The Path to Independence: Progression in Entrustment Reflected in Entrustable Professional Activity Ratings

In 2016 the American Board of Surgery introduced Entrustable Professional Activities (EPAs) as an assessment framework to support competency-based education within general surgery. EPAs operationalize milestones and competencies into a practical assessment framework, enabling timely, targeted feedback and progressive entrustment.

We hypothesize that variability in trainee entrustment may identify specific EPAs that function as performance targets, allowing earlier identification of trainees who may need additional support.

National ABS EPA data for PGY-1 through PGY-5 residents from July 2023 to July 2025 were reviewed. Microassessments (MAs) using the ABS entrustment scale (1=Limited Participation; 4=Practice Ready) were compared by EPA, phase, and postgraduate year. Descriptive statistics summarized formative entrustment ratings and progression within postgraduate year.

Subjects included 9,932 residents from 345 programs, with 185,901 EPA MAs. For several intraoperative EPAs, over half of trainees achieved a median formative assessment of Indirect Supervision/Practice Ready at the PGY-3 level, including appendicitis (58.2%, n=819), abdominal wall hernia (50.4%, n=618), breast disease (52.7%, n=309), and cutaneous/subcutaneous neoplasm (66%, n=325). Colon disease (73.4%, n=756), gallbladder disease (86.6%, n=1410), inguinal hernia (76.5%, n=734), and thyroid/parathyroid disease (61.3%, n=184) showed a slower progression, not achieving 50% of residents until the PGY-4 level. Earlier progression was noted for soft tissue infection with 54.8% (n=355) attaining indirect supervision or higher at the PGY-2 level.

The introduction of EPAs and shift towards competency-based assessment enables the identification of periods of rapid entrustment progression and supports the identification of targets that may facilitate the development of a competency-based training framework.