Invited Commentary
May 8, 2024
Surgical Competency Assessment Using Entrustable Professional Activities
Stephanie L. Nitzschke, Stanley W. Ashley, Gilbert R. Upchurch Jr
JAMA Surg. 2024;159(7):809. doi:10.1001/jamasurg.2024.0815
This year the American Board of Surgery (ABS) endorsed the use of entrustable professional activities (EPAs), a competency-based assessment tool, in all general surgery residencies.1 This represents the next step in a visionary effort led by the ABS that engages all the major stakeholders in surgical education. A core group of dedicated educators developed individual EPAs and mapped them to specific behaviors linked to 5 levels of progressive entrustment of the individual resident.2
Montgomery and associates3 describe the results of a 2-year ABS EPA pilot study conducted in 28 volunteer residency programs. EPA microassessments were completed by faculty for residents during the course of clinical encounters and then reviewed by clinical competency committees (CCCs) at the conclusion of 6-month cycles; if the CCCs determined that enough information was available, they selected the entrustment level most closely corresponding to the preponderance of microassessments, along with an accompanying decision confidence level. They found that 17 565 CCC entrustment decisions were possible in 565 residents and almost three-fourths were made with moderate or high confidence. Confidence increased with increasing number of microassessments and with subsequent study cycles, suggesting that they became more comfortable with determining entrustability as experience with EPAs increased. The authors suggest that these data provide early validation for the use of EPAs and should help inform programs in the implementation stage.
We agree that these are exciting data heralding the possibility of a national standardized assessment tool, something that heretofore has been lacking. While this is only a pilot, there are several limitations that will need to be addressed as EPAs are rolled out nationally. Overall, numbers of microassessments seem low and tapered off during the last 2 study intervals; at least some of this may be attributable to the COVID-19 pandemic. Strategies to maintain compliance are needed for national implementation so that microassessments become the workflow norm. A second challenge is with preoperative and postoperative evaluations, which were smaller in number compared to operative assessments. These skill sets are less frequently observed by the faculty and strategies to improve their use will need to be developed. In addition, the CCC’s entrustment decisions were not blinded and seem likely to have been based not only on the microassessments, but also on the assortment of data already available to the CCC for making competency or milestone assessments and on the individual CCC members’ familiarity with the resident. The authors acknowledge the potential for bias.
Despite these concerns, we clearly seem much closer to the holy grail of a standardized competency-based assessment tool that can be applied practically during general surgery training. As a profession, we owe an enormous debt to the committed educators who participated in this effort. We look forward to further refinement of EPAs in the context of national implementation.
