Entrustable professional activities in undergraduate homoeopathy: A competency-based perspective

INTRODUCTION

Competency-based education (CBE) has become the dominant framework for undergraduate (UG) health professions education, including homoeopathy. Its emphasis on clearly defined outcomes, progressive development and accountability to societal needs aligns well with the objectives of undergraduate training. In parallel, entrustable professional activities (EPAs) have emerged as a means of operationalising competencies within authentic clinical contexts.

While EPAs are well established in postgraduate medical education, their application at the undergraduate level, particularly as a primary curricular framework, requires careful scrutiny. This article integrates educational and policy perspectives to examine the relevance and limitations of EPAs in undergraduate homoeopathy professional education (HPE) and proposes a CBE-led model with embedded, developmental EPAs as the most appropriate approach.

CONCEPTUAL AND DEVELOPMENTAL LIMITS OF EPAS AT THE UNDERGRADUATE LEVEL

EPAs are fundamentally grounded in authentic professional work involving responsibility, risk and accountability for patient outcomes.^[1,2] Entrustment implies a deliberate transfer of responsibility from supervisor to learner. Undergraduate learners, however, are pre-professionals who function within protected learning environments and lack legal and ethical authority for independent clinical decision-making.

In undergraduate homoeopathy, core clinical activities such as case taking, analysis, repertorisation and prescription are performed under close faculty supervision. Reframing undergraduate (UG) curricula entirely around EPAs risks premature professionalisation and dilution of the concept of entrustment. As Ten Cate and Scheele emphasise, entrustment decisions are meaningful only when genuine responsibility can be transferred-an assumption that does not hold true for most UG clinical activity.^[3]

CBE AS THE FOUNDATIONAL FRAMEWORK

UG health professions education is fundamentally concerned with the gradual development of foundational knowledge, essential clinical skills, professional attitudes and the formation of a coherent professional identity. At this stage, learners are transitioning from theoretical understanding to supervised clinical participation, requiring a framework that supports structured growth without prematurely assigning professional responsibility. CBE is particularly well suited to this developmental context because it articulates clear expectations while preserving appropriate educational and ethical boundaries.

CBE defines explicit, observable and assessable outcomes that guide both teaching and learning. These outcomes clarify what UG learners in homoeopathy are expected to know, do and demonstrate at different stages of training, enabling transparency and alignment across curriculum, instruction and assessment. By emphasising outcomes rather than time-based exposure alone, CBE supports graded progression and spiral learning, allowing students to revisit core concepts, such as case analysis, repertorisation and remedy selection with increasing depth and clinical sophistication.

Importantly, CBE maintains a clear separation between education and licensure. Competence at the UG level is framed as readiness for supervised participation in clinical care rather than entitlement to independent practice. This distinction allows robust assessment of clinical performance without implying that learners are prepared to assume unsupervised responsibility for patient outcomes. Such an approach is ethically essential in UG homoeopathy, where patient safety and public trust must be carefully safeguarded. Within UG homoeopathy education, CBE ensures the systematic development of competencies across key domains, including homoeopathic philosophy, clinical reasoning, repertory use, patient communication and professionalism. The primary educational objective at this stage is not autonomous professional work, but preparedness for structured supervision and further training. As such, CBE provides a coherent, defensible and developmentally appropriate foundation for UG HPE.^[4]

DEVELOPMENTAL ROLE OF EPAS IN UG HOMOEOPATHY

Although EPAs are unsuitable as the primary organising framework, they retain educational value when used selectively and developmentally. At the UG level, EPAs should be framed as introductory or pre-entrustable activities, characterised by high levels of supervision, low clinical risk and explicit educational intent.

For example, an EPA such as conducting a complete homoeopathic case under direct supervision allows learners to integrate multiple competencies within a real clinical context without implying independent authority. In such settings, entrustment is conditional and formative, rather than summative or declarative.^[5]

EPAS AS TRANSITION TOOLS: FINAL YEAR AND INTERNSHIP

The most appropriate use of EPAs in UG homoeopathy is during the final year and compulsory internship, where learners begin transitioning from students to supervised practitioners. Internationally, this approach is reflected in the Association of American Medical Colleges’ Core EPAs for entering residency, which are positioned as exit-level expectations rather than early UG organising units.^[6] Similarly, in homoeopathy, EPAs at this stage can support preparedness for postgraduate education while maintaining patient safety and regulatory accountability.

AN INTEGRATED EDUCATIONAL-POLICY MODEL

An integrated educational-policy model for UG homoeopathy must balance pedagogic innovation with regulatory accountability and patient safety. From both educational and governance perspectives, a competency-based curriculum provides the most stable and defensible foundation for UG training. Competencies articulate the knowledge, skills, attitudes and professional behaviours expected of a graduate, without implying readiness for independent practice. This clarity is essential in UG homoeopathy, where learners are still developing clinical reasoning, therapeutic judgment and professional identity under close supervision.

Within this competency-led framework, milestones function as developmental signposts that describe progressive levels of performance across the UG continuum. Milestones allow educators to track learner growth from novice understanding to competent, supervised clinical participation, while maintaining alignment with curricular outcomes and assessment standards. Importantly, milestones reinforce the principle that progression reflects increasing capability under supervision, rather than entitlement to independent clinical authority.

EPAs, when embedded within this structure, serve a distinct but complementary function. Rather than acting as curricular organisers, selected EPAs operate as integrative demonstrations that bring together multiple competencies in authentic clinical contexts. In UG homoeopathy, such EPAs must be explicitly framed as educational and conditional, with clearly defined levels of supervision. Entrustment decisions at this stage represent permission to participate more meaningfully in clinical work under guidance, not a declaration of professional autonomy.

From a policy perspective, this integrated model offers strong regulatory defensibility. It preserves the conceptual integrity of entrustment by reserving full entrustment decisions for contexts where legal and ethical responsibility can genuinely be transferred, such as postgraduate training. At the same time, it allows UG programmes to benefit from the integrative and workplace-oriented strengths of EPAs without compromising patient safety or public trust.

Educationally, this model supports coherence across the UG curriculum. Competencies define what learners must achieve, milestones clarify how they progress over time and EPAs illustrate how competencies are enacted in real clinical settings. Such alignment strengthens assessment validity, supports faculty judgement and promotes transparency for learners and regulators alike.

In the context of UG homoeopathy education in India, a CBE-led curriculum with embedded, developmental EPAs thus represents a pragmatic and future-oriented approach. It aligns with contemporary educational theory, international best practices and the ethical obligation to protect patients while nurturing the next generation of homoeopathic practitioners.

CONCLUSION

UG homoeopathy education should not be reframed as fully EPA-based. It should remain competency-based in structure and intent, while incorporating EPAs judiciously as developmental scaffolds, particularly in advanced phases of training. Such a balanced approach preserves the integrity of both CBE and EPAs, respects the developmental and ethical realities of UG learners and strengthens the transition to postgraduate education and professional responsibility.