Implementation of Entrustable Professional Activities in General Surgery

Abstract

Objective: The ongoing complexity of general surgery training has led to increased focus on ensuring competence of graduating residents. Entrustable professional activities (EPAs) are units of professional practice that provide an assessment framework to drive competency-based education. The American Board of Surgery convened a group from the American College of Surgeons, ACGME Surgery Review Committee, and Association of Program Directors in Surgery to develop and implement EPAs in a pilot group of residency programs across the country. The objective of this pilot study was to determine feasibility and utility of EPAs in general surgery resident training. Methods: 5 EPAs were chosen based on the most common procedures reported in ACGME case logs and by practicing general surgeons (right lower quadrant pain, biliary disease, inguinal hernia), along with common activities covering additional ACGME milestones (performing a consult, care of a trauma patient). Levels of entrustment assigned (1-5) were observation only, direct supervision, indirect supervision, unsupervised, and teach others. Participating site recruitment and faculty development occurred in 2017-2018. EPA implementation at individual residency programs began July 1, 2018 and was completed June 30, 2020. Each site was assigned 2 EPAs to implement and collected EPA microassessments on residents for those EPAs. The site clinical competency committees (CCC) used these microassessments to make summative entrustment decisions. Data submitted to the independent deidentified data repository every 6 months included the number of microassessments collected per resident per EPA and CCC summative entrustment decisions. Results: 28 sites were selected to participate in the program and represented geographic and size variability, community and university-based programs. Over the course of the 2-year pilot programs reported on 14 to 180 residents. Overall, 6,272 formative microassessments were collected (range, 0 to 1144 per site). Each resident had between 0 and 184 microassessments. The mean number of microassessments per resident was 5.6 (SD = 13.4) with a median of 1 (IQR = 6). There were 1,763 summative entrustment ratings assigned to 497 unique residents. Average number of observations for entrustment was 3.24 (SD 3.61) with a median of 2 (IQR 3). In general, PGY1 residents were entrusted at the level of direct supervision and PGY5 residents were entrusted at unsupervised practice or teaching others. For each EPA other than the consult EPA, degree of entrustment reported by the CCC increased by resident level. Conclusions: These data provide evidence that widespread implementation of EPAs across general surgery programs is possible, but variable. They provide meaningful data that graduating chief residents are entrusted by their faculty to perform without supervision for several common general surgical procedures and highlight areas to target for successful widespread implementation of EPAs.

Decision-Making Confidence of Clinical Competency Committees for Entrustable Professional Activities

“…Summative data were collected by program CCCs at each 6-month interval and provided to the ABS; individual EPA microassessment data were kept at the program level alone. Further detail about the development of the EPA Pilot Study and initial results have been described by Brasel et al 6…”

“…In this retrospective analysis of the ABS EPA Pilot Study conducted at 28 general surgery residency programs with assessment of 565 residents, CCC confidence in their EPA summative entrustment decisions increased with an increasing number of EPA microassessments. This study is among the first reported analyses of the ABS EPA Pilot Study and offers potentially informative data for general surgery residency programs across the US for the ongoing implementation of surgery EPAs nationally …”

Entrustable Professional Activities in Surgery

“…Pilot EPAs included evaluation and management of a patient with right-lower-quadrant pain, inguinal hernia, gallbladder disease, and blunt or penetrating trauma, as well as performing general surgical consultation. As recently reported by Brasel et al, more than 6000 EPA microassessments were collected over the course of the pilot study, with 1763 summative entrustment ratings (determined by program clinical competency committees at 6-month study intervals based on accumulated microassessment data) completed for 497 residents. Increasing levels of entrustment were seen with increasing postgraduate-year level.…”

“…Importantly, the authors noted wide variability in the numbers of microassessments completed per resident by program, with a mean (SD) of 5.6 (13.4) microassessments but a median of only 1 microassessment per resident . The pilot study allowed programs to implement EPAs and collect microassessment data using methods of their choosing, and this freedom, plus differences in program structures and cultures, likely contributed to the variability of EPA utilization during the pilot.…”

A realist synthesis of prospective entrustment decision making by entrustment or clinical competency committees

“…[1][2][3][4][5] Despite widespread acceptance conceptually and national regulatory bodies adopting this approach to their work, fundamental challenges around implementation persist. [6][7][8][9][10] Many on-the-ground educators express uncertainty, and even scepticism, regarding scaled implementation given barriers related to educational time, structures and finances. [11][12][13] Another challenge is the lack of consistency around terminology and approach.…”