When National Competency Standards Become Difficult to Enact in Practice: Phantom EPAs in Taiwan's Nationwide CBME...

Competency-based medical education (CBME) aims to deliver individualized, outcome-oriented training. However, implementing entrustable professional activities (EPAs) across diverse institutional and healthcare environments remains challenging. Taiwan's nationwide implementation of the medical radiation technologist (MRT) EPA framework across 122 teaching hospitals provides an opportunity to examine how educational goals intersect with institutional constraints. Using data from the national "Emyway" e-portfolio system for the first implementation year (January to December 2024), we analyzed EPA implementation patterns for MRTs in three subspecialties: diagnostic radiology, radiation therapy, and nuclear medicine. At the institutional level, 81 (66.4%) of the 122 accredited teaching hospitals registered on Emyway. Of the 81 registered hospitals, 52 (64.2%) documented EPA training. Registration rates differed significantly by hospital tier (medical centers 100% vs. regional/district hospitals 57.3%, p < 0.001), although documentation rates did not differ significantly (73.1% vs. 60.0%, p = 0.25). At the trainee level, 340 MRT trainees were registered on the platform, of whom 186 (54.7%) had at least one documented workplace-based EPA assessment; 49 (14.4% of registered trainees) progressed to summative Clinical Competency Committee entrustment decisions. We also identified three EPAs with very low assessment documentation during the first implementation year. These patterns of EPA engagement could potentially be interpreted as typical implementation challenges but may also point to structural barriers of various types. Given one year of descriptive data, they should be read as a hypothesis of misalignment between standardized frameworks and local clinical realities requiring further study rather than as established structural barriers. Taiwan's experience suggests that national CBME frameworks may benefit from differentiating between universally attainable competencies and context-dependent activities and from incorporating flexible EPA portfolios and tier-sensitive expectations to promote both assessment validity and educational equity across heterogeneous training environments.