Does Case Complexity Impact EPA Entrustment? Analysis Across PGY Levels and Phases of Care

The American Board of Surgery will require Entrustable Professional Activity (EPA) assessments for general surgery certification beginning in 2028. Though many studies have examined EPA implementation, a gap exists in understanding the relationship between procedural complexity and entrustment scores, and the influence of phase of care (POC) and postgraduate year (PGY) level.

De-identified EPA data from one institution were analyzed using linear and ordinal mixed models. Residents were grouped as juniors (PGY1-2) and seniors (PGY3-5). Interactions of case complexity with PGY and POC were examined to assess influence on entrustment.

A total of 1413 EPA assessments were analyzed. A linear mixed-effects model demonstrated a significant interaction between PGY group and case complexity (p < 0.01). Scores were significantly higher in nonoperative phases (β = 0.60, 95% Confidence Interval [95% CI]: 0.52-0.68, p < 0.001), and PGY3-5 residents received higher ratings across all complexities: +1.02 (95% CI: 0.83-1.21) for straightforward, +0.77 (95% CI: 0.48-1.06) for moderate, and +0.87 (95% CI: 0.51-1.24) for complex cases. For junior residents, scores did not differ significantly between straightforward and moderate cases (β = -0.01, p = 0.87) but declined significantly in complex cases (β = -0.23, 95% CI: -0.42 to -0.03, p = 0.02). The PGY × complexity interaction resulted in a greater drop in mES for senior residents, as compared to junior residents, when moving from straightforward to moderate cases (β = -0.25, 95% CI: -0.41 to -0.09, p < 0.01). While senior residents also experienced a significant decline from straightforward to complex cases, this decrease was not significantly different from that experienced by junior residents (β = -0.14, 95% CI: -0.36-0.07, p = 0.20).

Entrustment scores decrease with increasing procedural complexity and increase with PGY level and nonoperative phases of care. The effect of complexity differed by training levels: junior resident scores remained stable from straightforward to moderate cases and declined only in complex procedures, while senior resident scores declined significantly at both the moderate and complex threshold. These findings underscore the importance of interpreting EPA data in the context of both case complexity and trainee experience.