale for competency-based medical education. Medical Teacher, 39(6), 574–581.

Kusurkar, R. A., ten Cate, T. J., van Asperen, M., & Croiset, G. (2011). Motivation as an independent and a dependent variable in medical education: A review of the literature. Medical Teacher, 33(5), e242–e262.

Leung, W. C. (2002). Competency based medical training: review. BMJ, 325(7366), 693–696.

Martin, L., Sibbald, M., Vegas, D. B., Russell, D., & Govaerts, M. (2020). The impact of entrustment assessments on feedback and learning: Trainee perspectives. Medical Education, 54(4), 328–336.

Melvin, L., Rassos, J., Stroud, L., & Ginsburg, S. (2020). Tensions in Assessment: The Realities of Entrustment in Internal Medicine. Academic Medicine, 95(4), 609–615.

Ryan, R. M., & Deci, E. L. (2000). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist, 55(1), 68–78.

ten Cate, O., Chen, H. C., Hoff, R. G., Peters, H., Bok, H., & van der Schaaf, M. (2015). Curriculum development for the workplace using Entrustable Professional Activities (EPAs): AMEE Guide No. 99. Medical Teacher, 37(11), 983–1002.

ten Cate, O. T. J., Kusurkar, R. A., & Williams, G. C. (2011). How self-determination theory can assist our understanding of the teaching and learning processes in medical education. AMEE Guide No. 59. Medical Teacher, 33(12), 961–973.

ten Cate, O., & Scheele, F. (2007). Competency-Based Postgraduate Training: Can We Bridge the Gap between Theory and Clinical Practice? Academic Medicine, 82(6), 542–547.

ten Cate, O., & Taylor, D. R. (2020). The recommended description of an entrustable professional activity: AMEE Guide No. 140. Medical Teacher, 1–9.

van der Burgt, S. M. E., Kusurkar, R. A., Wilschut, J. A., Tjin A Tsoi, S. L. N. M., Croiset, G., & Peerdeman, S. M. (2018). Motivational Profiles and Motivation for Lifelong Learning of Medical Specialists. Journal of Continuing Education in the Health Professions, 38(3), 171–178.