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Entrustable Professional Activities (EPAs)
In February 2022, the ABS announced the move to competency-based assessment of surgical trainees with the introduction of the ABS Entrustable Professional Activities (EPA) Project, which launched in July 2023 for general surgery residency programs and will expand to all ABS specialties by 2026.
What is an EPA?
EPAs are units of work a physician performs that can be directly observed
Entrustable Professional Activities (EPAs) were developed to provide the opportunity for frequent, time-efficient, feedback-oriented and workplace-based assessment in the course of daily clinical workflow. EPAs are an important clinical assessment component of competency-based resident education (CBRE). They offer the opportunity to operationalize competency evaluation and related entrustment decisions in the course of regular patient care, and address some of the challenges educators and trainees have faced in bridging core competency theory into clinical practice and performance assessment.
It is important to note that EPAs are NOT competencies, but rather a complement to competencies, and serve as a way to translate the broad concept of competency into everyday practice.
- EPAs are units of work a physician performs that can be directly observed - things people do, such as evaluating and managing a patient experiencing a specific medical concern.
- Competencies are broad and foundational domains of ability, such as medical knowledge or interpersonal skills.
- Milestones are capabilities that describe progress at advancing levels of competence along the sequence from novice to expertise.
A suite of EPAs for a specialty can define the core clinical activities that a resident should exhibit to be deemed competent and worthy of autonomy and entrustment in patient care. Because EPAs are anchored in clinical practice, they allow a way to capture the in-the-moment decisions that attending physicians are already making about how much supervision or autonomy they will give a trainee in a real-world setting and can inform the trainee’s progress towards entrustment for a patient’s care.
The Transition to a Competency-Based Assessment Model
Now being implemented at all U.S. ACGME-accredited general surgery residency programs
For many years, surgery has relied on surrogate measures of competence such as case logs, attestations of program directors, and test performance to infer readiness for independent practice. The resulting educational systems have been time-based rather than based on objective demonstration of necessary competence. By many measures, including graduate self-assessment, board exam performance, post-residency mentor assessment, and patient outcome assessment as a function of residency program of origin, the results have been highly variable and questionably worthy of the public trust accorded the profession.
Competency and outcomes-focused education has been increasingly advocated for since the mid-20th century, with gathering momentum in medical education over the last quarter century. Features of CBRE alongside EPAs as a workplace-based assessment strategy include curricular reform and expanded use of simulation as an adult-learning appropriate and safe skill development paradigm. Assessment structures that allow direct observation based on frequent evaluation of performance to drive feedback and learning have been recognized, espoused, and piloted in other countries, including at a national level in Canada. Initiatives in U.S.-based GME such as standardized cognitive and skills curricula (SCORE, FLS, FES, ATLS, ACS/APDS Resident Skills Curriculum, ACS/APDS/ASE Residency Prep Curriculum) and competency-oriented accreditation reform (RRC-S requirements for simulation, core competency and milestone assessment, and duty hour regulation) have been driven by this trend.
In this overall framework of education reform and its goal of producing a more standardized and attestably competent product, EPAs provide the opportunity to create a new habit or pattern of assessment that is:
- Achievable in any context as it is based in already existing clinical patient care;
- Scalable in that it relies on frequent micro-assessment at the time of work already being accomplished, will replace less meaningful and time-consuming practices such as end of rotation evaluations, and will allow automatic population of key documentation elements of resident progression such as milestone maps that inform CCC promotion decisions;
- Relevant through its direct link to the performance of the duties of a surgeon in patient care;
- Adaptable in that it creates a new habit of ongoing feedback and dialog in the clinical performance arena that can teach trainees skills of implementation and improvisation required in the uncertainties of clinical practice; and
- Hippocratic in its commitment to an ongoing and real time-based formation of the next generation of surgeons as a daily menu of training environment behavior.
Given this vision and in necessary partnership with the whole house of surgery, the ABS launched EPAs for general surgery in July 2023. EPAs are also in development for the other ABS specialties, with plans to launch EPAs for vascular surgery in 2024 and the other ABS specialties including pediatric surgery, complex general surgical oncology, and surgical critical care in 2025.
Lessons Learned from the EPA Pilot
An ABS EPA Pilot program ran from 2018-2020 at 28 diverse general surgery residency programs
The ABS began exploring EPAs as a potential foundation for competency-based surgical training and initial board certification in 2016, following several years of discussion around various strategies to improve traditional time-based residency training models. The ABS then developed five index EPAs and piloted them at 28 diverse surgical residency programs from 2018-2020. Lessons learned from this pilot have been collated and formed into best practice strategies that are being deployed in developing and supporting programs of all types and resource streams during implementation of the EPA assessment model.
With the onset of the COVID-19 pandemic in early 2020, it became more apparent than ever that a move to competency-based assessment is necessary to appropriately determine trainee readiness to enter the ABS certification process and independent patient care. The ABS is currently developing a full suite of EPAs for all of its specialty areas, encompassing the core patient care activities of the specialty, to form the foundation for competency-based assessment of surgical trainees.Â
EPAs by Specialty
Beginning with general surgery, the ABS has now started developing and implementing EPAs for all specialties
General Surgery
The implementation of 18 core general surgery EPAs began on July 1, 2023. Since its launch, trainees and staff have been using the ABS EPA App to create and complete assessments.
Vascular Surgery
There are 15 core vascular surgery EPAs that are currently being reviewed and finalized. Informative webinars and town halls will be hosted by the ABS in anticipation of the launch in fall 2024.
ABS EPA App Totals
EPAs by the numbers
The implementation of general surgery EPAs began on July 1, 2023. Since then, trainees and staff have been using the ABS EPA app to create and complete assessments. The data below shows the most current* EPA numbers.Â
72000
Total Completed Assessments
9000
Total Users Created 1 or More Assessment
* Data as of Mar. 31, 2024
ABS as a Facilitator
There are many groups directly involved in the development of EPAs for each ABS specialty
As the organization that sets the standards to achieve certification in several surgical specialties and subspecialties, the ABS felt it was appropriate to develop and implement this method of resident and trainee assessment in partnership with other key surgical education organizations as listed below, without whose engagement a reform of this scale would not be possible.
There were two councils and five working groups responsible for the development and implementation of the general surgery EPAs: the EPA Advisory Council; the EPA Scope Council; the EPA Revision Working Group; the EPA Best Practices Working Group; the EPA Technology Task Force; the EPA Writing Group; and the EPA Development Task Force. Some, but not all, of these groups have also been established for each additional ABS specialty area.
All of the working groups include resident members who provide valuable insight and recommendations from the trainees’ perspective.
EPA Advisory Council
The EPA Advisory Council oversees the entire EPA project and provides much-needed expertise about surgical education and EPAs. This group is comprised of members and representatives from many of our partnering organizations, including a number of program directors from varying program types who were part of the 2018-2020 ABS EPA Pilot.
While there is one EPA Advisory Council for the majority of ABS specialties, vascular surgery has combined their EPA Scope and Advisory Councils, with one group serving dual roles.
EPA Revision Working Group
The EPA Revision Working Group led the revision of the initial five EPAs evaluated during the 2018-2020 pilot to make them Milestones 2.0 compliant. This group was also responsible for the development of the final entrustment scale, which will be used across all specialty EPA programs. There are not separate EPA Revision Working Groups for each ABS specialty.
EPA Scope Council
The EPA Scope Councils use a variety of inputs including existing definitions of the specialty as well as trainee and practicing surgeon case logs to define the final set EPAs for their specialty area. The goal of the scoping process is to define the foundation of the specialty that can be expected of all trainees in all programs, as framed by current training requirements, practice data, and demographic need, including those domains that are common enough to be meaningfully and reliably assessed in all training environments.
General surgery, pediatric surgery, and complex general surgical oncology each have their own EPA Scope Council. Vascular surgery has combined their EPA Scope and Advisory Councils, with one group serving dual roles. Surgical critical care will utilize the Trauma, Burns, and Surgical Critical Care Board of the ABS as their EPA Scope Council.
EPA Best Practices Working Group
The EPA Best Practices Working Group was responsible for gathering and assessing input from pilot sites as a foundation for “best practice” strategies to be used in EPA implementation. This group collaborated with the EPA Development Task Force and the Education and Training Committee of the ABS Council to inform the initial EPA training tools for program directors, administrators, faculty, and trainees.
The work of this group has been amended by iterative learning that occurs through other specialty boards’ own implementation processes, though the foundational work done by the original General Surgery Best Practices Working Group is expected to be applicable to programs of all ABS specialty boards. There are not separate EPA Best Practices Working Groups for each ABS specialty.
EPA Writing Group
The EPA Writing Groups are responsible for the actual creation of all of the EPAs for each specialty area. Each completed EPA includes a description, essential functions, scope and expected behaviors. These groups work in dyads, each writing up to two EPAs. Membership of these groups is broad, and includes members of the various ABS specialty boards, APDS representatives, and residents. There are designated EPA Writing Groups for each ABS specialty area.
EPA Development Task Force
The EPA Development Task Force is comprised of educators, program directors, residency administrators, and residents, and is developing the actual materials and strategies which will equip programs, faculty, and residents in implementation of the EPAs at the full spectrum of program types. The materials that have been developed are provided to programs based on insights gained from the EPA Best Practices Working Group, and will be adapted for and used across all ABS specialty areas. Each ABS specialty area has their own EPA Development Task Force.
EPA Technology Task Force
The EPA Technology Task Force established a list of the essential features of the electronic tools required to implement EPAs in surgical residencies and was responsible for sourcing or developing the application that would be used to track EPAs in all U.S.-based general surgery residency programs.
Following a thorough review process, the ABS announced in September 2022 that it had selected the SIMPL Collaborative to provide the mobile platform for the ABS EPA Project. The ABS has provided this tool free of charge to all training programs for their use, with priorities around ease and efficiency of use, secure data management, and meaningful dashboard and other outputs to assist learners, programs, and accrediting agencies in their critical work.
The same tool is being utilized for the assessment of EPAs for the other ABS surgical specialties are they are introduced.
Building on Partnership
Multiple surgical organizations have been instrumental in the development of EPAs
The ABS is working very closely with several key surgical education partners and stakeholders across the nation to refine the lessons learned from the EPA pilot experience into a full suite of EPAs representative of the core elements of each specialty area of practice.
Partner organizations engaged in this initiative include:
- Accreditation Council for Graduate Medical Education (ACGME) and the Residency Review Committee (RRC) for various surgical specialties
- Association of Program Directors in Surgery (APDS)
- Association of Program Directors in Vascular Surgery (APDVS)
- Association of Residency Administrators in Surgery (ARAS)
- American College of Surgeons (ACS)
- American Board of Medical Specialties (ABMS) and its member boards
- Association for Surgical Education (ASE)
- American Surgical Association (ASA)
- Fellowship Council (FC)
- Royal College of Physicians and Surgeons of Canada (RCPSC)
- Society of Surgical Chairs
Through surveys, focus groups, one-on-one discussions, and substantive membership in the various EPA Writing Groups, the ABS has also engaged current surgical trainees and fellows, as well as the medical student community, to allow these young physicians to share their experiences and have their voices heard during the development of these programs.
Program Resources
Resources for programs to begin preparing for EPA implementation
The ABS team has produced a full suite of resources for programs to use during EPA implementation, which includes documents and guides, training videos, pre-recorded webinars, presentations, and more. Please note that any resource documents linked will be updated regularly.