Entrustable Professional Activities in Surgery: A Review

Overview

Journal JAMA Surg

Publisher American Medical Association

Specialty General Surgery

Date 2024 Mar 13

PMID 38477902

Authors

Kelsey B Montgomery

John D Mellinger

Brenessa Lindeman

Affiliations

Soon will be listed here.

Abstract

Importance: Entrustable professional activities (EPAs) compose a competency-based education (CBE) assessment framework that has been increasingly adopted across medical specialties as a workplace-based assessment tool. EPAs focus on directly observed behaviors to determine the level of entrustment a trainee has for a given activity of that specialty. In this narrative review, we highlight the rationale for EPAs in general surgery, describe current evidence supporting their use, and outline some of the practical considerations for EPAs among residency programs, faculty, and trainees.

Observations: An expanding evidence base for EPAs in general surgery has provided moderate validity evidence for their use as well as practical recommendations for implementation across residency programs. Challenges to EPA use include garnering buy-in from individual faculty and residents to complete EPA microassessments and engage in timely, specific feedback after a case or clinical encounter. When successfully integrated into a program's workflow, EPAs can provide a more accurate picture of residents' competence for a fundamental surgical task or activity compared with other assessment methods.

Conclusions And Relevance: EPAs represent the next significant shift in the evaluation of general surgery residents as part of the overarching progression toward CBE among all US residency programs. While pragmatic challenges to the implementation of EPAs remain, the best practices from EPA and other CBE assessment literature summarized in this review may assist individuals and programs in implementing EPAs. As EPAs become more widely used in general surgery resident training, further analysis of barriers and facilitators to successful and sustainable EPA implementation will be needed to continue to optimize and advance this new assessment framework.

Citing Articles

Establishing a set of qualities for clinical teaching faculty in undergraduate medical internship.

Song J, Wei G, Cheng H, Yan Y, Yang S BMC Med Educ. 2025; 25(1):298.

PMID: 39994785 PMC: 11854011. DOI: 10.1186/s12909-025-06868-7.

References

Krecko L, Jung S, Martin S, Krebsbach C, Rosser A, Stahl C . Enhancing the Value of Surgical Entrustable Professional Activities through Integrative Learning Analytics. J Surg Educ. 2023; 80(10):1370-1377. DOI: 10.1016/j.jsurg.2023.07.018. View

Oliver J, McFarlane J, Kunac A, Anjaria D . Declining Resident Surgical Autonomy and Improving Surgical Outcomes: Correlation Does Not Equal Causality. J Surg Educ. 2022; 80(3):434-441. DOI: 10.1016/j.jsurg.2022.10.009. View

Brasel K, Lindeman B, Jones A, Sarosi G, Minter R, Klingensmith M . Implementation of Entrustable Professional Activities in General Surgery: Results of a National Pilot Study. Ann Surg. 2023; 278(4):578-586. DOI: 10.1097/SLA.0000000000005991. View

Chen X, Sullivan A, Smink D, Alseidi A, Bengtson J, Kwakye G . Resident Autonomy in the Operating Room: How Faculty Assess Real-time Entrustability. Ann Surg. 2019; 269(6):1080-1086. DOI: 10.1097/SLA.0000000000002717. View

Mattar S, Alseidi A, Jones D, Jeyarajah D, Swanstrom L, Aye R . General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors. Ann Surg. 2013; 258(3):440-9. DOI: 10.1097/SLA.0b013e3182a191ca. View

Klingensmith M, Lewis F . General surgery residency training issues. Adv Surg. 2013; 47:251-70. DOI: 10.1016/j.yasu.2013.05.001. View

Williams R, Dunnington G, Mellinger J, Klamen D . Placing constraints on the use of the ACGME milestones: a commentary on the limitations of global performance ratings. Acad Med. 2014; 90(4):404-7. DOI: 10.1097/ACM.0000000000000507. View

Williams R, Sanfey H, Chen X, Dunnington G . A controlled study to determine measurement conditions necessary for a reliable and valid operative performance assessment: a controlled prospective observational study. Ann Surg. 2012; 256(1):177-87. DOI: 10.1097/SLA.0b013e31825b6de4. View

Greenberg J, Minter R . Entrustable Professional Activities: The Future of Competency-based Education in Surgery May Already Be Here. Ann Surg. 2018; 269(3):407-408. DOI: 10.1097/SLA.0000000000003153. View

10.

Williams R, George B, Bohnen J, Dunnington G, Fryer J, Klamen D . A Proposed Blueprint for Operative Performance Training, Assessment, and Certification. Ann Surg. 2020; 273(4):701-708. DOI: 10.1097/SLA.0000000000004467. View

11.

Meyerson S, Teitelbaum E, George B, Schuller M, DaRosa D, Fryer J . Defining the autonomy gap: when expectations do not meet reality in the operating room. J Surg Educ. 2014; 71(6):e64-72. DOI: 10.1016/j.jsurg.2014.05.002. View

12.

Kearse L, Schmiederer I, Anderson T, Dent D, Payne D, Korndorffer Jr J . American Board of Surgery Entrustable Professional Activities (EPAs): Assessing Graduating Residents' Perception of Preoperative Entrustment. J Surg Educ. 2021; 78(6):e183-e188. DOI: 10.1016/j.jsurg.2021.09.004. View

13.

Nieboer P, Huiskes M, Cnossen F, Stevens M, Bulstra S, Jaarsma D . The Supervisor's Toolkit: Strategies of Supervisors to Entrust and Regulate Autonomy of Residents in the Operating Room. Ann Surg. 2020; 275(1):e264-e270. DOI: 10.1097/SLA.0000000000003887. View

14.

Bohnen J, George B, Williams R, Schuller M, DaRosa D, Torbeck L . The Feasibility of Real-Time Intraoperative Performance Assessment With SIMPL (System for Improving and Measuring Procedural Learning): Early Experience From a Multi-institutional Trial. J Surg Educ. 2016; 73(6):e118-e130. DOI: 10.1016/j.jsurg.2016.08.010. View

15.

Brazelle M, Zmijewski P, McLeod C, Corey B, Porterfield Jr J, Lindeman B . Concurrent Validity Evidence for Entrustable Professional Activities in General Surgery Residents. J Am Coll Surg. 2022; 234(5):938-946. DOI: 10.1097/XCS.0000000000000168. View

16.

Brasel K, Klingensmith M, Englander R, Grambau M, Buyske J, Sarosi G . Entrustable Professional Activities in General Surgery: Development and Implementation. J Surg Educ. 2019; 76(5):1174-1186. DOI: 10.1016/j.jsurg.2019.04.003. View

17.

Lindeman B, Sarosi G . Competency-based resident education: The United States perspective. Surgery. 2019; 167(5):777-781. DOI: 10.1016/j.surg.2019.05.059. View

18.

Padilla E, Stahl C, Jung S, Rosser A, Schwartz P, Aiken T . Gender Differences in Entrustable Professional Activity Evaluations of General Surgery Residents. Ann Surg. 2021; 275(2):222-229. PMC: 8514571. DOI: 10.1097/SLA.0000000000004905. View

19.

Eaton M, Scully R, Schuller M, Yang A, Smink D, Williams R . Value and Barriers to Use of the SIMPL Tool for Resident Feedback. J Surg Educ. 2019; 76(3):620-627. DOI: 10.1016/j.jsurg.2019.01.012. View

20.

Williams R, Swanson D, Fryer J, Meyerson S, Bohnen J, Dunnington G . How Many Observations are Needed to Assess a Surgical Trainee's State of Operative Competency?. Ann Surg. 2017; 269(2):377-382. DOI: 10.1097/SLA.0000000000002554. View