Entrustment Signal Distortion: Addressing Specialty Misalignment in Entrustable Professional Activity Assessment of...

Entrustable professional activities (EPAs) provide structured, real-world assessments aligned with competency-based surgical education. However, EPA implementation and engagement vary by specialty, potentially distorting signals of trainee competency. This study evaluates EPA assessment patterns across surgical specialties to identify structural misalignments in the current framework.

We retrospectively analyzed EPA evaluations from the Firefly Platform (July 2023-July 2025), including 650 faculty across 46 institutions. Each faculty's specialty was confirmed via program or public data. EPA assessment rates were calculated by faculty and stratified by phase of care (preoperative, intraoperative, and postoperative). Differences between specialties were assessed using Kruskal-Wallis tests and post hoc Dunn's tests with Bonferroni correction. Specialties with fewer than three faculty were excluded from statistical comparisons.

Engagement varied significantly by specialty and demonstrated marked non-normal distribution. The median total engagement per faculty was highest in hepatopancreatobiliary (21.0 [interquartile range (IQR) 92.0]) and trauma/acute care surgery (15.0 [IQR 47.0]), whereas plastic surgery (2.5 [IQR 3.5]) and vascular surgery (3.0 [IQR 5.75]) demonstrated the lowest engagement. Significant differences were observed for total (P < 0.0001), preoperative (P = 0.0004), and intraoperative (P < 0.0001) phases, but not postoperative (P = 0.068). Post hoc testing revealed significantly higher preoperative engagement in trauma/acute care surgery compared to vascular surgery and surgical oncology, and significantly lower intraoperative engagement in vascular surgery compared to multiple services. Nationally, the top 10% of faculty accounted for 60.8% of all EPA submissions, and within-specialty Gini coefficients ranged from 0.21 to 0.76, indicating substantial participation concentration.

Wide variability in EPA engagement reflects specialty-specific misalignment with the current EPA structure. In low-engagement fields, limited EPA applicability may underrepresent faculty teaching and resident competency. Revisions to the EPA framework are needed to improve fairness, fidelity, and actionable feedback across diverse surgical specialties.