Entrustable Professional Activities (EPAs) and Applications to Surgical Training

The concept of an Entrustable Professional Activity originated out of concerns that competency-based training frameworks (ACGME or CanMEDS)^1,2 were too abstract and theoretical to be practically applied in the daily training and assessment of medical learners. In response, Olle ten Cate first pioneered EPAs in 2005 in an effort to help translate this theory into practice by allowing faculty to make competency-based decisions about the level of supervision required by trainees^3-5 for specific tasks, skills, and procedures.  Because trust is central to any decision about a level of supervision, the concepts of trustworthiness and self-awareness of limitations leading to appropriate help-seeking behavior are fundamental competencies underlying all entrustment decisions for clinical behaviors.⁶

It is important to realize that EPAs are not alternatives to competencies, but rather a complementary way to translate the broad concepts of competency into everyday practice. EPAs should be thought of as the units of work of a physician, while competencies are abilities of individuals to carry out that work^4,6  (Figure 1).

Although the formalized concept of EPAs is relatively new, the concept of surgeons making entrustment decisions about a trainee’s competence on an ad hoc basis is part of the tradition of surgical training. In the context of an operation, the surgeon considers multiple variables to determine the level of responsibility and autonomy that they will grant to the trainee they are working with. The variables that affect these entrustment decisions have been categorized in the following manner⁴:

1. Attributes of the trainee (tired, confident, level of training)
2. Attributes of the supervisor (lenient or strict)
3. Context (time of day, facilities available)
4. The nature of the activity or EPA (rare, complex versus common, easy)

Dr. ten Cate also went on to define five levels of supervision that may be employed with each EPA. These are not identical to, but are aligned with, other measures of progressive responsibility or autonomy in surgical training.⁷ They include⁴:

1. Observation but no execution by the trainee, even with direct supervision
2. Execution with direct, proactive supervision
3. Execution with reactive supervision, i.e., on request and quickly available
4. Supervision at a distance and/or post hoc
5. Supervision provided by the trainee to more junior colleagues

While these levels of supervision do not perfectly correlate with achievement of specific milestones, trainees that have reached requisite milestones across the competencies necessary for an EPA may be entrusted with the highest levels of independence in terms of supervision.

Due to the work of ten Cate and others, the concept of EPAs has begun to gain traction within the United States medical education system, particularly in Undergraduate Medical Education (UME). In 2014, the Association of American Medical Colleges (AAMC) convened a panel of education experts to identify a short list of “integrated activities expected of all MD graduates” in response to increasing concern from residency training programs that some graduates are not prepared for residency.^8-9 The panel defined the Core EPAs for Entering Residency (CEPAER)⁶ and this work has become the foundation for a pilot program at 10 medical schools across the US to implement EPAs as part of the UME curriculum in both formative and summative student assessment.¹⁰ For example, AAMC Core EPAs for Entering Residency that a third-year medical student could perform during a surgical clerkship could include:

• Gather a history and perform a physical examination
• Recommend and interpret common diagnostic and screening tests
• Provide an oral presentation of a clinical encounter

Although much work remains in this domain to fully implement EPAs in surgery, other medical specialties are beginning to use an EPA framework for assessment in Graduate Medical Education. The American Board of Pediatrics published 17 EPAs that pediatric training program graduates should be trustworthy to perform at the completion of training.¹¹ These EPAs are also being piloted in conjunction with the Core EPAs for Entering Residency in the Education in Pediatrics Across the Continuum (EPAC) project to fully implement competency-based assessment and advancement of students interested in pediatrics from medical school through entry to practice.¹²

With recent concern over the preparedness for graduates of general surgery training programs to enter unsupervised practice,^11,12 the time seems right for introduction of a competency-based assessment and advancement system that has appropriate theoretical grounding, but is easily understandable and measurable in the daily clinical context. That system will likely incorporate a framework of broad-based as well as surgery-specific EPAs. Members of the American College of Surgeons, Association of Program Directors in Surgery, the Resident Review Committee in Surgery, the American Board of Surgery, and the Association of Surgical Education, and the Fellowship Council have begun to express interest in formulating EPAs for General Surgery training. Once these EPAS are defined, there will continue to be much work to do to determine how these will best be assessed, and when and how formalized entrustment decisions will be made, as well as the best remediation for those trainees that are not yet ready for entrustment. Surely this will be an area ripe for innovation in surgical education for years to come.

Figure 1.

1. CanMEDS 2000 Project. Skills for the New Millennium. Report of the Societal Needs Working Group, Ottawa, September 1996.
2. Swing SR. The ACGME Outcome project: Retrospective and prospective. Med Teach. 2007;29(7):648-654.
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4. ten Cate O. Nuts and bolts of entrustable professional activities. J Grad Med Educ. 2013;5(1):157-158.
5. Ten cate O, Scheele F. Viewpoint: Competency-based postgraduate training: Can we bridge the gap between theory and clinical practice? Acad Med. 2007;82(6):542-547.
6. Englander R, Flynn T, Call S, et al. Toward defining the foundation of the MD degree: Core entrustable professional activities for entering residency. Acad Med. 2016. Epub ahead of print; PMID 27097053.
7. George BC, Teitelbaum EN, Meyerson SL, et al. Reliability, validity, and feasibility of the Zwisch scale for the assessment of intraoperative performance. J Surg Educ. 2014;71(6):e90-96.
8. Naylor RA, Hollett LA, Castellvi A, et al. Preparing medical students to enter surgery residencies. Amer J Surg. 2010;199:105-109.
9. Lindeman BM, Sacks BC, Lipsett PA. Graduating students’ and surgery program directors’ views of the Association of American Medical Colleges Core Entrustable Professional Activities for Entering Residency: where are the gaps? J Surg Educ. 2015;72(6):e184-192.
10. Association of American Medical Colleges. Core Entrustable Professional Activities for Entering Residency. 2015. http://www.aamc.org/initiatives/coreepas/ [Accessed August 26, 2016]
11. American Board of Pediatrics. Entrustable Professional Activities. 2016. https://www.abp.org/entrustable-professional-activities-epas [Accessed August 26, 2016]
12. Association of American Medical Colleges. Education in Pediatrics Across the Continuum (The EPAC Project). 2015. http://www.aamc.org/initiatives/coreepas/goals/ [Accessed August 26, 2016]
13. Mattar SG, Alseidi AA, Jones DB, et al. General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors. Ann Surg. 2013;258(3):440-9.
14. Hashimoto DA, Bynum WE, Lillemoe KD, et al. See more, do more, teach more: surgical resident autonomy and the transition to independent practice. Acad Med. 2016;91(6):757-60.

Dr. Lindeman is a Clinical Fellow and Associate Surgeon in the Department of Surgery, Brigham and Women’s Hospital, and Instructor of Surgery at Harvard Medical School. Dr. Petrusa is an Educational Research Specialist in the Department of Surgery, Massachusetts General Hospital, and Associate Professor of Surgery at Harvard Medical School. Dr. Phitayakorn is the Director of Surgery Education Research in the Department of Surgery, Massachusetts General Hospital, Assistant Professor of Surgery at Harvard Medical School, and the Director of Education Research and Development at the New England Journal of Medicine Group.