What Surgery Can Learn from Global Experience with EPAs

Entrustable professional activities (EPAs) are discrete, directly observable tasks used to assess the level of autonomy with which a learner can be trusted to perform an activity.^1,2

In July 2023, the American Board of Surgery (ABS) launched 18 EPAs for general surgery residency programs in the US.³ The ABS subsequently introduced EPAs for additional surgical specialties. Beginning with the 2028 General Surgery Qualifying Examination, applicants will be required to submit a composite profile of their EPA assessments.³

Although EPAs are relatively new to US surgical training, the concept originated in graduate medical education in the Netherlands more than 20 years ago and was later adopted by pediatric training programs in Canada and the US.² Experience in these settings offers lessons about the benefits and challenges of integrating EPAs into competency-based medical education (CBME).

Competency-Based Medical Education Evolves in the US

Concerns about patient safety and resident supervision intensified after the 1984 death of college student Libby Zion in New York City and, more broadly, after the 1999 Institute of Medicine report “To Err Is Human.”¹

These developments contributed to increased scrutiny of resident duty hours, supervision, and graduated autonomy. At the same time, medical educators increasingly questioned whether completing a prescribed number of rotations and procedures was sufficient to demonstrate readiness for independent practice.

CBME grew from the recognition that learners acquire skills and knowledge at different rates and may require varying levels of experience to achieve mastery. Rather than emphasizing a prescribed educational process, CBME focuses on defined outcomes, allowing trainees the time and experience needed to demonstrate competency.¹

In 1999, the Accreditation Council for Graduate Medical Education (ACGME) introduced a new CBME framework for graduate medical education comprising six core competencies: patient care, medical knowledge, interpersonal and communication skills, systems-based practice, practice-based learning and improvement, and professionalism.¹

While an important first step, the competencies lacked specificity and standardized grading rubrics to help programs assess trainee performance. Without that standardization, meaningful changes to the existing evaluation structure were difficult to achieve.

The ACGME addressed these limitations by launching the Next Accreditation System and implementing specialty-specific Milestones in 2014. Nested within the six core competencies, the Milestones define the knowledge, skills, and attitudes expected within each specialty across five performance levels, from novice to expert.¹

Even with subsequent revisions, however, educators may find it difficult to map residents’ day-to-day clinical work to broad competency scales.¹ The ABS therefore sought an assessment approach that could provide residents with more frequent formative feedback and clinical competency committees (CCCs) with additional data for evaluating progress.

The Netherlands Puts EPAs into Practice

In 2005, Olle ten Cate, a professor of medical education at the University Medical Center Utrecht, introduced EPAs as a way to translate broad competency frameworks into observable professional work.¹

Over the next several years, multiple specialties developed EPAs for GME, although implementation remained limited.⁴ One challenge was reaching agreement on the activities trainees needed to master before graduation.⁴

After national budget cuts to GME in 2014, the Dutch Association of Medical Specialists and the national government spearheaded a large-scale curricular reform centered on EPAs.⁵ The reforms sought to reduce the average length and cost of training, supported by legislation that allowed greater flexibility in graduation timing.⁴

In this model, residents collect EPA assessments in electronic portfolios. When they believe they have achieved competence in a domain, they apply to a CCC for a summative entrustment decision.

The committees meet four times per year and award certificates for individual EPAs. Once trainees receive all EPA certificates required for their specialty, they can register as independent specialists and complete training.⁴ Since implementation, average training time has decreased by 5 to 7 months in 6-year surgical specialties.⁴

With this model, the Netherlands became one of the first countries to transition to a truly time-variable, competency-based GME system. Several structural features support this approach. Medical students graduate at multiple points during the year, residency positions are listed year-round, and residents may train part time.⁴

An online system helps address continuity of care by tracking residents’ clinical responsibilities and identifying other clinicians who can assume those tasks when a resident graduates.⁴ The Dutch system also is considerably smaller than the US GME system, with approximately 10,000 residents across 35 teaching hospitals, compared with more than 167,000 residents and fellows in ACGME-accredited programs in the US.⁴

Canada Develops the CanMEDS Framework

As the US developed its core competencies, Canada introduced the CanMEDS (Canadian Medical Education Directives for Specialists) framework in 1996. It describes seven physician roles: medical expert, communicator, collaborator, manager, health advocate, scholar, and professional.⁵ The framework has been adopted internationally and was revised in Canada in 2005 and 2015; the 2015 framework renamed the manager role as leader.

Canada Reassesses Competence by Design

In 2017, the Royal College of Physicians and Surgeons of Canada launched Competence by Design, incorporating EPAs into specialty training to add specificity to CanMEDS. Surgical specialties have developed numerous EPAs spanning simple and complex activities to support progressive responsibility during training.⁵ The system also uses stage-specific expectations to guide advancement, an approach that differs from the ACGME Milestones framework.

Nearly a decade after implementation began, the Royal College has acknowledged challenges with Competence by Design and is adapting the model.⁶

Concerns include the administrative burden of EPA documentation, overreliance on EPA observation forms relative to other assessments, variation in how programs make progression decisions, and faculty engagement.⁶

The Royal College is now in the process of reducing assessment burden and giving programs and competence committees more flexibility in how they collect evidence and make decisions, while maintaining specialty-specific expectations for progression.⁶ Canada’s experience illustrates the need to balance standardized assessment with feasibility in day-to-day training.

Competence by Design also shows how difficult it can be to make training truly time-variable. Funding, licensing, accreditation, and examination cycles remain tied largely to fixed training structures. Although competence committees can use richer assessment data to identify residents who need additional support, accelerating progression remains difficult. The US GME system has similar structural constraints and may face many of the same challenges, particularly if new assessments are added without replacing existing requirements.

US Pediatrics Offers Another Model

Pediatrics was among the first US specialties to develop EPAs for GME. The American Board of Pediatrics (ABP) initially developed 17 EPAs for general pediatric residents and additional EPAs for fellowship subspecialties.⁷

Pilot and longitudinal studies subsequently examined their use across residency and fellowship programs.⁸ These studies found a strong correlation between EPA and Milestone ratings among pediatric cardiology fellows and good reliability when multiple EPAs were used to inform readiness-for-practice decisions among general pediatrics residents.⁸ In 2026, the ABP revised and consolidated the general pediatrics framework to 12 EPAs as it prepares to incorporate EPA-based readiness into initial certification.

Beginning in 2028, the ABP plans to require program directors to attest that graduates are practice ready in the essential activities defined by its EPAs as part of initial certification.⁷ Programs therefore are working to integrate EPAs more consistently into training. Implementation challenges remain, including faculty time, faculty development, and consistent interpretation of entrustment levels.⁹ Earlier research using the original 17-activity framework also found gaps between expected and observed entrustment ratings.¹⁰

These findings may reflect limitations in implementation or differences between EPA ratings and other judgments of readiness for practice. US programs also must navigate assessment requirements from both specialty boards and the ACGME, adding complexity to the evaluation system.

What Global Experience Means for Surgery

The ABS designed EPAs to supplement the ACGME Milestones in several ways.³ They can provide residents with frequent formative feedback and give CCCs additional data to inform judgments about progression.

Digital platforms, including the ABS EPA app powered by the Society for Improving Medical Professional Learning, are intended to make brief workplace-based assessments easier to complete and aggregate.³ The general surgery EPAs span multiple phases of care and encompass activities beyond the operating room, such as providing surgical consultations and caring for critically ill patients.

The framework also has limitations that will need continued attention. EPAs depend on direct faculty observation, which can be constrained by time and may be influenced by differences among assessors. Programs also need enough observations across settings and phases of care to build a meaningful picture of a resident’s performance. The ABS initially emphasized EPAs as formative assessments designed to support learning and feedback.³

Beginning in 2028, however, applicants to the General Surgery Qualifying Examination must submit a composite EPA profile. The ABS has not yet established specific minimum numbers or entrustment levels for the 2028 application; standard setting is expected to inform future requirements.³

That evolution makes clarity about how formative EPA data will contribute to higher-stakes decisions particularly important for trainees and programs. Experience in Canada and pediatrics suggests that successful implementation will depend not only on the assessment tool itself but also on faculty engagement, manageable documentation, clear expectations, and integration with existing evaluation systems.

CBME seeks to strengthen medical education by focusing assessment on whether trainees can perform the work required for safe, effective patient care. Decades after competency frameworks were introduced in the US, educators continue to refine how readiness for practice is assessed.

As EPAs become more consequential in surgical training and certification, lessons from other countries and specialties can help programs preserve their value as feedback tools while building an assessment system that is rigorous, practical, and trusted.

Dr. Rachael Acker is a PGY-6 general surgery resident at the University of Pennsylvania in Philadelphia. Her research interests include surgical education and health services research. She is specifically interested in using robust scientific methods to design competency-based graduate medical education.

References

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3. American Board of Surgery. EPAs for general surgery. Available at: https://www.absurgery.org/get-certified/epas/general-surgery/. Accessed October 1, 2026.
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5. Karpinski J, Frank JR. The role of EPAs in creating a national system of time-variable competency-based medical education. Acad Med. 2021;96(7 suppl):S36–S41.
6. Royal College of Physicians and Surgeons of Canada. Competence by Design Adaptations Plan. Available at: https://www.royalcollege.ca/content/dam/document/newsroom/CBD%20Adaptations%20Plan.pdf. Accessed October 1, 2026.
7. American Board of Pediatrics. Implementation expectations and ABP requirements. Available at: https://www.abp.org/content/implementation-expectations-and-abp-requirements. Accessed October 1, 2026.
8. Schumacher DJ, Sklansky DJ, Rissmiller B, et al. Use of entrustable professional activities for reliable overall entrustment decisions. Acad Med. 2026;101(1):79–85.
9. Langhan ML, Boyer DL, Hsu D, et al. Implementing entrustable professional activities in pediatric fellowships: facilitating the process. Pediatrics. 2024;153(6).
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