Does direct observation happen early in a new competency-based residency program?

A key component of competency-based medical education is workplace-based assessment, which includes observation (direct or indirect) of residents. Direct observation has been emphasized as an ideal form of assessment yet challenges have been identified that may limit its adoption. At present, it remains unclear how often direct and indirect observation are being used within the clinical setting. The objective of this study was to describe patterns of observation in an emergency medicine competency-based program 2 years postimplementation.

Emergency medicine residents (n = 19) recorded the type of observation they received (direct or indirect) following workplace-based entrustable professional activity (EPA) assessments from December 15, 2019, to April 30, 2020. Assessment forms were reviewed and analyzed to describe patters of observation.

Assessments were collected on all 19 eligible residents (100% participation). A total of 1,070 EPA assessments were completed during the study period, of which 798 (74.6%) had the type of observation recorded. Of these recorded observations, 546 (68.4%) were directly observed and 252 (31.6%) were indirectly observed. The length of written comments contained within assessments following direct and indirect observation did not differ significantly. There was no significant association between resident gender and observation type or resident stage of training and observation type. Certain EPA assessments showed a clear preference toward either direct or indirect observation.

To the best of our knowledge, this study is the first to report patterns of observation in a competency-based residency program. The results suggest that direct observation can be quickly adopted as the primary means of workplace-based assessment. Indirect observation comprised a sizeable minority of observations and may be an underrecognized contributor to workplace-based assessment. The preference toward either direct or indirect observation for certain EPA assessments suggests that the entrustable professional activity itself may influence the type of observation.