T3: Transparent Thursday Topics

Thank you so much we completely agree!!

There are some kind of feedback loops, which are challenging to close For example, when there is a complaint about a specific supervisor for confidentiality reasons it is difficult for us to let learners know about the result of a faculty review. However, learners are absolutely entitled to know virtually all other aspects of postgraduate functioning.  We already send important information and alerts via email. In addition, we have the monthly CBD newsletters. We have just agreed that all minutes from PRPC, PEAC and CBD operations committee will also be circulated to residents so that they can be aware of agenda items, discussions and decisions. In addition, we are working hard with PRAT, PGY representatives, and Chief Residents to make sure that they are regularly informed of any information that they can then pass on to the wider resident body.... and of course this very paragraph you are reading is meant to help as well.

This is a common concern in all specialties across the country. It is an absolute mandatory Royal College requirement. You should know that EPAs can be completed on a desktop computer, laptop, tablet, or phone, but the Royal College requires that the data be captured for review by the Competence Committee. This is an accreditation standard. In our experience so far, the competence committee is able to pick up on themes across rotations/EPAs that would not previously have been recognized. This is being fed back to residents to help them improve.

We also know that in most cases, faculty were already observing and providing feedback to residents on their performance but where this was previously not happening this new system will necessitate more observation and conversation which we think is to the benefit of learners.

As far as the useability/interface.... stay tuned as we're switching to Elentra July 1, 2020. This is the platform being used by all programs at U of T and about half of the Universities across the country. It's a little more pretty, a little more slick and has a few more features.

The book allowance was a wonderful feature of our program for many years. It was entirely funded by psychiatrists out of their own pockets. It does not come from any university or AFP or any other source of funding. Recently, as we have tried to put into place all kinds of extra supports for residents including longitudinal coaching (which is  Royal College requirement), as well as the Competence Committees and increased observation, we have been asking more of our partner hospital sites. In addition, some aspects of patient flow and billing have changed as a result of the LAE. Sites were expressing reservations about continuing to contribute their own money to a resident book fund in the context of all these other accreditation/programmatic/curricular changes.

There was real risk that the book fund was going to disappear completely. Please note that book funds are not mandatory and not an accreditation standard but one of the many ways we have been delighted to voluntarily support residents. Rather than completely eliminating the book fund, we were able to negotiate with the psychiatrists in chiefs for them to take 75% of the book allowance money and reallocate it directly back into education. They continue to contribute the remaining 25% directly to residents, but, appropriately insisted that there be some kind of adjudication process for receiving the funds. We struck a joint committee between several residents and psychiatrists in chiefs to determine the terms of reference. In the end, we were delighted to offer academic awards which previously did not exist. Every year we receive requests for funding for conferences, seminars or research and we had no ability to fund those requests. Although it would have been nice to continue to have staff psychiatrists give money to residents - in a time of university, provincial, and OHIP cutbacks, which also coincides with the increased educational infrastructure it just was not possible. We are very happy to have preserved some funds to support the scholarly development of our learners. We have enough money to ensure that every single learner who has a viable application will receive a "resident scholarly development award" at least once over the course of their training.

The structure of the PGY2 academic day was changed for a number of important reasons.

1) There is loads of evidence to suggest that teaching and clinical experience should be aligned as closely as possible. In the old system you could have a lecture on a relevant topic in September but may not encounter a clinical situation until February. The new system allows us to better target lectures that relate specifically to the rotations on which residents are working. This is an evidence-based approach that we developed with consultation from educational scientists.

2) As the size of our residency program has grown, space and comfort has become an increasing issue. We did not have access to a room that was large enough to consistently accommodate all PGY2s for every week of the year. Furthermore smaller lectures promote better learning and participation. The new curriculum structure allows us to have groups of approximately 12-13 residents instead of 40 at each lecture.

3) Despite years of effort, resident attendance at core lectures and in large groups has been extremely poor. This led to a sense of inequity amongst residents. In addition, we were routinely receiving complaints from faculty who had taken the time to prepare lectures only to have 1-2 residents show up in the room. Some of our expert faculty were refusing to teach under these conditions.

4) The "new" structure for PGY2 lectures mirrors the structures we have always had in PGY3 and 4. Those have always been well-received and well-attended.

5) With the introduction of a longitudinal clinic (which was strongly requested by previous resident cohorts, more to come in a future question) having a full additional academic day would mean that residents were only present on their core rotations 3 days a week. We considered the possibility of half days of either LAE or teaching but that would absolutely necessitate significant travel for a large majority of residents, and we received feedback that this would not be well-received.

While this new structure is different for the PGY2 year it has been tried and tested in PGY3 and 4. It allows for an LAE that was requested by residents and is aligned with educational principles and literature. We do understand that some social aspects of the day have been lost - but we continue to protect and support a weekly resident lunch. We continue to protect and support 2 PRAT retreats. We are certainly open to other ideas that may promote friendship and collegiality in our program - send those ideas to us directly!

We understand that there is bound to be variability in a program of our size. To some extent, this is desirable. We want sites to offer slightly different experiences. We also appreciate that different residents learn and perform at different rates. The goal of CBD is actually to allow for more individualization of the educational curriculum.

However, we also want to have some shared standards and "floors". There is already a document available on our Departmental Website (Longitudinal Rotation Structure under Departmental Policies and Guidelines: https://www.psychiatry.utoronto.ca/policies-and-guidelines) that outlines how an LAE should function. In addition, our LAE Working Group surveyed PGY1 and 2 residents as well as supervisors at our sites in January 2020. The group is currently reviewing the data to provide recommendations to the LAE sites so we can change those guidelines in accordance with feedback or help sites come into alignment with them.

Please remember that we started 6 brand new PGY2 clinics about 7 months ago. Some amount of learning and adjustment is to be expected. Bear with us, we're on it!

All site directors and administrators have been asked to contact learners 1 month before the scheduled start of their rotation to provide them with relevant information pertaining to their start. This includes access to office space, orientation, registration and when/where to meet. We regularly remind sites of this expectation. If you are starting a rotation and have not heard from anyone about the details, please reach out to Mark Fefergrad (mark.fefergrad@sunnybrook.ca).

A diverse group of departmental members and residents, met for two years to debate any changes to the previous rotation structure. The three biggest factors were: 1) community/societal need, 2) resident input, and 3) the wish to create more PLEX (elective) time. For example, we previously had 1 month of addictions in PGY1 and a brief PGY4 experience. Given the rate of substance use disorders in the populations for whom we care and hearing from residents about their comfort level, we thought that experience was grossly inadequate. As a result there is now 2 month experience in each of PGY2 and PGY4. This experience includes training in acute withdrawal, methadone, partial agonists/anti-craving medications and motivational interviewing - all of which we think will make for better prepared clinicians who can meet the needs of their patients.

As an another example, previously no rotation lasted longer than 6 months (other than psychotherapy) which meant there was never any longitudinal patient care. Numerous stakeholders across the system including patients and residents, have advocated for some mechanism to follow chronically unwell patients over a longer duration. The kind of care and relationships associated with that longitudinal model are more similar to actual practice and require a different skill set. Those factors along with the wish to provide one on one observation and feedback to learners, were important factors in the decision to create a longitudinal ambulatory experience.

We also reduced the duration of almost all rotations on the basis of resident feedback. We are a broad specialty and we want people to have the latitude to explore and invest in areas of interest. We also wanted PLEX (elective) time to be spread across training to facilitate research and so that any resident behind on their competencies/EPAs would have an opportunity built into the curriculum structure to catch up without needing to extend their training.

1. There were several reasons that the program decided to move the core child rotation to PGY-2, largely based on resident feedback. These include earlier exposure to an area of potential interest, more opportunity for elective time in general and an opportunity to decide earlier whether or not to apply for the sub-specialty.

[Addendum (April 21, 2020): There were several reasons that the program decided to move the core child rotation to PGY-2, largely based on resident feedback. Earlier exposure to children and adolescents emphasizes that most mental disorders start early in life; this developmental perspective will be essential for all the following rotations and for your psychotherapy and other LAE patients. Also, it provides more opportunity for elective time in general and to decide earlier whether or not to consider the sub-specialty.]

2. In consultation with faculty and residents, it wouldn’t make sense to move child call to PGY-2 (i.e., recoupling it, more or less, with the core child rotation), because the nature of CAP call (a subspecialty population, more often having to navigate family/systems issues, working more independently) makes it more suitable for a more senior resident. Furthermore, it's possible that this could be a resident's first ever on-call experience which seemed unwise. 

3. An advantage of doing adult call during the core CAP rotation is that residents continue to have experience assessing adults, which is likely helpful with respect to STACER preparation and keeping up knowledge/skills with adults more generally. 

4. An advantage of doing the core child rotation in PGY-2 followed by child call in PGY-3 is that residents have the opportunity to see kids at 2 different stages of their training. Thus, in PGY-3 they can consolidate and build on what they learned in PGY-2. This is an approach we've taken (again based on resident feedback) with inpatients, ER and addictions.

5. We continue to believe that some child call is an advantage to a robust training program. Downtown Toronto is very unique. In virtually every other call experience, it's likely that you will be called upon to assess kids in the ER.

In the old curriculum, residents had a six-month inpatient block in PGY2. Residents consistently gave us feedback that this was too long on the most intense rotation early on in training. Many residents asked for a shorter experience saying that it would support their wellness and that the bulk of the learning occurred in the first 2/3 of the rotation. Furthermore, in the old system, it was possible to do an inpatient rotation until December of PGY2 and then graduate without ever again being on an inpatient unit.

By shortening the PGY2 inpatient rotation by two months and instead providing PLEX (elective time) we are hoping to allow residents the opportunity to explore potential areas of interest including the subspecialties early in training before any decisions need to be made. In addition, we believe the creation of a CTU like team with the PGY4 rotation will give all residents an opportunity to be a senior resident on the team. It will also allow the PGY4s to focus on other competencies like leader/manager, teacher, and other more senior/staff activities.

Up until recently the program took the stance that we would recognize and adhere to all accommodations supported by a medical note. In fact, we believe this is best for resident well-being and it is our legal obligation. However, over the last one to two years several residents have expressed concerns that some people may be misusing the generosity of that system. In principle, we would rather err on the side of a small number of residents getting accommodations that they don’t entirely need, rather than make the process for accommodations more challenging for a resident who is genuinely unwell. However, we also recognize the impact that this system can have on the rest of our hardworking call pools.

As a result, we are working with the University to implement a specific accommodation form. This is based on the kinds of forms that other large institutions or insurance companies use. This form will necessitate a specific description of any disabilities that need to be accommodated. In our current system, any physician can essentially write a note "this resident cannot do call" and we immediately take that resident out of the call pool. We are hopeful that the specificity required in the new form will diminish any misuse of medical notes.

In addition, it is important to note that rumors of widespread accommodations are overblown. In the current academic year, we have had a total of 28 residents with some form of call accommodations (for some period of time) out of 197 residents which works out to 14%. The numbers of residents requiring accommodation for 6 months or less is substantially smaller. While we always strive to improve our processes, this is not a number that suggests that multiple people are misusing the system, rather a few outliers.

Residents should also be aware that on occasion, when it has come to the program's attention that people are misusing call accommodations, we have acted swiftly. More than one resident has gone to the Faculty of Medicine Board of Examiners on the basis of these professionalism issues. If you are concerned about any professionalism issue with any of your colleagues, please feel free to bring it to our attention and we will not hesitate to follow-up.

Lecture materials such as PowerPoint Slides, and readings are posted on Quercus (https://q.utoronto.ca/). Materials are posted by the postgraduate office as soon as we receive them from our teachers; timing will be variable (either before or after a scheduled session) depending on when we receive the materials and the preferences of the teachers (some teachers prefer for their notes to be distributed only after their lecture).

Admittedly, some variability exists as lecture materials for some cohorts are easier to obtain than others. It is especially harder to maintain standards for teaching that occurs offsite (not centrally on the 8th floor of CAMH). Our postgraduate administrative colleagues do try to keep on top of this by maintaining regular communications with our hospital administrators who help run the off-site lectures.

Unless specifically requested by the teacher, the postgraduate office will not email lecture notes to students as they are always posted on Quercus. There may be times when residents receive e-mails with lecture materials for some core curriculum teaching, like for PGY4 teaching, however these materials will also be posted on Quercus.

Residents can find lecture materials on Quercus by navigating to their PGY section (i.e. PGY1) > Core Curriculum (PGY1 Core Curriculum) > academic year (PGY1 Core Curriculum 2019-2020). Available materials are posted in chronological order with the most recent on top.

The postgraduate administrative team is hard at work collating all our EPA data, running our Competence Committees and generating feedback reports to our learners. All this while also preparing​ for the upcoming academic year.

As a result, Transparent Thursday Topics will go on a very brief hiatus.

But before you break out into tears of misery.... have no fear... we have lots more questions to answer and Transparent Thursday Topics will be back before you know it. In the meantime, you are still welcome to use the channels below to submit new questions which we'll address soon.

Residents are allowed to attempt any EPA on any rotation. However, some will be easier to achieve in certain contexts. For example, the child EPA (COD2) is most achievable during your child rotation. We have created rotation plans and cards that highlight which EPAs we think will be most appropriate in each rotation. Please have a look as you start your rotation so that you can be proactive in your planning. The rotation plans and cards are available here: https://www.psychiatry.utoronto.ca/entrustable-professional-activities-epas under the “EPA Rotation Cards and Plans” section.

Residents can reach ahead to attempt EPAs that are above their stage of competency training. For example, the expectation in Foundations of Discipline is that you achieve the foundational EPAs. However, if you are entrustable in many of those and/or you have opportunities to complete EPAs in the Core of Discipline stage, please go ahead and try those as well. As long as you are on track for the EPAs in your stage, there is nothing preventing you from reaching ahead. In fact, it is encouraged!

Triple Dipping? Absolutely!

While we want residents to have excellent skills in different settings with diverse populations, we also want to allow for maximal flexibility with respect to mandatory requirements so that residents can immerse themselves in their preferred areas of interest. As a result, a group CBT case during a child rotation would count towards child, group and CBT requirements simultaneously.

In general, we want residents to experience psychotherapy with a diverse group of supervisors who practice using different approaches/models/styles. In addition, we want our supervisors to be available to new trainees rather than being "locked up" for years at a time by a single resident. As a result, residents are expected to change supervisors every 6 to 12 months. Under exceptional circumstances, this expectation may be reviewed.

After much deliberation, there are two main reasons we decided to include an evaluative component to the Centering Madness course. Firstly, we hope the assignment will stimulate learning and self-reflection. Secondly, we were very concerned about the appearance of having this important piece of curriculum remain un-evaluated. There was concern expressed that not having this "count" would undermine the teachers and perceived value of the course. The Psychiatry Competence Subcommittee takes every assessment in context, this is only one of many assessments you will receive over the course of training. However, we think it is important to treat this content seriously and rigorously to emphasize the value we put on education that centres the scholarship of service users and critical intersectional analysis of the structural determinants of mental health. 

Yes, definitely! Residents should focus on the off-service EPA i.e. FOD-1 Assessing, diagnosing, and participating in the management of patients with medical presentations relevant to psychiatry.  Your off-service rotations include Behavioural Neurology, Emergency Medicine, Family Medicine,  General Internal Medicine, Neurology, Palliative Care, and Pediatrics. 

We have also created the rotation cards and an EPA map to help guide you on which EPAs you are more likely to attempt on a specific rotation. Theoretically, any EPA can be attempted on a rotation. For example, you can attempt the critical appraisal EPA (FOD5) during GIM when you’re participating in journal club.

Here are the links to the Rotations Cards and the EPA Map:
• PGY1 Rotation Cards: https://www.psychiatry.utoronto.ca/sites/default/files/pgy1_rotation_cards_ttd_fod.pdf 
• PGY1 EPA Map: https://www.psychiatry.utoronto.ca/sites/default/files/epa_map_for_pgy1_ttd_fod.pdf

Residents are required to observe 2 X two-hour DBT group sessions.  Please connect with Erika Schmidt (erika.schmidt@camh.ca) regarding scheduling details and availability. Of course, if you have an interest there are opportunities for more learning and immersion in DBT. This represents the minimum requirements. 

The annual reviews serve many important functions in our program.
 
1) Annual reviews are an opportunity for residents and program leadership to review important academic requirements (for example, psychotherapy training experiences), and to ensure that all residents are achieving academic requirements so they can graduate on time.

2) Annual reviews are an opportunity to meet regularly and one on one with program leadership – the Program Director (Mark Fefergrad) and Associate Program Director (Deanna Chaukos) want to get to know you, and in such a large program, we find these meetings help us learn more about your individual career goals and training experiences.

3) These meetings are an important aspect of mentorship. A resident’s interests and experiences are always reviewed with a view to providing support, suggestions, and mentorship around the use of electives, and potential professional trajectories.

4) Although these meetings are done on an individual basis, because they all occur over a relatively short space of time the program director/associate program director are often in a position to be able to identify important subtle trends with respect to sites, rotations, or supervisors that may not otherwise be apparent or obvious.

5) Annual reviews also focus on the developmental stage of training. For example, PGY3 annual reviews occur at the beginning of PGY4, so are a nice opportunity to discuss PGY5 plans.

6) Finally, annual reviews are a built-in opportunity for residents to bring up any concerns or challenges experienced in residency. Many residents disclose either personal or professional challenges during these 1:1 meetings. Creating that safe and recurring space is very important to us.
 
We are always open to adjusting the format if there are other elements of these meetings that could be added or enhanced. If you have feedback on that front, please send it to Mark Fefergrad (mark.fefergrad@sunnybrook.ca) or anonymously via the SurveyMonkey link below.

Family/couples psychotherapy experience can occur in any rotation (minimum of 1-3 cases, 8 sessions total and minimum 2 sessions per family). Prime opportunities include any inpatient rotation, the child psychiatry rotation, the geriatric psychiatry rotation, and the C-L rotation.

The general psychiatry training program at the University of Toronto prides itself on being academically rigorous, diverse, and socially progressive. Issues relating to culture, social determinants of health, and racism have occupied a substantial proportion of core curriculum time over the last few years. In fact, these topics have the third most hours allocated to them after child psychiatry and psychopharmacology. We continue to add and refine all aspects of the curriculum on an annual basis as society and the needs of our learners and patients evolve. The recent international protests against systemic racism and the necessary social change they represent are incompletely represented in the curriculum at this time.  We are quickly adding seminars on an ad hoc basis where we see a need/opportunity. For example, this year for the first time with resident input we added a seminar to the psychotherapy series on the psychoanalytic view of race. An excerpt from the syllabus says: “As psychiatrists (as physicians, as people) we are always working with people whose life experiences are very different from our own. In this seminar we hope to provide you with an opportunity to think about and talk about that experience using ‘race’ as an exemplar.”

This seminar included a discussion of implicit bias and a paper by Dr. Dionne Powell, a Black psychoanalyst from Columbia, on the profession’s silence on race and the damage that causes.

In addition, we are working with resident leaders and other interested stakeholders to take a more holistic approach to these important content areas in the curriculum. In other words, some changes we have and will make right away, but some require more careful consultation in order to do them well, those processes are already underway. Bear in mind that we have already included Centering Madness as a primer in the PGY1 Springboard. We have multiple lectures on cultural safety, and a cultural psychiatry curriculum. We have recently revamped the lectures on gender, and sexuality. We selected a postgraduate social justice lead. We have the new Underserved/Marginalized Community Selectives in PGY1 and PGY3. The PGY3 selective has teaching associated with it, with topics such as structural determinants of health including immigration status, homelessness, racism LGBTQ health, as well as advocacy. In addition to this curriculum content, we are also looking very carefully at the structures and processes in our program to ensure they reflect the kind of values we want to promote as a community. For example, we will be mandating for the first time this year that all assessors involved in the CaRMS process will need to engage with implicit bias/anti-racism training. We are proud of how far we have come. We are leaders in this field both in the university and nationally. We also recognize that we need to do more, without undue delay. Stay tuned for more developments in the coming weeks!

A: Yes, you can but we find that it can be difficult for residents when they get too far behind on EPAs to catch up and we don’t want people to run the risk of not progressing at the expected rate. Slow and steady wins the race! It should be achievable to get at least 1  EPA once a week in your core rotation and one every other week in the LAE. We have accounted for vacation time and post-call days in the numbers that we have developed. Don’t forget, we have also significantly reduced the expectations from the Royal College for the time being.  Please make every effort to get your EPAs.

A; Given the impact of COVID on grand rounds across the city, the program wants to be maximally flexible while still allowing residents to engage in scholarly activities over the course of the year. Any resident who had their grand rounds cancelled last year as a result of COVID (i.e. presentation March through June) does NOT need to make up the grand rounds. In addition, we recognize that sites may be implementing different approaches to grand rounds for this year. As always, we leave it to residents and sites to work together on scheduling, format, duration, etc.

For this year only, there are just three requirements for a presentation to "count" as a grand rounds from the perspective of the program.

1) It needs to be interdisciplinary meaning at least two professions are in attendance. Please note this could be your supervisor and a nurse or a PT and an OT, we are flexible.

2) There needs to be an evaluation of the rounds that you can send in to the Postgrad office.

3) The presentation needs to be at least 30 minutes.

We continue to believe that the opportunity to present in front of colleagues and hone your presentation skills is a valuable one. Any residents who are able to schedule a more formal grand rounds are encouraged to do so. However, given the pandemic and the number of grand rounds that were cancelled last year, these three standards should allow you to fulfil the grand rounds requirements over a lunch hour with your supervisor and one other professional if a formal spot is not available to be booked at your site. Please be sure to coordinate your plans with your site and of course to send in the slides and evaluations to the PG office so they can be added to your file.

We anticipate reverting to our usual grand rounds format in July 2021, but of course, we will review this as events on the ground evolve.

Q: Since LAE is over 3 years long, why is there a culture in which LAE is highly protected at the expense of other rotations? For example, not being post-call for LAE, not being able to do international electives because of LAE. Why is it okay to miss large chunks of other blocks but not LAE?

A: It is always difficult to know what kinds of activities to prioritize with respect to post-call days. For example, we would not want all post-call days to be on teaching days, nor would we want all post-call days to involve missing core rotation time. The LAE is no different, except that because it is only once a week, to miss a day of LAE results in a longer gap both for you and for the patients you care for.

There is no specific rule from the program about which days are suitable for call, however, informally we do advise the chief residents (who make the call schedules) to try and ensure that no activity or rotation is disproportionally disadvantaged. We anticipate that residents will occasionally be post-call on their LAE day, but because of the gap between LAE days and the wish for continuity, those days should be relatively few over the course of the year.

A: We are getting in touch to clarify the requirements for attendance with respect to special academic days.
Please note that in the old curriculum, these days were mandatory for every resident every single year. To give
residents flexibility and in recognition of asymmetric interests, last year we modified those requirements so
that residents only need to attend each special academic day once over the course of their 5 years of training.

You are certainly allowed to attend any given day more than once however, you will need to use one of your 7
PARO allocated professional days if you are missing clinical duties.

For your convenience, we have attached:
i) All teaching days for the year (conveniently arranged by PG year)
ii) The curricular days mandatory and protected time schedule
iii) A list of all feedback sessions scheduled for the year

A: While the Royal College is interested primarily in entrustable observations, locally we are interested in both quality and quantity. Our reasoning is as follows:

1) You will learn more by having multiple assessment points, with multiple assessors.

2) The numbers for your cohort of required entrustable EPAs is far below the RC numbers. While at present the RC is allowing leeway, eventually they will expect us to fall in line, so we need to get used to completing more EPAs (faculty and staff).

That said, if you are entrustable in all FOD EPAs, then you can move on to getting COD EPAs to count towards your number of attempts. If you are entrustable in all COD EPAs, you can move on to TTP EPAs.

Also, it would make the most sense to attempt EPAs that you feel less confident about, even if you are entrustable. For example, we could all benefit from improving our formulation skills or psychopharm skills or integrated psychotherapy skills and having an opportunity for feedback in these arenas, even if you are theoretically “entrustable” is likely useful.

In addition, it’s important to recognize that the Royal College numbers are educationally informed but somewhat arbitrary. Over time as we accumulate several cohorts of data, we anticipate that we will be able to run some statistical analyses that will inform how many observations and entrustments are required for each EPA to be valid. Intuitively, this will likely vary depending on the stage and complexity of each EPA. Since we are the largest training program in Canada, we will certainly take those data to the Royal College for consideration nationally.

A: All residents have access to POWER and can view completed the ITARs/ITERs that supervisors have completed on them. In order to do this, a resident must complete both the teacher evaluation and the rotation evaluation. Once these two evaluations are completed by the resident, then they will be able to view their ITARs/ITERs. Even if the resident does not complete the above parameters, the Competence Committee will still have access to these ITARs/ITERs.

We have also been advocating strongly for a more informative dashboard on Elentra. This is currently being worked on by the University and we anticipate vastly improved data visualization options in the new calendar year.

A: Double dipping! Yes, you can! But it might be onerous to do this as you will have to trigger separate EPAs. Unfortunately, Elentra does not have the capacity to generate multiple assessment forms at any one time. Additionally, the amount of feedback required may be overwhelming for the assessor and the learner and the quality of feedback could be less effective. But you can definitely do two or more EPAs for one encounter if both the learner and assessor are willing.