EPAs are defined as responsibilities or tasks that can be entrusted to trainees for unsupervised practice once they have attained sufficient specific competencies.^{1, 2} First published in 2005.³ EPAs have since been supported by workshops, courses, and conferences aimed at helping faculty develop programs and assessment procedures.^{1, 4, 5} However, there remains a significant need for clarification and effective implementation of EPAs.⁴ Well-written EPAs provide a natural framework for establishing training objectives, requiring comprehensive descriptions that justify each component1, ⁴ importantly, EPAs are not substitutes for competencies; they translate competencies into day-to-day clinical tasks.^{4, 6} Competencies describe the traits of a physician, while EPAs delineate the specific work.^{1, 6} Several published EPAs exist for nephrology postgraduate training programs, such as those from Canada and the United States.^{2, 7-11} However, adopting EPAs from other cultures can be challenging due to differences in local culture, patient values, and healthcare systems. Institutions worldwide that have adopted EPAs have developed and validated their own based on specific needs.² The Canadian Medical Education Directives for Specialists (CanMEDS) framework^12,13 widely used in postgraduate training, outlines physician competencies that extend beyond medical expertise, emphasizing roles that meet societal needs. In response, the Saudi Commission for Health Specialties (SCFHS) is integrating the CanMEDS framework into the core curriculum for all training programs, including the nephrology fellowship.^14,15 For example, educators may struggle with defining the practical applications of these competencies and ensuring consistent assessment across diverse clinical settings. EPAs, in contrast, outline the essential tasks that a newly graduated nephrologist must perform independently, thus advancing competency-based medical education (CBME) by enabling specific clinical tasks to be entrusted to trainees once they are proficient.^{2, 12, 16, 17} The aim of this study is to develop and validate end-of-training EPAs for nephrology fellowship training in Saudi Arabia. This study is part of a larger initiative aimed at developing and validating EPAs across various internal medicine specialties in the country, building on previously published work that established foundational EPAs in related fields.¹⁸

The study consisted of two phases: the first phase aimed to develop a preliminary list of EPAs for the nephrology fellowship program based on a comprehensive literature review and expert opinions. The second phase sought to establish consensus on the suggested EPA list through two rounds of Delphi techniques with nephrology experts. The study was approved by the institutional review board at Umm Al-Qura University, Makkah, Saudi Arabia.

This study aimed to develop a consensus-based set of EPAs for Saudi Arabia’s nephrology fellowship programs.^2,19,23 These EPAs are designed to enhance the training, assessment, and clinical skills of nephrology fellows, ultimately improving patient care in Saudi Arabia. To meet international standards while addressing local healthcare needs, it is essential to incorporate these EPAs into fellowship programs and evaluate their impact on trainee performance and patient outcomes. The development process followed established guidelines for creating effective EPAs.⁵ The initial list of EPAs and the number of nephrology consultants involved in the Delphi process were based on expert recommendations.^2,15,19 Feedback from the panel of nephrologists was carefully reviewed, leading to necessary adjustments during the second round of the Delphi technique. This iterative process allowed the study to reach a consensus, resulting in a final list of 34 EPAs, consistent with literature suggestions.^{5, 6}

The initiative is part of a broader institutional project to develop an EPA framework for Internal Medicine Specialized fellowship programs, promoting standardization in training. By providing a structured approach, these EPAs ensure that trainees acquire consistent skills and knowledge, leading to improved patient outcomes.^2,19 Furthermore, the development of the EPAs framework supports the implementation of Competency-Based Medical Education (CBME) in nephrology training, allowing for focused and individualized assessments.^12,20,21 EPAs outline the essential tasks that graduating nephrologists must perform independently in clinical practice.⁶ They encompass multiple competencies, allowing for varied approaches to achieving mastery. EPAs translate competencies into practical tasks, emphasizing hands-on experience to facilitate the transition from training to autonomous practice.²⁴ Therefore, they should be viewed as part of a dynamic curriculum process, with regular reviews to align with evolving trends in nephrology healthcare practice.⁵ The alignment of EPAs with the Saudi Commission for Health Specialties (SCFHS) development and quality improvement initiatives is crucial. By identifying essential skills and knowledge required for nephrologists, programs can target areas for improvement, ensuring that trainees meet the evolving needs of patients.^{17, 21, 25} Feedback from nephrology consultants during the Delphi process led to adjustments in the EPAs.

For example, EPA A3 was modified to encompass a broader scope of "Applying basic medical knowledge in daily practice," reflecting the necessity for comprehensive training. Some EPAs, such as EPA B11, 'Assessing the suitability of deceased donors and potential living donors for kidney transplantation,' were excluded due to their specificity to transplant nephrologists, indicating the need for further training or dedicated fellowships. However, the importance of transplantation was emphasized, as fellows should manage pre- and post-operative care for renal transplant recipients and assess eligibility for kidney transplantation, as demonstrated in EPAs B9, 10, and 12.The exclusion of procedural skills, such as HD catheter placement (EPA C2) and kidney biopsies (EPA C3), sparked significant debate, particularly with nearly 45% of respondents disagreeing with these decisions in the second round. This highlights the ongoing discussions about nephrologists' responsibilities in their training.^{20,22,26, 27} While international standards from organizations like the American Society of Nephrology (ASN)^{22, 28} and Canadian EPAs,⁸ recognize certain procedures as essential to nephrology training, the common practice in Saudi hospitals often involves interventional radiologists performing these tasks. This situation complicates the discussion around the EPAs, as some important procedures, such as HD catheter insertion, are left out of the fellowship training framework. Despite this omission, gaining hands-on experience in these areas remains vital for fellows, helping them manage complications effectively and provide comprehensive care to dialysis patients. For example, learning how to insert HD catheters is a key part of nephrology training and fits well with guidelines for managing vascular access.^{17, 22, 28} Similarly, developing skills in native or transplant kidney biopsies is important for accurately diagnosing and treating patients.^{26, 27} This ongoing debate highlights the need to find a balance between global standards and local practices, ensuring that nephrology fellows are well-prepared to handle these critical procedures. We noted a 45% disagreement regarding the exclusion of certain EPAs. This analysis helped us understand the diverse perspectives on the issue. Ultimately, we decided not to make certain EPAs mandatory, believing that it's important for nephrology fellows to develop these essential skills at their own pace. This approach encourages engagement and motivation, allowing them to effectively tackle challenges in dialysis and nephrology care. In summary, our final decision balanced the need for skill development with the autonomy of individual learning.

The study has several limitations. Firstly, generalizability may be limited; while a diverse panel of nephrology experts from Saudi Arabia contributed, the findings might not be applicable to other regions. Future research should explore the generalizability of these EPAs. Additionally, the potential for expert bias exists, as the Delphi technique relies heavily on expert opinions. To mitigate this, future studies could incorporate broader methodologies, such as systematic literature reviews or focus groups. In terms of future research, concrete next steps could include longitudinal studies aimed at tracking the effectiveness of these EPAs in improving patient outcomes and the quality of fellowship training. Specific suggestions for implementing EPAs in Saudi fellowship programs include faculty training workshops, pilot programs, and establishing feedback loops for ongoing revisions. By integrating global standards while respecting local healthcare constraints, Saudi fellowship programs can enhance their training frameworks effectively.

This study successfully established and validated EPAs for the Saudi nephrology fellowship training program, marking a meaningful progression in regional medical education. These EPAs aim to elevate the training, assessment, and clinical abilities of nephrology fellows in Saudi Arabia. To ensure they are in line with international standards while addressing the specific needs of local healthcare, it is vital to integrate these EPAs into fellowship programs and assess their effects on both trainee performance and patient care outcomes. Future research should prioritize validating this framework within the nephrology community, gathering insights from both educators and trainees to continuously refine and improve the EPAs. This ongoing feedback loop will be essential for adapting the EPAs to meet the dynamic challenges of nephrology practice in Saudi Arabia.