EPA Force Field Analysis: Real-life EPA practice habits differ from expected

EPA Force Field Analysis: Real-life EPA practice habits differ from expected | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article EPA Force Field Analysis: Real-life EPA practice habits differ from expected Carolyn Chang, Phillip Jenkins, Jonathan Jesneck, Julie Doberne, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7775545/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Purpose The American Board of Surgery (ABS) Entrustable Professional Activity (EPA) initiative aims to address the deficit of data on entrustment outside the operating room. We hypothesize that current EPAs may inadequately capture key observable behaviors (OBs) critical to non-operative entrustment, particularly in the clinic and hospital preoperative area. Methods We conducted a force-field survey analysis to explore faculty perceptions of EPAs, identify where OBs relevant to non-operative entrustment are observed, and determine which OBs drive entrustment. Pre- and postoperative phases of the 10 most frequently completed general surgery EPAs were mapped to 21 generalized OBs (gOBs). A survey was distributed to faculty at 18 US general surgery programs. Chi-square and Fisher’s exact tests were used for categorical associations, and descriptive statistics were calculated for numerical data. Results Of the 200 faculty, 43 (21.5%) from 12 institutions and 11 specialties responded. 70% received formal EPA training and 64.7% reported strong understanding of EPAs. Faculty agreed EPAs are effective and support resident development (median: 4; IQR 3–4). The hospital ward and ED were the most common sites for gOB observation (p > 0.05). Faculty reported a median of 10 preoperative and 4 postoperative gOBs necessary to determine entrustment. Key drivers for entrustment in the pre and postoperative phases included understanding surgical indications and anticipating early postoperative complications. Conclusion Current EPAs incompletely capture OBs relevant to non-operative entrustment in the pre and postoperative phases. Development of setting-specific EPAs may improve assessment of critical pre- and postoperative skills in diverse clinical environments. Surgical education competency based medical education observable behaviors entrustable professional activities force field analysis human centered design Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction The American Board of Surgery (ABS) launched its Entrustable Professional Activities (EPA) initiative for general surgery residency programs in July 2023 [ 1 ]. This major shift moved surgical education away from using graduation readiness surrogate markers, such as case volume and time, paired with inconsistent assessments, to a competency-based education (CBE) framework. The initiative is defined by 18 EPAs in general surgery. Each EPA contains microassessments focused on direct observable behaviors (OBs) that collectively reflect the core principles of surgical entrustment. A trainee’s ability to perform OBs at the level of practice readiness or indirect supervision is ideal for graduation [ 2 ]. Preliminary data have shown that EPAs are effective CBE tools, however, they require a substantial amount of learning data, gathered at a high frequency [ 3 ]. Many methods to improve EPA participation have been implemented, including electronic health record (EHR) systems integration and automatic EPA triggering via digital education tools (DETs), workflow-directed interfaces available on mobile or computer devices, and the development of dedicated trainee and faculty education sessions with local champions [ 4 ]. However, there is more work to be done. The ABS EPAs requires users to integrate information across multiple OBs to determine the level of entrustment. In their current state, EPAs are challenging to complete consistently. Human-centered design (HCD) is a technology development approach that places people at the core of the process [ 5 ]. Understanding how and why users prefer or use a specific tool is critical to HCD and should serve as the foundation of EPA development. Discordance commonly occurs between what a human-user expects and what the tools designers anticipated in achieving a predefined goal [ 6 ]. This discordance makes it difficult to achieve these goals. To better understand this, a force field-analysis can be conducted. This social scientific technique maps forces that either support or oppose a desired behavior and allows us to learn from human-user experience to make iterative design changes [ 7 ]. While force field-analysis is widely used in other applications, such as planning a change in a nursing unit shift system, it has not been used in medical education [ 8 ]. Sixteen of the 18 EPAs have OBs to be observed across three phases of care – preoperative, intraoperative, and postoperative – within specific but different clinical settings. For example, the preoperative phase OBs are expected to be observed in clinical settings like the clinic. Several OBs (e.g. preoperative phase for “RLQ pain and appendicitis” EPA) are infrequently observed within certain clinical settings and creates dissonance between expectations and reality. In these instances, this may lead to ineffectiveness of the EPAs and make the EPAs cognitively tasking for users to compete. There is an evident imbalance in the number of EPAs completed within the preoperative, intraoperative, and postoperative care phase. The intraoperative care phase is the predominant EPA completed nationally [ 4 ]. The preoperative and postoperative care phases were designed to address entrustment assessment in settings such as the clinic setting. However, that may not be clear to all users or fit with where they observe OBs related to those phases of care. This can result in fewer EPAs in those care phases or those done with a different objective than which that care phase EPA was created for. We need to understand how users are interpreting the EPA assessments to address these barriers to ensure the EPAs are capturing what is intended. In this study, we conducted a force field-analysis of the national EPA initiative to better understand where OBs are actually observed, to make data-driven adjustments to the EPA design and implementation process through HCD. We hypothesized that the EPAs currently do not adequately cover important OBs relevant to entrustment in the preoperative phase, specifically the clinic. Our goal is to make EPAs more accurate and easier to complete, which will overall benefit trainees, faculty, and national education policy makers. Methods Two-hundred general surgery teaching faculty across 18 U.S. residency programs were sent a survey (Qualtrics, LLC, Seattle, Washington) (Appendix 1) on October 11, 2024. The survey closed on October 30, 2024. Identifying the most common clinical settings for OB observation and the key OBs defining entrustment were the objectives for this force field analysis study. We focused on the preoperative and postoperative care phases. The intraoperative care phase was excluded because OBs are limited to the operating room setting. We identified the 10 most commonly completed EPAs from the national cohort of EPAs completed based on data from the American Board of Surgery app and the Firefly app. The observable behaviors of the preoperative and postoperative phases of these 10 EPAs were extracted from the ABS EPA descriptions. The primary reviewer (general surgery resident) identified themes and developed the first iteration of generalizable observable behaviors (gOB), mapped to each observable behavior. The second reviewer (faculty surgeon) accepted or rejected the changes and made further modifications. This iterative process was completed until both reviewers had no further mapping modifications (Appendix 2). Overall, 21 generalized observable behaviors (Table 1 ) were mapped from the set of preoperative OBs and postoperative OBs. Table 1 List of generalizable observable behaviors (gOB), mapped from the pre- and postoperative phases of the 10 most commonly completed general surgery EPAs. Preoperative: Postoperative: A. Obtains history and physical B. Performs thorough chart review C. Establishes differential diagnosis D. Orders diagnostic labs, imaging or adjuncts E. Initiates resuscitative efforts F. Understands when to involve consultants G. Understands indications for surgical intervention H. Identifies perioperative risk factors I. Optimizes perioperative risk factors J. Understands timing for surgical intervention K. Understands alternatives to surgical interventions L. Obtains informed consent M. Develops a surgical plan N. Communicates with health care team members, patients and families O. Understands immediate post-operative care and disposition P. Anticipates early post-operative complications Q. Anticipates late postoperative complications R. Understands the treatment of post-operative complications S. Coordinates multidisciplinary care T. Understands follow-up needs U. Understands appropriate discharge milestones We defined 5 key clinical settings for gOB observation (clinic, emergency department, pre-operative area, hospital ward, intensive care unit) in the survey. We measured the frequency of gOB for each clinical setting reported by the faculty. Faculty were asked basic demographic and surgical practice specialty questions. Institutional review board was approved (00027683). Statistical analysis Chi-square tests were performed on faculty demographic data and responses to survey questions. Descriptive data analysis was performed using NumPy, Pandas and SciPy in Python (version 3.24). The comparison of survey responses between trauma surgery and critical care faculty and non-trauma surgery and critical care faculty was performed with a Fisher’s exact test. Results Baseline demographics The survey was completed by 43 of 200 faculty (21.5%). Of those that completed the survey, 42% of the faculty were female and nearly a quarter were trauma surgery and critical care faculty. The remaining faculty were distributed across the general surgery subspecialities (Table 2 ). Table 2 Baseline demographics Characteristic Overall n = 45 (%) p-value Female sex 18 (41.9) 0.287 Dominant surgical practice 0.038 Trauma Surgery and Critical Care 10 (23.3) Colon and Rectal Surgery 6 (14.0) Surgical Oncology 4 (9.3) Breast Surgery 5 (11.6) Elective General Surgery 4 (9.3) Minimally Invasive Abdominal Surgery 1 (2.3) Endocrine Surgery 2 (4.7) Vascular Surgery 1 (2.3) Transplant Surgery 2 (4.7) Thoracic Surgery 2 (4.7) Foregut and Bariatric Surgery 0 Pediatric Surgery 6 (14.0) Other 0 Hernia Surgery 0 Years in practice , median [IQR] 12 [8.5] > 0.0001 Understanding of EPAs and frequency of completion Teaching faculty report a strong overall understanding of EPA assessments, with most having received formal education on both the EPA assessment process and the ABS EPA initiative. Many faculty complete EPA assessments on a weekly basis, typically 2–3 times per week, while 19% have never completed an EPA assessment. Only a small number of faculty perform EPA assessments daily or four or more times per week (Table 3 ). Table 3 Understanding of EPAs and frequency of completion Characteristic Overall n = 45 (%) p-value General understanding of EPA assessments > 0.0001 Very well 29 (67.4) Sort of 13 (30.2) Not well at all 1 (2.3) Received formal EPA assessment education 30 (70.0) 0.0095 Frequency of EPA completion 0.0002 Daily 1 (2.3) 4–6 times a week 4 (9.3) 2–3 times a week 9 (20.9) Once a week 21 (48.8) Never 8 (18.6) Perceived effectiveness of EPAs Faculty view EPA assessments as effective tools for evaluating resident performance, with a median rating of 4 (IQR 3–4) on a scale from 1 (strongly disagree) to 5 (strongly agree) (Fig. 1 ). Similarly, they perceive EPA assessments as beneficial for supporting resident learning and progression toward independent practice, also with a median score of 4 (IQR 3–4). Barriers to completing EPAs When asked about barriers to completing EPA assessments, 35% (16/45) of faculty reported a lack of time, 15.5% (7/43) reported that residents were not initiating EPAs and 13.3% (6/43) reported poor-user experience with the interface. One faculty member mentioned the “difficulty in accurately assessing an EPA level based on a single case,” and another expressed concern that they are only “asked to complete EPAs when residents thrive, but not when they struggle, making the process too selective.” Observed behaviors across clinical settings Most common observed behaviors by all faculty Among the 2,386 total number of times gOBs are reported as common, 628 (26.3%) were observed within the hospital ward, while only 386 (16.2%) were observed in the hospital preoperative area (Fig. 2 and Table 4 ). Table 4 Frequency of commonly observed gOB across varying clinical settings Clinical setting Frequency of commonly observed gOB (%) Hospital Ward 628 (26.3) Emergency Department 518 (21.7) Intensive Care Unit 429 (18.4) Clinic 416 (17.4) Hospital preoperative area 385 (16.2) In the hospital ward, the most frequently observed gOB was understanding appropriate discharge milestones, followed by recognizing indications for surgical intervention and effectively communicating with patients and families. In the emergency department, the most common gOBs were developing differential diagnoses and formulating surgical plans. In the hospital preoperative area, identifying post-operative disposition was observed most often, followed by understanding when to involve a consultant. In the clinic setting, the most prevalent gOBs included appropriately involving consultants, initiating multidisciplinary care, and anticipating early post-operative complications. Lastly, in the ICU, communication with patients and families was the most frequently observed gOB, although overall, the various gOBs were observed with similar frequency (Fig. 3 ). Even with the exclusion of trauma surgery and critical care faculty, who have less clinic-focus in practice than the other respondent surgeons, the hospital ward remains the location with the most gOB observed (Fig. 4 ). This was assessed with Fisher’s exact test; p value > 0.05. Furthermore, there is no difference across all the clinical settings between the trauma surgery and critical care faculty and the non-trauma surgery and critical care faculty (Appendix 3). Ranked importance of preoperative and postoperative behaviors for entrustment Preoperative phase Understanding indications for surgical intervention (85.7%), obtaining a history and physical (54.7%), and identifying perioperative risk factors (54.7%) were the most frequently selected behaviors deemed necessary for entrustment in the preoperative phase. Conversely, the behaviors identified as less critical were understands when to involve consultants (7.1%) and orders diagnostic labs and imaging (7.1%) (Fig. 5 ). Overall, faculty reported a median of 10 (7.5–12.5) of the 14 pre-operative gOB that were felt necessary to determine entrustment level for this phase. Postoperative phase Anticipating early post-operative complications was deemed essential by 74.4% of faculty, followed by understanding post-operative disposition (60.5%) and understanding treatment of postoperative complications (53.5%) in the postoperative phase (Fig. 6 ). While the least important were understands appropriate discharge milestones (41.9) and anticipates late postoperative complication (27.9). Overall, faculty reported a median of 4 (2–6) of the 7 post-operative gOB that were felt necessary to determine entrustment level for this phase. Discussion Historically, intraoperative skill and entrustment assessment has been the easiest to gather data on [ 4 ]. This was Dr. Halstead’s method in deeming residents competent for independent practice and subsequently implemented for decades to follow [ 9 ]. We now understand that progression to becoming a fully competent surgeon requires skills and behaviors that extend beyond the operating room. This highlights the importance of the EPA initiative which assesses residents holistically. A key objective of the ABS EPA initiative is to address the data deficit in entrustment outside of the operating room. Though we have made extraordinary strides in improving the way we train and assess surgical residents, ongoing quality improvement and process analysis is critical to continue this forward momentum. We utilized force field analysis in this study, which is a highly useful practice to identify the forces that help or prevent achieving a desired goal [ 10 ]. Using this method, we assessed how well the existing EPAs evaluate the core principles needed for entrustment within specific clinical settings across phases of care The hospital ward and ED are the primary settings for gOBs associated with the existing EPA assessments in our analysis of the current EPA assessment deployment. This is expected, as these are the areas where trainees spend much of their time. Trainees have the most extended direct interactions with faculty rounding, seeing consults, and providing patient care [ 11 ]. The existing EPA design, however, does not adequately assess the specific behaviors expected of the hospital pre-operative area, clinic or ICU. The pre- and postoperative phases were developed with the goal of measuring entrustment within settings such as the clinic. Yet, we find that the clinic setting is one of the least common locations for OBs currently included in the ABS EPAs, in addition to the hospital preoperative area. This leaves a significant gap in entrustment measurement currently. Our analysis provides some insight into this discrepancy. First, it may be unclear to faculty whether the preoperative and postoperative phases are meant to encompass clinic and the other clinical settings. While the ideal clinical settings have been shared through ABS communications, they have not been formalized. Additionally, it is generally accepted that people remember only a small percentage of what they hear, read and see (penetration of data to people) [ 12 ]. Because people will not retain the majority of what is presented to them in various formats (webinars, presentations, papers, websites), incongruence between what is expected and what is observed in real life can be amplified. Second, our results suggest that the current listed behaviors are not necessarily suitably targeted to specific clinical settings. Assessment of entrustment in the clinic and a diverse set of hospital settings are critical to comprehensive CBME. The current EPAs do not achieve this completely and would benefit from better adaptation to the clinic setting and hospital preoperative area. More specifically, surgical patient care in the clinic setting is a keystone skill. Preoperatively, it is where patients are assessed for surgical conditions, fitness for surgery and have their surgical plans developed. Postoperatively, surgical patients are assessed for satisfactory recovery after surgery and complications, along with ongoing surveillance or follow up needs. Arguably, the clinic setting offers the broadest experiences in surgical patient management. Entrustment in the clinic is highly unique compared to the in-hospital settings (ICU, ED, preoperative area, hospital ward). One example includes the ability to practice patient focused interventions such as shared decision making which has been shown to strengthen therapeutic relationships between surgeon and patient with improvement in quality of interaction [ 13 ]. There is a clear need for EPAs tailored to each unique location if we aim to have setting-diverse assessments of entrustment. The goal locations should also be more clearly defined within the EPA. This point is further reinforced by a faculty member's survey comment that more attention should be given to developing EPAs that focus on non-surgical aspects of practice. The mapping process revealed redundant microassessments within each phase of care, suggesting that EPAs could be streamlined without compromising their ability to assess trainees effectively. For example, when mapping the abdominal wall hernia preoperative EPA OB to gOB, OBs for modifiable risk factors such as “identify effects of malnutrition” and “identify multisystemic effect of tobacco” are listed. Yet, the EPA also lists a generalized “evaluate and optimize co-morbidities and perioperative risk factors” OB. Redundancy can contribute to an appreciable cognitive load [ 14 ]. Further refinements should be considered to existing microassessments in a concise, yet content-specific manner. While recognizing that the EPA framework is not perfect and requires continuous optimization, most faculty agree that EPAs and the assessment process are effective to assess resident entrustment. A growing body of evidence from multi-institutional studies support the external validity of EPAs including increasing entrustment levels with increasing resident postgraduate-year level and ability to achieve full entrustment [ 15 – 17 ]. We acknowledge several limitations to this study. First, the complexity of the topic posed challenges in adapting it to a survey format and may have contributed to difficulties in survey completion among faculty participants. The short survey window and use of email/online distribution which are known to yield lower participation rates, likely contributed to our response rate. Although interviews could have yielded richer insights and potentially improved participation, a survey was the most feasible methodology given resource constraints. While our response rate likely introduces selection bias, EPA assessment completion is inherently skewed so our results likely reflect real-world patterns [ 18 ]. Second, selection bias may also have been introduced by the process of identifying the ten EPAs, which were chosen from several, but not exhaustive, data sources. Additionally, the mapping process was another potential source of bias, however, we attempted to mitigate this by employing two independent reviewers to enhance objectivity. Lastly, we simplified key concepts into binary choices, which may have inadvertently oversimplified nuanced topics. Conclusion Though faculty believe that EPA assessments are effective in evaluating resident performance, a dissonance exists between the expected clinical setting and reality, such as the clinic. The current EPA design inadequately captures key observable behaviors relevant to non-operative entrustment. Addressing entrustment in these settings are critical as they capture keystone skills needed to be a well-rounded surgeon. Faculty recognize subsets of gOB as key drivers of entrustment, which suggests that EPA assessments can be streamlined and lessen cognitive workload when completing EPA assessments. Our findings suggest that clinical setting specific EPAs, such as for clinic, should be developed and can be streamlined to accurately assess keystone skills demonstrated in the nonoperative setting. Declarations Conflict of interest: On behalf of all authors, the corresponding author states that there is no conflict of interest. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. References American Board of Surgery. Entrustable Professional Activities (EPAs) for General Surgery. Accessed May 5, 2025. https://www.absurgery.org/get-certified/epas/general-surgery/ Schumacher DJ, West DC, Schwartz A, et al. Longitudinal Assessment of Resident Performance Using Entrustable Professional Activities. JAMA Netw Open . 2020;3(1):e1919316. doi: 10.1001/jamanetworkopen.2019.19316 Montgomery KB, Mellinger JD, Lindeman B. Entrustable Professional Activities in Surgery: A Review. JAMA Surg . 2024;159(5):571. doi: 10.1001/jamasurg.2023.8107 Chang C, Jesneck J, Lee E, et al. EHR-Driven Delivery of EPA Assessments Significantly Improves Participation. J Surg Educ . 2024;81(11):A12-A22. doi: 10.1016/j.jsurg.2024.06.015 Landry L. What is human-centered design? HBS Online Business Insights Blog. Published December 15, 2020. Accessed May 5, 2025. https://online.hbs.edu/blog/post/what-is-human-centered-design Gould JD, Lewis C. Designing for usability: key principles and what designers think. Commun ACM . 1985;28(3):300–311. doi: 10.1145/3166.3170 Friedman CP, Wyatt JC, Ash JS. Evaluation Methods in Biomedical and Health Informatics . 3rd ed. Springer; 2022. doi: 10.1007/978-3-030-86453-8 Shafaghat T, Zarchi MKR, Nasab MHI, Kavosi Z, Bahrami MA, Bastani P. Force field analysis of driving and restraining factors affecting the evidence-based decision-making in health systems; comparing two approaches. J Educ Health Promot . 2021;10(1):419. doi: 10.4103/jehp.jehp_1142_20 Cameron JL. William Stewart Halsted: our surgical heritage. Ann Surg. 1997;225(5):445–458. Agency for Healthcare Research and Quality (AHRQ). Force Field Analysis. Health IT Evaluation Toolkit . Accessed May 5, 2025. https://digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/force-field-analysis Walser E. Surgical Residency Workload, Perceptions, and Educational Value: Implications for Competency-Based Medical Education [master’s thesis]. The University of Western Ontario; 2021. Available from: Electronic Thesis and Dissertation Repository. Schneider VI, Healy AF, Carlson KW, Buck-Gengler CJ, Barshi I. How much is remembered as a function of presentation modality? Memory. 2019;27(2):261–267. doi: 10.1080/09658211.2018.1502784 Herath M, Reid JL, Ting YY, et al. Patient focused interventions and communication in the surgical clinic: a systematic review and meta-analysis. eClinicalMedicine . 2023;57:101893. doi: 10.1016/j.eclinm.2023.101893 Trypke M, Stebner F, Wirth J. Two types of redundancy in multimedia learning: a literature review. Front Psychol . 2023;14:1148035. doi: 10.3389/fpsyg.2023.1148035 Brazelle M, Zmijewski P, McLeod C, et al. Concurrent validity evidence for entrustable professional activities in general surgery residents. J Am Coll Surg . 2022;234(5):938–946. doi: 10.1097/XCS.0000000000000168 Kearse LE, Schmiederer IS, Anderson TN, Dent DL, Payne DH, Korndorffer JR. American Board of Surgery Entrustable Professional Activities (EPAs): Assessing Graduating Residents’ Perception of Preoperative Entrustment. J Surg Educ . 2021;78(6):e183-e188. doi: 10.1016/j.jsurg.2021.09.004 Steiman J, Sullivan SA, Scarborough J, et al. Measuring Competence in Surgical Training through Assessment of Surgical Entrustable Professional Activities. J Surg Educ . 2018;75(6):1452–1462. doi: 10.1016/j.jsurg.2018.05.004 Jenkins P, Oran A, Chang CC, et al. Not All EPAs Are Created Equal: Fixing Sampling Bias With Utility Modeling. J Surg Educ . 2025. 2025:103708. doi: 10.1016/j.jsurg.2025.103708 Supplementary Files EPAFFASurveyAppendix1.docx EPAMappingAppendix2.docx FischerexacttesttableAppendix3.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 11 Nov, 2025 Reviewers invited by journal 11 Nov, 2025 Editor invited by journal 10 Nov, 2025 Editor assigned by journal 10 Nov, 2025 First submitted to journal 03 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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09:12:31","extension":"html","order_by":21,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":73370,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7775545/v1/84a29a544ace2d6a6a49ba02.html"},{"id":96493306,"identity":"5742fb37-f018-409b-acde-0ba4394e2af1","added_by":"auto","created_at":"2025-11-21 18:16:08","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":176655,"visible":true,"origin":"","legend":"\u003cp\u003eFaculty perceived effectiveness of EPA assessments\u003c/p\u003e","description":"","filename":"image1.png","url":"https://assets-eu.researchsquare.com/files/rs-7775545/v1/d33ac2739c35651f2709396b.png"},{"id":96493315,"identity":"fa01b6c3-94d5-4a0c-8d24-17bb6a063d81","added_by":"auto","created_at":"2025-11-21 18:16:09","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":898343,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic of generalizable observable behaviors within specific clinical settings (created using chatGPT.com)\u003c/p\u003e","description":"","filename":"image2.png","url":"https://assets-eu.researchsquare.com/files/rs-7775545/v1/6b64961a78a81bbc2d811e8d.png"},{"id":96493307,"identity":"6f9f3287-5572-4563-b643-0db2ff9adcbf","added_by":"auto","created_at":"2025-11-21 18:16:08","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":156771,"visible":true,"origin":"","legend":"\u003cp\u003eFrequency of the 21 gOB’s commonly observed by faculty across five clinical settings, represented as a heatmap\u003c/p\u003e","description":"","filename":"image3.png","url":"https://assets-eu.researchsquare.com/files/rs-7775545/v1/2be71a627b19761f3a7372a6.png"},{"id":96603965,"identity":"3ab720d2-1175-4775-930c-860a81ca00f2","added_by":"auto","created_at":"2025-11-24 09:12:16","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":128875,"visible":true,"origin":"","legend":"\u003cp\u003eFrequency of the 21 gOB’s commonly observed by faculty across five clinical settings, represented as a heatmap, excluding trauma surgery and critical care faculty\u003c/p\u003e","description":"","filename":"image4.png","url":"https://assets-eu.researchsquare.com/files/rs-7775545/v1/73bc36e90416f087d7cd7929.png"},{"id":96604059,"identity":"a97fa124-a348-4512-bc8c-75282e698513","added_by":"auto","created_at":"2025-11-24 09:12:35","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":57616,"visible":true,"origin":"","legend":"\u003cp\u003eFaculty rating of the most important preoperative gOB for entrustment\u003c/p\u003e","description":"","filename":"image5.png","url":"https://assets-eu.researchsquare.com/files/rs-7775545/v1/db616e1091dc663426c38fda.png"},{"id":96604405,"identity":"53b1e3cc-cad4-4360-8759-8a4eb1c2d3fd","added_by":"auto","created_at":"2025-11-24 09:13:50","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":41266,"visible":true,"origin":"","legend":"\u003cp\u003eFaculty rating of the most important postoperative phase gOB for entrustment\u003c/p\u003e","description":"","filename":"image6.png","url":"https://assets-eu.researchsquare.com/files/rs-7775545/v1/7ebeae4c157300be46d39c04.png"},{"id":96913152,"identity":"b5bcb147-7a16-4b03-8d0c-a70cbc1b490f","added_by":"auto","created_at":"2025-11-27 13:53:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2127284,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7775545/v1/13073faa-be84-43e4-b6a8-87399400f475.pdf"},{"id":96603655,"identity":"a4dff41b-0d67-42c3-8cbd-e4bb28228818","added_by":"auto","created_at":"2025-11-24 09:10:55","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":664854,"visible":true,"origin":"","legend":"","description":"","filename":"EPAFFASurveyAppendix1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7775545/v1/17ced2331a4c74bb945effab.docx"},{"id":96604054,"identity":"d7108751-798f-4466-9a2d-aac27041efcb","added_by":"auto","created_at":"2025-11-24 09:12:34","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":37042,"visible":true,"origin":"","legend":"","description":"","filename":"EPAMappingAppendix2.docx","url":"https://assets-eu.researchsquare.com/files/rs-7775545/v1/6742ae2b6ab448509b05c4ce.docx"},{"id":96493311,"identity":"8faa036e-6961-4736-8c0e-f5f8e3ba5ba4","added_by":"auto","created_at":"2025-11-21 18:16:08","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":34058,"visible":true,"origin":"","legend":"","description":"","filename":"FischerexacttesttableAppendix3.docx","url":"https://assets-eu.researchsquare.com/files/rs-7775545/v1/f49b29f15f25247158019316.docx"}],"financialInterests":"","formattedTitle":"EPA Force Field Analysis: Real-life EPA practice habits differ from expected","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe American Board of Surgery (ABS) launched its Entrustable Professional Activities (EPA) initiative for general surgery residency programs in July 2023 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This major shift moved surgical education away from using graduation readiness surrogate markers, such as case volume and time, paired with inconsistent assessments, to a competency-based education (CBE) framework. The initiative is defined by 18 EPAs in general surgery. Each EPA contains microassessments focused on direct observable behaviors (OBs) that collectively reflect the core principles of surgical entrustment. A trainee\u0026rsquo;s ability to perform OBs at the level of practice readiness or indirect supervision is ideal for graduation [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePreliminary data have shown that EPAs are effective CBE tools, however, they require a substantial amount of learning data, gathered at a high frequency [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Many methods to improve EPA participation have been implemented, including electronic health record (EHR) systems integration and automatic EPA triggering via digital education tools (DETs), workflow-directed interfaces available on mobile or computer devices, and the development of dedicated trainee and faculty education sessions with local champions [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, there is more work to be done.\u003c/p\u003e\u003cp\u003eThe ABS EPAs requires users to integrate information across multiple OBs to determine the level of entrustment. In their current state, EPAs are challenging to complete consistently. Human-centered design (HCD) is a technology development approach that places people at the core of the process [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Understanding how and why users prefer or use a specific tool is critical to HCD and should serve as the foundation of EPA development. Discordance commonly occurs between what a human-user expects and what the tools designers anticipated in achieving a predefined goal [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This discordance makes it difficult to achieve these goals. To better understand this, a force field-analysis can be conducted. This social scientific technique maps forces that either support or oppose a desired behavior and allows us to learn from human-user experience to make iterative design changes [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. While force field-analysis is widely used in other applications, such as planning a change in a nursing unit shift system, it has not been used in medical education [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSixteen of the 18 EPAs have OBs to be observed across three phases of care \u0026ndash; preoperative, intraoperative, and postoperative \u0026ndash; within specific but different clinical settings. For example, the preoperative phase OBs are expected to be observed in clinical settings like the clinic. Several OBs (e.g. preoperative phase for \u0026ldquo;RLQ pain and appendicitis\u0026rdquo; EPA) are infrequently observed within certain clinical settings and creates dissonance between expectations and reality. In these instances, this may lead to ineffectiveness of the EPAs and make the EPAs cognitively tasking for users to compete. There is an evident imbalance in the number of EPAs completed within the preoperative, intraoperative, and postoperative care phase. The intraoperative care phase is the predominant EPA completed nationally [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The preoperative and postoperative care phases were designed to address entrustment assessment in settings such as the clinic setting. However, that may not be clear to all users or fit with where they observe OBs related to those phases of care. This can result in fewer EPAs in those care phases or those done with a different objective than which that care phase EPA was created for. We need to understand how users are interpreting the EPA assessments to address these barriers to ensure the EPAs are capturing what is intended.\u003c/p\u003e\u003cp\u003eIn this study, we conducted a force field-analysis of the national EPA initiative to better understand where OBs are actually observed, to make data-driven adjustments to the EPA design and implementation process through HCD. We hypothesized that the EPAs currently do not adequately cover important OBs relevant to entrustment in the preoperative phase, specifically the clinic. Our goal is to make EPAs more accurate and easier to complete, which will overall benefit trainees, faculty, and national education policy makers.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eTwo-hundred general surgery teaching faculty across 18 U.S. residency programs were sent a survey (Qualtrics, LLC, Seattle, Washington) (Appendix 1) on October 11, 2024. The survey closed on October 30, 2024. Identifying the most common clinical settings for OB observation and the key OBs defining entrustment were the objectives for this force field analysis study. We focused on the preoperative and postoperative care phases. The intraoperative care phase was excluded because OBs are limited to the operating room setting.\u003c/p\u003e\u003cp\u003eWe identified the 10 most commonly completed EPAs from the national cohort of EPAs completed based on data from the American Board of Surgery app and the Firefly app. The observable behaviors of the preoperative and postoperative phases of these 10 EPAs were extracted from the ABS EPA descriptions. The primary reviewer (general surgery resident) identified themes and developed the first iteration of generalizable observable behaviors (gOB), mapped to each observable behavior. The second reviewer (faculty surgeon) accepted or rejected the changes and made further modifications. This iterative process was completed until both reviewers had no further mapping modifications (Appendix 2). Overall, 21 generalized observable behaviors (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) were mapped from the set of preoperative OBs and postoperative OBs.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eList of generalizable observable behaviors (gOB), mapped from the pre- and postoperative phases of the 10 most commonly completed general surgery EPAs.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePreoperative:\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePostoperative:\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA. Obtains history and physical\u003c/p\u003e\u003cp\u003eB. Performs thorough chart review\u003c/p\u003e\u003cp\u003eC. Establishes differential diagnosis\u003c/p\u003e\u003cp\u003eD. Orders diagnostic labs, imaging or adjuncts\u003c/p\u003e\u003cp\u003eE. Initiates resuscitative efforts\u003c/p\u003e\u003cp\u003eF. Understands when to involve consultants\u003c/p\u003e\u003cp\u003eG. Understands indications for surgical intervention\u003c/p\u003e\u003cp\u003eH. Identifies perioperative risk factors\u003c/p\u003e\u003cp\u003eI. Optimizes perioperative risk factors\u003c/p\u003e\u003cp\u003eJ. Understands timing for surgical intervention\u003c/p\u003e\u003cp\u003eK. Understands alternatives to surgical interventions\u003c/p\u003e\u003cp\u003eL. Obtains informed consent\u003c/p\u003e\u003cp\u003eM. Develops a surgical plan\u003c/p\u003e\u003cp\u003eN. Communicates with health care team members, patients and families\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eO. Understands immediate post-operative care and disposition\u003c/p\u003e\u003cp\u003eP. Anticipates early post-operative complications\u003c/p\u003e\u003cp\u003eQ. Anticipates late postoperative complications\u003c/p\u003e\u003cp\u003eR. Understands the treatment of post-operative complications\u003c/p\u003e\u003cp\u003eS. Coordinates multidisciplinary care\u003c/p\u003e\u003cp\u003eT. Understands follow-up needs\u003c/p\u003e\u003cp\u003eU. Understands appropriate discharge milestones\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eWe defined 5 key clinical settings for gOB observation (clinic, emergency department, pre-operative area, hospital ward, intensive care unit) in the survey. We measured the frequency of gOB for each clinical setting reported by the faculty. Faculty were asked basic demographic and surgical practice specialty questions.\u003c/p\u003e\u003cp\u003e Institutional review board was approved (00027683).\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eChi-square tests were performed on faculty demographic data and responses to survey questions. Descriptive data analysis was performed using NumPy, Pandas and SciPy in Python (version 3.24). The comparison of survey responses between trauma surgery and critical care faculty and non-trauma surgery and critical care faculty was performed with a Fisher\u0026rsquo;s exact test.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eBaseline demographics\u003c/h2\u003e\u003cp\u003eThe survey was completed by 43 of 200 faculty (21.5%). Of those that completed the survey, 42% of the faculty were female and nearly a quarter were trauma surgery and critical care faculty. The remaining faculty were distributed across the general surgery subspecialities (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline demographics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOverall\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;45 (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFemale sex\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18 (41.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.287\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDominant surgical practice\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.038\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTrauma Surgery and Critical Care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (23.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eColon and Rectal Surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (14.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgical Oncology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (9.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBreast Surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (11.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eElective General Surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (9.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMinimally Invasive Abdominal Surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEndocrine Surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (4.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVascular Surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTransplant Surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (4.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThoracic Surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (4.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eForegut and Bariatric Surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePediatric Surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (14.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHernia Surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eYears in practice\u003c/b\u003e, median [IQR]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 [8.5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eUnderstanding of EPAs and frequency of completion\u003c/h3\u003e\n\u003cp\u003eTeaching faculty report a strong overall understanding of EPA assessments, with most having received formal education on both the EPA assessment process and the ABS EPA initiative. Many faculty complete EPA assessments on a weekly basis, typically 2\u0026ndash;3 times per week, while 19% have never completed an EPA assessment. Only a small number of faculty perform EPA assessments daily or four or more times per week (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eUnderstanding of EPAs and frequency of completion\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOverall\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;45 (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGeneral understanding of EPA assessments\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVery well\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e29 (67.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSort of\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13 (30.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNot well at all\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1 (2.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eReceived formal EPA assessment education\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e30 (70.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.0095\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFrequency of EPA completion\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.0002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDaily\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1 (2.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u0026ndash;6 times a week\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4 (9.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u0026ndash;3 times a week\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9 (20.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOnce a week\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e21 (48.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNever\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8 (18.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003ePerceived effectiveness of EPAs\u003c/h3\u003e\n\u003cp\u003eFaculty view EPA assessments as effective tools for evaluating resident performance, with a median rating of 4 (IQR 3\u0026ndash;4) on a scale from 1 (strongly disagree) to 5 (strongly agree) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Similarly, they perceive EPA assessments as beneficial for supporting resident learning and progression toward independent practice, also with a median score of 4 (IQR 3\u0026ndash;4).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eBarriers to completing EPAs\u003c/h2\u003e\u003cp\u003eWhen asked about barriers to completing EPA assessments, 35% (16/45) of faculty reported a lack of time, 15.5% (7/43) reported that residents were not initiating EPAs and 13.3% (6/43) reported poor-user experience with the interface. One faculty member mentioned the \u0026ldquo;difficulty in accurately assessing an EPA level based on a single case,\u0026rdquo; and another expressed concern that they are only \u0026ldquo;asked to complete EPAs when residents thrive, but not when they struggle, making the process too selective.\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eObserved behaviors across clinical settings\u003c/h3\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eMost common observed behaviors by all faculty\u003c/h2\u003e\u003cp\u003eAmong the 2,386 total number of times gOBs are reported as common, 628 (26.3%) were observed within the hospital ward, while only 386 (16.2%) were observed in the hospital preoperative area (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFrequency of commonly observed gOB across varying clinical settings\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClinical setting\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFrequency of commonly observed gOB (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHospital Ward\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e628 (26.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmergency Department\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e518 (21.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntensive Care Unit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e429 (18.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClinic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e416 (17.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHospital preoperative area\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e385 (16.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e In the hospital ward, the most frequently observed gOB was understanding appropriate discharge milestones, followed by recognizing indications for surgical intervention and effectively communicating with patients and families. In the emergency department, the most common gOBs were developing differential diagnoses and formulating surgical plans. In the hospital preoperative area, identifying post-operative disposition was observed most often, followed by understanding when to involve a consultant. In the clinic setting, the most prevalent gOBs included appropriately involving consultants, initiating multidisciplinary care, and anticipating early post-operative complications. Lastly, in the ICU, communication with patients and families was the most frequently observed gOB, although overall, the various gOBs were observed with similar frequency (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eEven with the exclusion of trauma surgery and critical care faculty, who have less clinic-focus in practice than the other respondent surgeons, the hospital ward remains the location with the most gOB observed (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). This was assessed with Fisher\u0026rsquo;s exact test; p value\u0026thinsp;\u0026gt;\u0026thinsp;0.05. Furthermore, there is no difference across all the clinical settings between the trauma surgery and critical care faculty and the non-trauma surgery and critical care faculty (Appendix 3).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eRanked importance of preoperative and postoperative behaviors for entrustment\u003c/h2\u003e\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\u003ch2\u003ePreoperative phase\u003c/h2\u003e\u003cp\u003eUnderstanding indications for surgical intervention (85.7%), obtaining a history and physical (54.7%), and identifying perioperative risk factors (54.7%) were the most frequently selected behaviors deemed necessary for entrustment in the preoperative phase. Conversely, the behaviors identified as less critical were understands when to involve consultants (7.1%) and orders diagnostic labs and imaging (7.1%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Overall, faculty reported a median of 10 (7.5\u0026ndash;12.5) of the 14 pre-operative gOB that were felt necessary to determine entrustment level for this phase.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003ePostoperative phase\u003c/h2\u003e\u003cp\u003eAnticipating early post-operative complications was deemed essential by 74.4% of faculty, followed by understanding post-operative disposition (60.5%) and understanding treatment of postoperative complications (53.5%) in the postoperative phase (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). While the least important were understands appropriate discharge milestones (41.9) and anticipates late postoperative complication (27.9). Overall, faculty reported a median of 4 (2\u0026ndash;6) of the 7 post-operative gOB that were felt necessary to determine entrustment level for this phase.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eHistorically, intraoperative skill and entrustment assessment has been the easiest to gather data on [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This was Dr. Halstead\u0026rsquo;s method in deeming residents competent for independent practice and subsequently implemented for decades to follow [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. We now understand that progression to becoming a fully competent surgeon requires skills and behaviors that extend beyond the operating room. This highlights the importance of the EPA initiative which assesses residents holistically. A key objective of the ABS EPA initiative is to address the data deficit in entrustment outside of the operating room. Though we have made extraordinary strides in improving the way we train and assess surgical residents, ongoing quality improvement and process analysis is critical to continue this forward momentum. We utilized force field analysis in this study, which is a highly useful practice to identify the forces that help or prevent achieving a desired goal [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Using this method, we assessed how well the existing EPAs evaluate the core principles needed for entrustment within specific clinical settings across phases of care\u003c/p\u003e\u003cp\u003eThe hospital ward and ED are the primary settings for gOBs associated with the existing EPA assessments in our analysis of the current EPA assessment deployment. This is expected, as these are the areas where trainees spend much of their time. Trainees have the most extended direct interactions with faculty rounding, seeing consults, and providing patient care [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The existing EPA design, however, does not adequately assess the specific behaviors expected of the hospital pre-operative area, clinic or ICU. The pre- and postoperative phases were developed with the goal of measuring entrustment within settings such as the clinic. Yet, we find that the clinic setting is one of the least common locations for OBs currently included in the ABS EPAs, in addition to the hospital preoperative area. This leaves a significant gap in entrustment measurement currently.\u003c/p\u003e\u003cp\u003eOur analysis provides some insight into this discrepancy. First, it may be unclear to faculty whether the preoperative and postoperative phases are meant to encompass clinic and the other clinical settings. While the ideal clinical settings have been shared through ABS communications, they have not been formalized. Additionally, it is generally accepted that people remember only a small percentage of what they hear, read and see (penetration of data to people) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Because people will not retain the majority of what is presented to them in various formats (webinars, presentations, papers, websites), incongruence between what is expected and what is observed in real life can be amplified. Second, our results suggest that the current listed behaviors are not necessarily suitably targeted to specific clinical settings.\u003c/p\u003e\u003cp\u003eAssessment of entrustment in the clinic and a diverse set of hospital settings are critical to comprehensive CBME. The current EPAs do not achieve this completely and would benefit from better adaptation to the clinic setting and hospital preoperative area. More specifically, surgical patient care in the clinic setting is a keystone skill. Preoperatively, it is where patients are assessed for surgical conditions, fitness for surgery and have their surgical plans developed. Postoperatively, surgical patients are assessed for satisfactory recovery after surgery and complications, along with ongoing surveillance or follow up needs. Arguably, the clinic setting offers the broadest experiences in surgical patient management. Entrustment in the clinic is highly unique compared to the in-hospital settings (ICU, ED, preoperative area, hospital ward). One example includes the ability to practice patient focused interventions such as shared decision making which has been shown to strengthen therapeutic relationships between surgeon and patient with improvement in quality of interaction [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. There is a clear need for EPAs tailored to each unique location if we aim to have setting-diverse assessments of entrustment. The goal locations should also be more clearly defined within the EPA. This point is further reinforced by a faculty member's survey comment that more attention should be given to developing EPAs that focus on non-surgical aspects of practice.\u003c/p\u003e\u003cp\u003eThe mapping process revealed redundant microassessments within each phase of care, suggesting that EPAs could be streamlined without compromising their ability to assess trainees effectively. For example, when mapping the abdominal wall hernia preoperative EPA OB to gOB, OBs for modifiable risk factors such as \u0026ldquo;identify effects of malnutrition\u0026rdquo; and \u0026ldquo;identify multisystemic effect of tobacco\u0026rdquo; are listed. Yet, the EPA also lists a generalized \u0026ldquo;evaluate and optimize co-morbidities and perioperative risk factors\u0026rdquo; OB. Redundancy can contribute to an appreciable cognitive load [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Further refinements should be considered to existing microassessments in a concise, yet content-specific manner.\u003c/p\u003e\u003cp\u003eWhile recognizing that the EPA framework is not perfect and requires continuous optimization, most faculty agree that EPAs and the assessment process are effective to assess resident entrustment. A growing body of evidence from multi-institutional studies support the external validity of EPAs including increasing entrustment levels with increasing resident postgraduate-year level and ability to achieve full entrustment [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWe acknowledge several limitations to this study. First, the complexity of the topic posed challenges in adapting it to a survey format and may have contributed to difficulties in survey completion among faculty participants. The short survey window and use of email/online distribution which are known to yield lower participation rates, likely contributed to our response rate. Although interviews could have yielded richer insights and potentially improved participation, a survey was the most feasible methodology given resource constraints. While our response rate likely introduces selection bias, EPA assessment completion is inherently skewed so our results likely reflect real-world patterns [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Second, selection bias may also have been introduced by the process of identifying the ten EPAs, which were chosen from several, but not exhaustive, data sources. Additionally, the mapping process was another potential source of bias, however, we attempted to mitigate this by employing two independent reviewers to enhance objectivity. Lastly, we simplified key concepts into binary choices, which may have inadvertently oversimplified nuanced topics.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThough faculty believe that EPA assessments are effective in evaluating resident performance, a dissonance exists between the expected clinical setting and reality, such as the clinic. The current EPA design inadequately captures key observable behaviors relevant to non-operative entrustment. Addressing entrustment in these settings are critical as they capture keystone skills needed to be a well-rounded surgeon. Faculty recognize subsets of gOB as key drivers of entrustment, which suggests that EPA assessments can be streamlined and lessen cognitive workload when completing EPA assessments. Our findings suggest that clinical setting specific EPAs, such as for clinic, should be developed and can be streamlined to accurately assess keystone skills demonstrated in the nonoperative setting.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eConflict of interest:\u003c/h2\u003e\u003cp\u003eOn behalf of all authors, the corresponding author states that there is no conflict of interest.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAmerican Board of Surgery. Entrustable Professional Activities (EPAs) for General Surgery. Accessed May 5, 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.absurgery.org/get-certified/epas/general-surgery/\u003c/span\u003e\u003cspan address=\"https://www.absurgery.org/get-certified/epas/general-surgery/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSchumacher DJ, West DC, Schwartz A, et al. Longitudinal Assessment of Resident Performance Using Entrustable Professional Activities. \u003cem\u003eJAMA Netw Open\u003c/em\u003e. 2020;3(1):e1919316. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jamanetworkopen.2019.19316\u003c/span\u003e\u003cspan address=\"10.1001/jamanetworkopen.2019.19316\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMontgomery KB, Mellinger JD, Lindeman B. 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Concurrent validity evidence for entrustable professional activities in general surgery residents. \u003cem\u003eJ Am Coll Surg\u003c/em\u003e. 2022;234(5):938\u0026ndash;946. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/XCS.0000000000000168\u003c/span\u003e\u003cspan address=\"10.1097/XCS.0000000000000168\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKearse LE, Schmiederer IS, Anderson TN, Dent DL, Payne DH, Korndorffer JR. 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Measuring Competence in Surgical Training through Assessment of Surgical Entrustable Professional Activities. \u003cem\u003eJ Surg Educ\u003c/em\u003e. 2018;75(6):1452\u0026ndash;1462. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jsurg.2018.05.004\u003c/span\u003e\u003cspan address=\"10.1016/j.jsurg.2018.05.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJenkins P, Oran A, Chang CC, et al. Not All EPAs Are Created Equal: Fixing Sampling Bias With Utility Modeling. \u003cem\u003eJ Surg Educ\u003c/em\u003e. 2025. 2025:103708. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jsurg.2025.103708\u003c/span\u003e\u003cspan address=\"10.1016/j.jsurg.2025.103708\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"global-surgical-education-journal-of-the-association-for-surgical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"GSED","sideBox":"Learn more about [Global Surgical Education - Journal of the Association for Surgical Education](https://link.springer.com/journal/44186)","snPcode":"44186","submissionUrl":"https://www.editorialmanager.com/gsed/default1.aspx","title":"Global Surgical Education - Journal of the Association for Surgical Education","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Surgical education, competency based medical education, observable behaviors, entrustable professional activities, force field analysis, human centered design","lastPublishedDoi":"10.21203/rs.3.rs-7775545/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7775545/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eThe American Board of Surgery (ABS) Entrustable Professional Activity (EPA) initiative aims to address the deficit of data on entrustment outside the operating room. We hypothesize that current EPAs may inadequately capture key observable behaviors (OBs) critical to non-operative entrustment, particularly in the clinic and hospital preoperative area.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe conducted a force-field survey analysis to explore faculty perceptions of EPAs, identify where OBs relevant to non-operative entrustment are observed, and determine which OBs drive entrustment. Pre- and postoperative phases of the 10 most frequently completed general surgery EPAs were mapped to 21 generalized OBs (gOBs). A survey was distributed to faculty at 18 US general surgery programs. Chi-square and Fisher\u0026rsquo;s exact tests were used for categorical associations, and descriptive statistics were calculated for numerical data.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eOf the 200 faculty, 43 (21.5%) from 12 institutions and 11 specialties responded. 70% received formal EPA training and 64.7% reported strong understanding of EPAs. Faculty agreed EPAs are effective and support resident development (median: 4; IQR 3\u0026ndash;4). The hospital ward and ED were the most common sites for gOB observation (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Faculty reported a median of 10 preoperative and 4 postoperative gOBs necessary to determine entrustment. Key drivers for entrustment in the pre and postoperative phases included understanding surgical indications and anticipating early postoperative complications.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eCurrent EPAs incompletely capture OBs relevant to non-operative entrustment in the pre and postoperative phases. Development of setting-specific EPAs may improve assessment of critical pre- and postoperative skills in diverse clinical environments.\u003c/p\u003e","manuscriptTitle":"EPA Force Field Analysis: Real-life EPA practice habits differ from expected","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-21 18:16:04","doi":"10.21203/rs.3.rs-7775545/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2025-11-11T22:11:22+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-11T16:18:39+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"Global Surgical Education - Journal of the Association for Surgical Education","date":"2025-11-10T22:44:16+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-10T14:14:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"Global Surgical Education - Journal of the Association for Surgical Education","date":"2025-10-03T14:03:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"global-surgical-education-journal-of-the-association-for-surgical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"GSED","sideBox":"Learn more about [Global Surgical Education - Journal of the Association for Surgical Education](https://link.springer.com/journal/44186)","snPcode":"44186","submissionUrl":"https://www.editorialmanager.com/gsed/default1.aspx","title":"Global Surgical Education - Journal of the Association for Surgical Education","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"57a2f837-2d6d-4ee1-8604-e5d2dbb5d447","owner":[],"postedDate":"November 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-24T23:15:32+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-21 18:16:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7775545","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7775545","identity":"rs-7775545","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}