How to Motivate Students: EPAs, Badges, and Experience Points

Older Man Studying for an Online Postgraduate Degree in Orofacial Pain and Oral Medicine on his Laptop at Home

The final installment in the F.I.S.G.R. acronym for effectively teaching online is “R,” which stands for rewards. In general, the principle is that rewards do in fact motivate students.

Before explaining badges and experience points, it is important to explain milestones and EPAs. As the name implies, milestones mark a student’s growth or progress towards the ultimate goal. EPAs are relatively new on the residency training scene.

Entrustable Professional Activities

EPA stands for Entrustable Professional Activities. Completing an EPA and being certified as completing it is critical in the education of both medical and dental residents. EPAs are used to determine when a resident (medical or dental) can be indirectly supervised as opposed to directly supervised. This is an important distinction since direct supervision requires the attending faculty be present when a resident works with a patient but indirect supervision does not.

The “father of EPAs” is Dr. Ollie Ten Cate who is a MD in the Netherlands. In his paper, Nuts and Bolts of Entrustable Professional Activities, in the Journal of Graduate Medical Education (March, 2013) he defines what EPAs:

  1. An EPA is a competency-based education target.
  2. Completing an EPA satisfactorily allows a resident to work with “indirect supervision” rather than direct.
  3. A program’s EPAs defines “proficiency to graduate.”
  4. Medical competencies are defined by CanMEDS.

In summary, EPAs use CanMEDS but translate these competencies into behaviors that occur in the actual real world of medical practice.

What are CanMEDs and OSCEs?

CanMEDs define needed qualities of a professional. The word is derived from two words: Canadian and Medical. They were originally written and published by Royal College of Surgeon of Canada and define the seven essential qualities and behaviors a physician needs to exhibit including being a: medical expert, collaborator, leader, health advocate, scholar, and professional.

Once you have EPAs (e.g. student must be able to conduct a thorough patient interview), you then need to have a set of Objective Standardized Clinical Examinations (OSCEs) that can be used to assess the students ability on this specific EPA.

Types of Supervision for Residents

The American Council of Graduate Medical Education (ACGME) defines three types of supervision they endorse:

  1. Direct Supervision – supervising doctor is physically present with the resident and patient.
  2. Indirect Supervision – supervising doctor is not physically present but immediately available to the resident and patient.
  3. Oversight – supervising doctor is available to review procedures/encounters with feedback provided soon after care is delivered.

Review and Reflection

Because none of the three types of ACGME supervision work if you are trying to train a resident in another city, state, or country, there is another type of supervision that is applicable in a hybrid online residency program called “Review and Reflection.”

Of course, if a faculty member has a resident who is in a location where the faculty is not physically present and licensed, they cannot be involved in direct, indirect or oversight supervision of patients as this could be considered practicing without a license.

Review and Reflection is a “non-supervision” style of supervision that involves discussions of patient care using de-identified cases and guided discovery questions. Review and Reflection can not be used not to directly or even indirectly guide ongoing treatment of a patient but instead to teach the principles of evidence-based care. Using “exemplar” de-identified cases the faculty can discuss, comment and teach the principles underlying Diagnosis and Treatment.

In our hybrid online “residency” training programs residents are onsite for part of their training so the supervision is different depending on the residents location. When residents are onsite they participate in direct, indirect and oversight. When they’re online we use we-identified exemplar cases, virtual patient cases, reflective journal reviews, and a final portfolio review.

How to Motivate Students and Increase Performance

F.I.S.G.R. Initialism - "R" Stands for RewardsUsing Rewards to Increase Student Performance and Participation

In this section we’ll cover using rewards to increase student performance and engagement through achievement badges, experience points, and we’ll cover the effects of game-based learning.

What are achievement badges?

Badges reward students for passing milestones and mastering specific EPAs. The future will tell if badges become more important in the professional world but certainly badges have personal value and maybe some will have a consumer value.

The personal value of badges is that they represent skills, competencies, activities, and achievements. If by earning a badge, an individual gains greater insight into themselves and their abilities, then the value of the badge is extremely high but entirely dependent upon the perception of the earner. The consumer value of badges largely depends on the consumer or market value. Earning a badge, or a series of badges is like earning currency. Some are silver while other badges are gold.

While programs will differ in how they award badges, students at USC will get a badge only after they:

  1. Successfully pass a USC course (usually 1 or 2 units) with a grade of B or higher;
  2. Pass a set of associated objective standardized clinical examinations [OSCEs] relevant to skill the badge represents
  3. Gain a minimum number of experience points (XPs) [documented with a mini-portfolio submission]

Experience Points

Experience Points (XPs) are gained based on experiences students have in an observational practicum and that are clearly documented in their “reflective journals.” Students must carefully document their experiences on their observational practicum and respond to all faculty questions in a Reflective Journal to earn XPs.

Related Reading: How to Increase Student Performance with Active Learning

What is the evidence that badges motivate students?

A 2016 and 2017 study examined student attitude about badges and found they were motivational and popular.

Game-Based Learning

Davidson SJ and Candy L.’s “Teaching EBP Using Game-Based Learning: Improving the Student Experience,” article from Worldviews on Evidence-Based Nursing (August 2016) evaluated game-based learning (GBL) tools.

Using an online nursing course with GBL methods student satisfaction was assessed at the middle and end of the term. The game platform’s analytics and narrative comments were used to assess student learning with end of course grades.


  1. Students showed high satisfaction with the course.
  2. 87% of the students (26/30) continued using game even after getting enough points to get an A grade
  3. Seven students completed every learning quest in game
  4. 17/30 students earned a final course grade of A+
  5. 13/30 students earned an A grade.

They concluded that individualized feedback and use of badges promoted student engagement and mastery.

Rather than use quizzes and a final exam you could use a complication of experience points and badges to issue a grade in a course to motivate students to engage in interactive activities.

Physical Health Problems19%84%
Mental Health Problems50%78%
Substance Abuse Conditions13%75%
Trimbordity (Physical, Mental, Substance)2%50%

One example of how we use game-based learning is through our Virtual Patient Game, which allows dental students opportunities to hone their diagnostic skills based on simulations of real-life patient case studies.

Play the Virtual Patient Game

Student Perceptions of Digital Badges

Here is a nice article by Fajiculay JR, et al’s, “Student perceptions of digital badges in a drug information and literature evaluation course,” from the Currents in Pharmacy Teaching and Learning (September 2017), which assessed student attitude about badges. Student perceptions were assessed with pre- and post-learning surveys.


  1. The response rate was 69% (106/153).
  2. At baseline, 53% of respondents thought badges could help.
  3. Badges posted on both LinkedIn (68%) and Facebook (19%).
  4. 73% with earned badges claimed increased confidence.
  5. 55% with earned badges claimed better knowledge

Digital badges were perceived by students as a positive adjunct to learning and may provide a novel mechanism for development of an electronic skills-based portfolio. Digital badges also helped increase confidence in course material, helped recall information for a quiz or exam, and should be implemented into other courses.

4 Things to Remember

One thing you must not do is expect that a course without a tangible and immediate benefit to the student will be popular.

That said here are the three things you SHOULD do:

  1. Design a set of competencies (badges) for each course and make sure each one has real value to the student.
  2. Place these achievement badges in a accessible password protected web-enabled locker.
  3. Each badge should contain metadata documenting the credentials of the issuer and all requirements to get it.

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Like what you’re learning? Consider enrolling in our online, competency-based certificate or master’s program in Orofacial Pain and Oral Medicine to deliver appropriate and safe care to your growing and aging dental patients.

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