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The Path to Independence: Progression in Entrustment Reflected in Entrustable Professional Activity Ratings
Andrada Diaconescu1, Julia Kasmirski1, Erin White1
1Department of Surgery, University of Alabama at Birmingham, Birmingham, AL.
Annals of Surgery
|June 12, 2026
Summary
Entrustable Professional Activities (EPAs) in general surgery training help identify performance targets. Variability in trainee entrustment allows for earlier identification of residents needing additional support in their competency-based education.
Area of Science:
- Medical Education
- Surgical Training
- Competency-Based Assessment
Background:
- The American Board of Surgery implemented Entrustable Professional Activities (EPAs) in 2016 for general surgery competency-based education.
- EPAs translate milestones into practical assessments for feedback and progressive entrustment.
Purpose of the Study:
- To investigate if variability in trainee entrustment within EPAs can pinpoint performance targets.
- To enable earlier identification of surgical residents requiring additional support.
Main Methods:
- Reviewed national American Board of Surgery EPA data from July 2023 to July 2025 for PGY-1 to PGY-5 residents.
- Analyzed microassessments using the ABS entrustment scale (1-4) across EPAs, phases, and postgraduate years.
- Summarized formative entrustment ratings and progression using descriptive statistics.
Main Results:
- Data included 9,932 residents and 185,901 EPA microassessments.
- Over half of trainees achieved "Indirect Supervision/Practice Ready" by PGY-3 for appendicitis, abdominal wall hernia, breast disease, and cutaneous/subcutaneous neoplasm EPAs.
- Slower progression was observed for colon, gallbladder, inguinal hernia, and thyroid/parathyroid disease EPAs, with 50% achievement by PGY-4.
- Soft tissue infection showed earlier progression, with 54.8% reaching indirect supervision or higher by PGY-2.
Conclusions:
- The adoption of EPAs facilitates identifying periods of rapid entrustment progression.
- This competency-based assessment approach aids in developing targeted interventions for surgical trainees.
- EPAs support the creation of a robust competency-based surgical training framework.
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