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The Path to Independence: Growth in Entrustment Reflected in EPA Ratings
*Andrada Diaconescu1, *Julia Kasmirski
1, *Erin White
1, James Korndorffer
2, *M Chandler McLeod
1, George A. Sarosi
3, *Carol L. Barry
4, *Andrew Jones
4, Rebecca minter
5, Karen Brasel
6, Brenessa Lindeman
11Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama; 2Department of Surgery and Perioperative Care, The University of Texas at Austin, Dell Medical School, Austin, Texas; 3Department of Surgery, University of Florida, Gainesville, Florida; 4American Board of Surgery, Philadelphia, Pennsylvania; 5Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; 6Department of Surgery, Oregon Health and Science University, Portland, Oregon
Objectives In 2016 the American Board of Surgery (ABS) began to explore Entrustable Professional Activities (EPAs) as an assessment framework to support competency-based education within General Surgery. EPAs operationalize milestones and competencies into a more relatable assessment framework, allowing for timely and frequent targeted feedback which enhances progressive entrustment. We hypothesize that variability in trainee progression in entrustment may allow for the identification of specific EPAs that can serve as performance benchmarks. Establishing such benchmarks could help programs with early identification of trainees who may need extra support throughout training.
Methods National EPA data from the ABS 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, 2=direct supervision, 3=indirect supervision, 4=practice ready) were compared by activity, phase, and post-graduate year for all EPAs. Descriptive statistics were utilized to summarize entrustment ratings and compare within post-graduate year.
Results Subjects included 9,966 residents from 344 programs. A total of 186,242 EPA MAs were available for analysis with a focus on the 58,914 intraoperative EPAs. Trainee average entrustment ratings were calculated across phases and post-graduate years for all EPAs, excluding trainees who only received 1 MA for a given EPA, and plotted by PGY. Greater than 50% of trainees progress to a mean entrustment rating of indirect supervision/practice ready at the PGY-3 level for the intraoperative management of appendicitis (65.3%, n=520), gallbladder disease (52.5%, n=670), abdominal wall hernia (52.7%, n=350), breast disease (61.2%, n=172), and cutaneous/subcutaneous neoplasm (78.1%, n=121). Colon disease (81.6%, n=422), inguinal hernia (81.4%, n=399), thyroid and parathyroid disease (66.7%, n=80), and renal replacement therapy (56.6%, n=47) showed a slower progression, occurring at the PGY-4 level. There was a notable early progression for soft tissue infection (56.9%, n=161) at the PGY-2 level. Figure 1 shows the progression of mean EPA scores at the PGY-2, PGY-3, and PGY-4 levels for representative activities.
Conclusions With the introduction of EPAs and the shift towards competency-based assessment, there is a new ability to identify periods of rapid progression and rising entrustment. This allows training programs the opportunity to establish benchmarks that can be used for early identification of trainees that struggle, subsequently providing them much needed support earlier in training. In particular, programs can expect trainees to show operative entrustment in soft tissue infection as early as PGY-2, with other EPAs closely following at PGY-3 and PGY-4, potentially serving as benchmarks.
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