Entrustable professional activities in general surgery residency: a comparative review of five national training systems.

Abstract

Entrustable professional activities (EPAs) are a framework for competency-based assessment that focus on observable units of clinical work and are increasingly used in general surgery training. This narrative review compares EPA implementation across five national systems and examines validity evidence, administrative burden, and digital infrastructure. The databases PubMed, Embase, Scopus, Web of Science, and ScienceDirect were searched using terms related to EPAs and general surgery training. Two reviewers independently screened records, with disagreements resolved by consensus, and framework details were supplemented by documents from national certifying bodies. EPA implementation differed substantially across systems. The Netherlands has the longest experience, with EPAs embedded in a competency-based curriculum and electronic portfolio. The United States uses 18 core EPAs, mobile microassessments, and certification-linked reporting beginning in 2028. Canada's Competence by Design organizes training into four stages with competence committee review. Australia and New Zealand integrate specialty-specific EPAs within Surgical Education and Training, while South Africa is developing a locally responsive workplace-based assessment framework. Validity evidence is strongest in the United States and Canada for relationships with training level, milestone ratings, and committee confidence, but evidence regarding the consequences of entrustment decisions remains limited. Across systems, administrative burden, inconsistent engagement, and variable feedback quality threaten formative value. Digital platforms improve feasibility but do not ensure sustained use without leadership and workflow integration. EPAs provide a practical bridge between competency frameworks and daily surgical practice, though implementation has varied across systems. Future work should prioritize consequences evidence, reduce documentation burden where possible, and strengthen assessment cultures that support meaningful feedback, appropriate supervision, and safe progression toward independent practice.