A new approach to assessing surgical residents’ competence, autonomy, and readiness for independent practice is coming. All general surgical training programs in the U.S. will begin using entrustable professional activities, or EPAs, as the model to assess resident training starting with the class entering in 2023. Panelists for the Clinical Congress session Resident Autonomy: The Next Frontier of Surgical Education will explore the EPA model on Saturday, October 23, at 12:00 noon Central Time.
“EPAs will add trust to the assessment conversation,” says Karen J. Brasel, MD, MPH, FACS, professor and program director for general surgery, vice-chair for education and professional development, and assistant dean for graduate medical education, Oregon Health and Science University, Portland. “More importantly, EPAs align what we assess as surgical educators with what we do as surgeons.”
The new model follows EPA trials at multiple surgical training programs by the American College of Surgeons (ACS), Accreditation Council for Graduate Medical Education (ACGME), the American Board of Surgery (ABS), and the Association of Program Directors in Surgery (APDS). The trials grew out of a growing recognition that general surgery training is in crisis. Duty-hour restrictions, liability concerns, a growing skillset that includes laparoscopic and robotic approaches, and other pressures have made it increasingly difficult for residents to recognize their own operative competence and for faculty to entrust residents with operative autonomy, Dr. Brasel explains.
The core problem is a general lack of understanding about how surgical residents become competent to practice autonomously, says panelist Keith A. Delman, MD, FACS, professor of surgical oncology and of surgical anatomy and technique, Emory School of Medicine, Atlanta, GA. Surgical competence, autonomy, and safety is a continuum that spans training, graduation, and beyond. Graduation and credentialing imply that a surgeon is fully autonomous and ready to practice without supervision, but the reality is more complex, he says.
“We have a responsibility to all patients across that continuum,” Dr. Belman says. “The first time a surgeon does a procedure independently should not be when no one else is around to backstop them, when they are out in practice.”
Few non-surgeons understand surgical residency, he explains. Patients and nonsurgical health care professionals assume that residents are still students only and outcomes likely will be better if the attending performs the entire procedure. “We have evidence that all of that is false,” Dr. Belman notes. “We need to educate patients and other providers about what a resident is and their involvement in care to combat those myths. There are good data supporting resident autonomy.”
Autonomy for surgical residents depends on both individual competence and on supervisors’ growing trust in each individual’s competence during training. That trust has traditionally been established through an apprenticeship-like training program with time for learning and entrustment. Shorter, more frequent rotations have eroded that traditional training model.
“Faculty will never see a resident in every clinical scenario,” says panelist, Gurjit Sandhu, PhD, associate professor of surgery and learning health sciences, University of Michigan Medical School, Ann Arbor. “An entrustment mechanism is needed.”
Traditional training models rely on faculty evaluations of each resident’s increasing competence, but those assessments depend as much on gut feelings as on evidence. That’s where EPAs can help, Dr. Brasel notes. EPAs are observable units of work that define a profession, she explains. In general surgery, that means 20 to 30 discrete behaviors that demonstrate increasing competence. She likens the model to a surgical global positioning system with explicit behaviors faculty supervisors expect to see.
“EPAs place the resident in the driver’s seat in attaining competence,” Dr. Brasel says. “Entrustment comes with competence and EPAs give the resident a roadmap of expectations leading to competence and autonomy.”
A training model based on EPAs adds reliability and predictability, says panelist Rebecca Williams-Karnesky, MD, PhD, MEdPsych, chief resident, University of New Mexico School of Medicine, Albuquerque. The current training model can leave residents, faculty, and fellowship directors uncertain about matriculating trainee skill levels and preparation for independent practice.
“EPAs provide a framework for implementing a competency-based education in surgical training and for making entrustment decisions,” Dr. Williams-Karnesky says. “EPAs add trust to the current paradigm. Not only does the learner know, know how, show how, or do, they are also trusted with the future care of patients.”
For a detailed discussion of this session, view an interview with the moderators, Mariam Eskander, MD, surgical oncologist and assistant professor, department of surgery, division of surgical oncology and section of gastrointestinal oncology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ; and Douglas Smink, MD, MPH, FACS, chief of surgery, Brigham and Women’s Faulkner Hospital, vice-chair for education, department of surgery, and associate professor, Harvard Medical School, Boston, MA, in today’s Daily Highlights. Conducting the interview is Meghana V. Kashyap, MD, DIM&PH, a postgraduate year-six general surgery resident, University of Nebraska Medical Center, Omaha, and Chair, Resident and Associate Society of the ACS Communications Committee (2020-2021).
This and other Clinical Congress 2021 sessions are available to registered attendees for on-demand viewing for a full year following Congress on the virtual meeting platform.