胜任力导向的医学教育是第三代医学教育改革的核心特征之一,置信职业行为(entrustable professional activities,EPAs)评价旨在通过观察学习者行为判断其胜任力水平,但在临床工作场所中实施存在诸多困难。基于模拟环境的EPAs评价是一个相对新兴的研究领域,国外已有研究聚焦于其可接受度、信度和效度、影响因素等方面。基于模拟环境的EPAs评价具有较高的可接受度,能够为学习者提供心理安全的环境;在效度方面,可有效区分不同能力水平的学习者;在信度方面,模拟环境下不同评价者之间的一致性优于临床环境,但与临床环境评价结果的相关性尚存争议;置信决策受评价者对“置信”的理解、情境真实性及临床任务多样性等因素影响。尽管目前研究尚显不足,但基于模拟环境的EPAs实施优势显著,可以提供可控的低风险环境,有效克服临床工作场所实施中标准化程度低、患者安全风险高等困难,但也面临着成本高昂、技术限制、评价标准制定等挑战。基于模拟环境实施EPAs主要解决胜任力标准化验证和低风险训练评估问题,为学习者提供安全的练习空间;临床工作场所中的EPAs评价仍然是做出置信决策的最终依据。基于模拟环境与临床工作场所的EPAs评价相辅相成,未来可以进一步探索模拟环境中的EPAs评价,以提升胜任力评价的科学性和可操作性,推动以胜任力为导向的医学教育的发展。
Competency-based medical education (CBME) is one of the core features of the third generation of medical education reform. The entrustable professional activity (EPA) framework is a valuable assessment method. EPAs aim to assess medical students' clinical competency for specific roles by observing their behaviors. Ideally, it should be conducted in the workplace, but numerous challenges exist, prompting some scholars to propose implementing EPAs based on simulation. Currently, simulation-based EPA assessment is a relatively novel research field, with studies focusing on acceptability, reliability, and validity, and influencing factors. Simulation-based EPA assessment has high acceptability and provides learners with a psychologically safe environment; in terms of validity, it can effectively differentiate learners across different competency levels; regarding reliability, inter-rater consistency is higher in simulated settings than in clinical settings, although the correlation between simulation-based and workplace-based assessment results remains controversial; entrustment decisions are influenced by factors such as raters' understanding of ″entrustment″, scenario authenticity, and the diversity of clinical tasks. Although current evidence remains limited, simulation offers clear advantages for EPA assessment: it provides a controlled, low-risk environment that can effectively address issues such as lack of standardization and patient safety concerns in workplace-based assessment. Nonetheless, challenges persist, including high costs, technical constraints, and the need for robust standard-setting. Simulation-based EPA assessment primarily serves to standardize competence verification and enable low-stakes training and evaluation, offering learners a safe space for practice. In contrast, workplace-based EPA assessment remains the ultimate basis for entrustment decisions. The two modalities are complementary. Future research should further explore simulation-based EPA assessment to enhance the scientific rigor and operational feasibility of competence evaluation, thereby advancing the development of competency-based medical education.
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