Entrustable professional activities were developed as a cornerstone of competency-based medical education. Rather than asking whether a resident has attended enough lectures or logged enough hours, EPAs ask a deceptively simple question: can this trainee be trusted to perform this core professional activity, unsupervised? In general surgery, the American Board of Surgery has rolled out a national EPA framework covering activities such as performing an operation, managing critically ill patients, and communicating with families. Faculty rate trainees on scales of supervision, from direct observation to full independence, and the assessments are meant to be formative, feeding forward into the resident’s ongoing development rather than serving merely as summative judgments. The mobile platform developed for the EPA project makes these assessments quick to complete in the middle of a busy clinical day, which is precisely why the accompanying narrative comments matter so much: they are the mechanism by which a rating becomes a lesson.

The research team, led by Gabrielle Moore of the University of Utah Spencer Fox Eccles School of Medicine, together with colleagues at the University of Utah and Wellstar MCG Health in Augusta, Georgia, set out to interrogate those narratives systematically. They collected EPA assessments of general surgery trainees completed by faculty between July 2023 and June 2025 across multiple institutions, yielding 896 assessments that included written narrative feedback. Each comment was then analyzed using deductive coding, a qualitative method in which two independent researchers categorize text according to a predefined framework drawn from previously established feedback literature. The framework captured six characteristics: whether the feedback was specific, whether it was coaching-oriented, whether it was formative, whether it was appreciative, whether it was evaluative, and whether it included person-focused descriptors such as comments on a trainee’s confidence or character rather than their observable performance.

The coding revealed a striking imbalance in what faculty choose to write. Nearly four in five assessments, 78.5 percent, contained specific feedback, and 75.7 percent were appreciative, praising what the resident had done well. But the developmental elements were far scarcer. Only 27.2 percent of comments were formative, meaning they were designed to guide future improvement, and only 21.4 percent contained coaching language that actively worked through how the trainee could get better. Just 8 percent included person-focused descriptors. In other words, the typical EPA narrative was specific and complimentary but rarely instructional, a pattern consistent with earlier studies suggesting that faculty feedback in surgery tends toward praise rather than critique. Because EPAs are explicitly intended to provide formative feedback for core activities of general surgery, the scarcity of formative and coaching content strikes at the heart of what the assessment tool was designed to do.

The most consequential finding, however, was not simply that feedback was thin, but that its quality varied systematically with the trainee’s level of entrustment. Residents judged to be practice-ready, meaning they could plausibly function at the level expected of a new independent surgeon, were dramatically less likely to receive coaching or formative feedback than their less advanced peers. After adjusting for other factors using mixed-effects logistic regression, practice-ready trainees had roughly 92 percent lower odds of receiving coaching feedback, with an odds ratio of 0.07, and about 92 percent lower odds of formative feedback, with an odds ratio of 0.08, compared with trainees who were not yet practice-ready. Both differences were highly statistically significant. The pattern is intuitive on one level, since faculty may feel there is little left to teach a resident who is nearly independent, but it inverts the logic of deliberate practice. Even expert surgeons continue to refine their technique, and the transition to independent practice is arguably the moment when candid, forward-looking feedback carries the highest stakes.

Case complexity produced a similar paradox. When residents participated in complex cases, their feedback was less likely to include coaching, with an odds ratio of 0.50, or formative language, with an odds ratio of 0.38, than when they participated in straightforward cases. Complex operations are precisely where technical nuance, decision-making under uncertainty, and teamwork under pressure are most instructive, yet the written narratives attached to those experiences offered less developmental content. The authors suggest this may reflect the cognitive load on faculty during demanding cases, or an implicit assumption that a resident entrusted with a complex case has already proven their competence. Either way, the result means that the richest learning opportunities in the operating room may be generating the poorest written guidance.

The study also uncovered gender-linked patterns that echo a growing body of literature on bias in medical assessment. Male trainees were significantly less likely than their female counterparts to receive evaluative feedback, with an odds ratio of 0.65, meaning their assessments were less likely to contain explicit judgment about their performance. There were no significant differences in feedback characteristics by trainee race or ethnicity, a null finding the authors report transparently. On the faculty side, the direction of the effect reversed: male faculty were less likely than female faculty to provide specific feedback, with an odds ratio of 0.33, or coaching language, with an odds ratio of 0.47. Previous work has documented gender differences in operative feedback and in the language used to describe surgical trainees, including studies of vascular surgery trainees and analyses of gender dyads between attending surgeons and residents. The new findings add general surgery EPA narratives to that evidence base and point toward faculty development as a concrete intervention point.

Methodologically, the study is notable for combining qualitative rigor with quantitative modeling. The deductive coding framework, applied independently by two researchers, grounds the text analysis in established constructs from the feedback literature rather than ad hoc categories, and the use of mixed-effects logistic regression allows the authors to estimate the association between each feedback characteristic and factors such as phase of care, case complexity, entrustment level, and demographics while accounting for the clustering of assessments within institutions, faculty, and residents. That clustering matters, because feedback is shaped by relationships: a given attending’s style, a given resident’s trajectory, and a given program’s culture all influence what gets written. The retrospective design and the reliance on voluntarily written narratives impose limits, since the analysis can identify associations but cannot establish why faculty write what they write, and comments may reflect the constraints of a quick mobile assessment as much as the faculty member’s intent.

The practical implications are direct. The authors argue that future faculty development should focus on increasing constructive feedback given to practice-ready residents and on mitigating gender bias in assessment. That could mean training attendings to treat high-entrustment assessments not as a signal to stop teaching but as an opportunity to coach at a higher level of performance, and it could mean building prompts or structured templates into the EPA platform that nudge faculty toward formative language. Prior research on feedback quality in surgery, including studies comparing end-of-rotation evaluations with workplace-based assessments, has repeatedly found that narrative comments are often generic and non-actionable, and national validity studies of EPAs have shown that the tool works best when the narratives do their job. As competency-based medical education continues to replace time-based training across surgical specialties, the words attached to each assessment may ultimately matter as much as the numbers, and this study makes clear that those words still fall short of the coaching that surgical education promises.

Subject of Research: Narrative feedback quality in entrustable professional activity assessments of general surgery residents

Article Title: What do entrustable professional activities really tell us? Evaluating narrative feedback in general surgery

Article References: Moore, G., Hegeholz, D., Sun, T., Weaver, M. L., Ward, E. P., Mabes, E. S., & Jaiswal, K. (2026). What do entrustable professional activities really tell us? Evaluating narrative feedback in general surgery. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 137. https://doi.org/10.1007/s44186-026-00542-2

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00542-2

Keywords: entrustable professional activities, general surgery, surgical education, narrative feedback, competency-based medical education, formative assessment, coaching, entrustment, gender bias, faculty development, residency training, mixed-effects regression

The stakes of this question are enormous. More than a quarter of adults and roughly 80 percent of adolescents worldwide fail to meet recommended physical activity levels, and physical inactivity is estimated to cause nearly 50 million new cases of non-communicable disease every year, with projected treatment costs of around 300 billion US dollars between 2020 and 2030. Childhood is widely seen as the most effective intervention point, because motor skill competence and physical activity form a self-reinforcing loop: children who move well tend to move more, and children who move more become better movers. Those who fall behind early can spiral into lifelong inactivity, which is why researchers are increasingly focused on the building blocks known as fundamental movement skills.

Fundamental movement skills are the basic movement patterns that children refine into the specialized actions needed for sports and other physical pursuits. They include locomotor skills such as running and jumping, object control skills such as catching, throwing and striking, and stability skills such as balancing on one foot or walking a beam. Physical education lessons are the traditional venue for teaching them, but the average school delivers only about 60 to 130 minutes of physical education per week, far short of the World Health Organization’s recommendation of at least 60 minutes of moderate to vigorous activity per day. Home-based activity is meant to fill the gap, yet excessive screen time is widely blamed for displacing it, and interventions that simply try to limit screen time have shown little success, partly because they create family conflict, demand parental energy that work and chores already consume, and run up against financial constraints such as lacking safe outdoor spaces.

The research team, led by Oscar O’Brien, proposes a broader conceptual category they call exergamoids: physical activities that involve sensors of physical activity controlling a games technology component of the experience. Exergames, in which players develop their health as they play a complete game, are one subset. Digital gamification of exercise, such as a leveling system layered onto a step counter, is another. The umbrella term is designed to organize a fragmented literature and allow findings to transfer across game types, hardware platforms and settings. What unites exergamoids is a feedback loop in which digital tracking of movement serves as input to a game system, and the game’s output augments the physically active experience, potentially motivating children to practice skills at home that they first learned at school.

To resolve the mixed evidence that has plagued this field, the researchers systematically searched ten databases, including PubMed, APA PsycINFO, SPORTDiscus, IEEE Xplore, ACM Digital Library, Scopus, ProQuest, Web of Science, ScienceDirect and Google Scholar, for studies published between January 2000 and December 2025. After screening 2,882 retrieved records, 545 abstracts, and hundreds of full texts against strict population, intervention, comparison and outcome criteria, they identified 12 studies containing 17 statistically significant comparisons across 28 experimental groups, covering children aged 4 to 12 in school, home and clinical-adjacent settings. The corpus included 22 unique games across four hardware platforms, most of them commercial titles, and the studies varied widely in whether they used researcher-made games with design enhancements, structured physical education sessions or loosely supervised play, and whether children received targeted coaching on movement skills.

The methodological innovation of the study lies in how it handled that variability. Rather than pooling effect sizes, which the authors argue would be undermined by heterogeneity and bias, they applied what they call systematic hypothesis testing, an approach built on set theory and order theory. They generated eleven plausible hypotheses about what causes variability in movement skill outcomes, each defined by mathematical constraints such as whether coaching, activity structure or exergame status has a positive, negative or zero effect. For every hypothesis, they predicted the direction of the outcome for each of the 17 comparisons based on how the experimental groups differed, and then checked whether the observed results matched the prediction. The hypothesis that survived every test was one in which skill improvement is a function of coaching and activity structure, while exergame status itself has exactly zero effect.

That finding is more surprising than it might appear. Many exergames can be operated with sloppy or incorrect movement patterns, since permissive sensors reward effort rather than technique, which has led critics to argue that skills learned in front of a screen will not transfer to the real world. Yet the meta-analysis found no evidence of a differential effect across the temporal, environmental and functional components of movement skill, meaning exergames worked equally well for locomotor, object control and stability skills. The authors draw on dynamic systems theory to explain why: acquiring a movement skill is a search for a correct movement pattern across many degrees of freedom, and what guides that search most effectively is knowledge of performance, the actionable feedback a human coach provides about how to adjust the movement. Simple scores and game rewards, which constitute knowledge of results, do not tell a child how to change their technique, so the accuracy of the simulation matters far less than the quality of the coaching around it.

The analysis also revealed a hierarchy of facilitation. Human-delivered coaching through verbal feedback and live demonstration had a strong effect on skill outcomes, and coaching delivered through digital media, such as skill demonstration videos within the game, also improved results. Activity structure showed a positive contribution as well, though it was not a statistically significant predictor on its own, likely because most studies varied coaching and game status rather than structure in isolation. Unstructured, free-play exergaming sessions consistently underperformed, mirroring broader evidence that unstructured activities are less effective for skill development than planned ones. In practice, the most successful interventions looked like well-run physical education lessons that happened to use a game: teachers selected activities aligned with developmental needs, modeled the skills, cued corrections, and adjusted difficulty for individual children.

The practical implications reach well beyond the school gym. The authors argue that low-barrier exergames, in which cheating produces no better score than playing correctly, deserve recognition as a distinct category, because their permissiveness lets children with imperfect technique participate and stay motivated while a coach fine-tunes the specificity of the activity through praise and goal setting. Exergames can also offer experiences that schools cannot easily provide, from virtual surfing and snowboarding between classes to practicing ball heading in virtual reality, where one study noted children reported reduced fear. They enable training during bad weather, promote exertion through heart-rate-driven game mechanics, and show hints of enhanced benefit for groups that traditional activity often misses, including children with developmental delays and those who skip physical education sessions. Barriers remain, including hardware costs, staff training, IT support and the need to choose games whose movements match the curriculum, but the researchers recommend that teachers and parents treat exergames as a legitimate, freely chosen option rather than a last resort.

Looking forward, the team outlines two frontiers that could push exergames beyond parity with traditional activity. Simulated coaching, in which games assess movement competence, deliver demonstrations and provide cues automatically, could embed the knowledge-of-performance feedback that currently depends on a human presence, making uncoached home play genuinely instructional. Co-teaching systems, in which a game acts as a teaching assistant that adapts around the teacher’s plans rather than displacing them, would require a new layer of interactivity but could draw on evidence that collaborative teaching yields benefits even when the second teacher is less skilled. The authors caution that their analysis operated at the whole-class level, did not examine individual participant characteristics, and could not assess whether small differences emerge in interventions longer than six to eight weeks. Still, their central message is clear: the screen is not the enemy of childhood movement skills. Coached, structured exergaming belongs alongside traditional games as a tool for breaking the spiral of inactivity, at school and at home.

Subject of Research: The effects of exergames on children's fundamental movement skills, examined through a systematic review and meta-analysis of methodological variables such as coaching and activity structure.

Article Title: The Effects of Exergames on Fundamental Movement Skills in Childhood: A Systematic Review and Meta-analysis

Article References: O’Brien, O., Kendrick, C., Ives, B., Yap, M. H., & Henry, J. (2026). The Effects of Exergames on Fundamental Movement Skills in Childhood: A Systematic Review and Meta-analysis. Sports Medicine – Open, 12(1), Article 139. https://doi.org/10.1186/s40798-026-01081-2

Image Credits: AI Generated

DOI: 10.1186/s40798-026-01081-2

Keywords: exergames, exergamoids, fundamental movement skills, children, physical activity, physical education, meta-analysis, motor skill development, coaching, screen time, childhood health, dynamic systems theory