Prototype entrustable professional activities for generalist physicians in remote rheumatic care: a consensus-based modified Delphi study

In remote areas and an increasingly aging society, patients with rheumatic diseases often experience delayed diagnoses due to limited access to specialists, which significantly impacts their quality of life. Effective training of primary care physicians is therefore essential to improve the quality of rheumatic disease care in these areas. Entrustable professional activities (EPAs) offer a robust framework for evaluating learners by defining specific, observable units of work. This study aimed to develop a consensus-based list of essential EPAs for young generalist physicians to enhance the quality of rheumatic care in underserved, remote settings.

We employed a modified Delphi method to build consensus among an expert panel of 25 members, including specialists in rheumatology, internal medicine, and family medicine (21 of whom had direct remote medical experience). The research team synthesized an initial task list from national and international medical education and rheumatology curricula. Experts rated each task on a five-point Likert scale over four iterative rounds. Consensus was defined by an average score of ≥4.0, a standard deviation of <1.0, and ≥75% agreement.

Response rates were exceptionally high throughout the process (96-100%). The Delphi rounds culminated in a finalized list of 14 EPAs. Key refinements included narrowing technical procedures (eg joint aspiration) to the knee and rephrasing clinical tasks to emphasize the timing of specialist collaboration. Expert feedback underscored the necessity of early diagnosis, maintaining a broad differential diagnosis during initial assessments, and the indispensable nature of structured handover skills in resource-limited environments.

This study successfully established a specialized EPAs framework for generalists in remote areas, addressing a critical gap between general residency training and subspecialty curricula. The list emphasizes managing rheumatic diseases within the constraints of limited resources while ensuring appropriate specialist synergy, ultimately aiming to improve patient outcomes in rural communities.