The study, published in Global Surgical Education, the Journal of the Association for Surgical Education, examined a program struggling with low adoption of the System for Improving and Measuring Procedural Learning, known as SIMPL. The smartphone-based platform was designed to let faculty deliver rapid, structured workplace-based assessments of residents using entrustable professional activities, or EPAs, which describe the discrete tasks a surgeon must be able to perform without supervision. The American Board of Surgery now requires EPA-based assessment for general surgery residency, typically delivered through SIMPL, but programs nationwide have reported inconsistent engagement that undermines the reliability of the resulting data.

Researchers at Sidney Kimmel Medical College at Thomas Jefferson University and Jefferson Einstein Philadelphia Hospital, led by Jandie Posner and Ramsey M. Dallal, approached the problem not as an education question but as an organizational change problem. They turned to ADKAR, a change-management model developed by Jeff Hiatt that breaks successful change into five sequential elements: awareness of the need for change, desire to participate, knowledge of how to change, ability to implement new skills, and reinforcement to sustain the change. Rather than simply asking faculty and residents to use the platform more, the team first diagnosed why they had stopped.

The diagnostic phase took the form of a faculty survey completed by 66 surgeons, whose responses were mapped onto the five ADKAR domains to identify where the implementation was failing. The findings informed a multicomponent intervention delivered between August and December 2024. It included re-education sessions for both faculty and residents on the purpose and mechanics of EPA assessments, a monthly leaderboard that gamified participation by ranking assessment activity, and formal recognition of high performers. The bundle was designed to act on multiple ADKAR domains simultaneously, raising awareness of the national mandate, cultivating desire through competition and recognition, restoring knowledge through refresher training, and building reinforcement into the program’s monthly rhythm.

To measure the effect, the investigators compared matched calendar quarters before and after the intervention: January through March 2024 served as the baseline, and January through March 2025 as the post-intervention period. The analysis included 48 resident-periods representing 31 unique residents, with 24 residents in each period. Because assessment counts are skewed count data, the team used count-data regression adjusted for postgraduate year and resident type, a statistical approach that accounts for the fact that senior residents and categorical residents might naturally accumulate more assessments than junior or preliminary residents. The model also accounted for residents who were present in both periods, allowing a within-person comparison.

The results were striking. Total EPA assessments rose from 36 to 100 across the two periods. Adjusted for training level and resident type, residents completed approximately 2.6 times as many assessments after the intervention, with an incidence-rate ratio of 2.58 and a 95 percent confidence interval of 1.17 to 5.73, reaching statistical significance at p equals 0.019. The confidence interval spans a range from a modest to a large effect, a nuance the authors acknowledged rather than smoothed over. Resident participation rates doubled, climbing from 37.5 percent to 75 percent, also statistically significant. Assessment activity expanded across all phases of surgical care, indicating that the gains were not confined to a single rotation or service line.

The statistical model revealed an additional pattern: activity varied significantly by training level, peaking among mid-level residents, but did not differ between categorical and preliminary residents. This distributional detail matters for program directors, because it suggests that mid-level trainees, who are often entrusted with greater operative autonomy, may be the natural center of gravity for workplace-based assessment, while interventions may need tailoring to activate junior and senior cohorts differently.

The authors were notably candid about the limits of their success. Decomposing the increase, they estimated that roughly 40 percent of the program-level gain reflected resident cohort turnover rather than behavior change among existing faculty and residents, as new interns arrived in a climate of heightened engagement. When the analysis isolated residents present in both periods, the within-resident change was not statistically significant, and a concurrent national trend toward increased EPA use may have contributed to the observed rise. The study was a single-center before-after design reported according to SQUIRE 2.0 quality-improvement standards, without a concurrent control group, so these uncontrolled results warrant caution. The team also emphasized that the study measured only EPA utilization, not the quality of feedback, resident learning, or actual competency outcomes, leaving open the question of whether more assessments translate into better surgeons.

Those caveats, however, do not erase the study’s practical value. The authors frame the intervention as a reproducible bundle: diagnose barriers systematically, map them to a recognized change framework, deliver targeted re-education, and embed reinforcement through gamification and recognition. The gamification element builds on a growing literature showing that leaderboards and competition can increase engagement in health professions education, while the ADKAR mapping gives other programs a vocabulary for figuring out which stage of change their own implementation is stuck at. A program whose faculty are unaware of the EPA mandate needs a different fix than one whose faculty know the mandate but lack the desire to comply, and the ADKAR lens makes that distinction actionable.

The work also extends a lineage of re-implementation studies. A prior BMC Surgery report from a different program, published under the pointed title When the First Try Fails, documented a similar recovery effort, and earlier multi-institutional trials had established SIMPL’s feasibility for real-time intraoperative assessment. What the new study adds is a theoretically grounded, low-cost template that programs facing low EPA engagement can adapt without new technology or funding. The research received no specific grant funding, the institutional review board deemed it exempt, and the authors report no conflicts of interest. As EPA-based assessment becomes a fixed feature of surgical training, the study’s central message resonates beyond surgery: implementing an assessment platform is a change-management exercise, and treating it as one may be the difference between a tool that collects dust and one that transforms how surgical competence is measured.

Subject of Research: ADKAR-guided re-implementation of the SIMPL EPA assessment platform in a general surgery residency program

Article Title: When implementing SIMPL is not so simple: an ADKAR-guided re-implementation and engagement strategy in a general surgery residency

Article References: Posner, J., Kardan, R., Godbole, M., Lei, J., Moran, B., & Dallal, R. M. (2026). When implementing SIMPL is not so simple: an ADKAR-guided re-implementation and engagement strategy in a general surgery residency. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 160. https://doi.org/10.1007/s44186-026-00569-5

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00569-5

Keywords: entrustable professional activities, SIMPL, ADKAR, change management, surgical education, general surgery residency, resident assessment, faculty engagement, gamification, quality improvement, workplace-based assessment, competency-based education

The commentary responds directly to an investigation by Kabbash, Fieber, Shaw, Cochran, Sarosi, and Falcone, who asked a question that sounds almost too obvious to need answering: does more mean better? Their study, published in the same journal, evaluated faculty-to-resident feedback in general surgery by measuring not just how often attending surgeons provided workplace-based assessments, but what those assessments actually contained. The concern underlying the work is familiar to anyone who has sat on a clinical competency committee. Volume of assessment data is easy to count. Quality is not. A resident may accumulate dozens of brief encounter ratings over the course of a rotation, and still graduate with no coherent picture of whether independent performance has been demonstrated in the operating room, on the wards, or in the emergency department.

The American Board of Surgery has embraced EPAs for general surgery precisely to close that gap. Rather than treating every task as a separate competency checkbox, EPAs bundle the discrete skills, knowledge domains, and attitudes required for units of professional work that can be entrusted to a learner. The board’s framework identifies the core activities a general surgeon must be able to perform unsupervised by the end of training, from managing critically ill patients to performing defining operations of the specialty. When an assessor marks a resident as entrusted for one of these activities, the judgment is meant to carry real weight: it is a statement about readiness for unsupervised practice, the same readiness that certification ultimately vouches for.

That weight is exactly why Lipman insists on extensiveness as a first condition. A sparse set of EPA ratings, gathered on only a handful of occasions or from only a subset of a resident’s supervisors, cannot capture the variability inherent in surgical work. Performance fluctuates with case complexity, patient acuity, team dynamics, and the sheer human reality of fatigue and stress. A resident entrusted after three observations on straightforward elective cases may not be equivalent to one entrusted after thirty observations spanning emergencies, revisions, and high-acuity trauma. Extensiveness, in this framing, is not bureaucratic accumulation for its own sake. It is the statistical and practical foundation that allows committees to distinguish a resident having a good week from a resident who is genuinely, reliably ready.

The second condition, that EPAs be practiced, addresses the often-ignored reality that assessment is itself a clinical skill. Faculty surgeons are experts in operating and in patient care, but the act of observing a trainee, anchoring that observation to the specific behavioral anchors of an EPA scale, and translating it into a calibrated trust judgment is a separate craft that requires deliberate rehearsal. Assessment researchers have long documented the hazards of uncalibrated raters: leniency bias, central tendency, halo effects that let a charming resident’s minor lapses slide, and harshness toward trainees whose style differs from the rater’s own. Without regular practice, rater drift is inevitable. Two attendings asked whether the same resident can be entrusted with the same activity should, in principle, reach the same conclusion. In unpracticed systems, they frequently do not.

The commentary highlights a scoring approach developed to address exactly this quality problem. The Quality of Assessment of Learning, or Qual, score, introduced by Chan, Sebok-Syer, Sampson, and Monteiro in Teaching and Learning in Medicine, provides validity evidence for a system that rates short, workplace-based comments on trainee performance. Instead of accepting any narrative feedback as equal evidence, the Qual framework distinguishes comments that contain specific, actionable, behaviorally anchored observations from vague platitudes like good job or needs to read more. Applied to EPA-linked assessments, such scoring gives programs a way to audit not just how many assessments their faculty complete, but how informative each one actually is. It converts the sprawling noise of workplace commentary into something a competency committee can weigh.

The Kabbash study’s central finding, that higher volumes of faculty feedback did not automatically translate into higher-quality feedback, reframes a comfortable assumption in surgical education. Programs have often responded to accreditation pressure by simply demanding more assessments, building dashboards that turn red when completion rates sag, and nudging faculty to submit ratings before their logs expire. But if the additional assessments are generic, unanchored, or copied between residents, the dashboard turns green while the underlying evidence base for trust decisions remains thin. Lipman’s commentary makes the corollary explicit: extensive but inaccurate assessment may be worse than limited assessment, because it manufactures false confidence in an entrustment decision that the data cannot actually support.

Accuracy, the third pillar, is where the technical demands on programs become most serious. For EPA judgments to be accurate, they must be grounded in direct observation of the specific activity in question, made by raters who have seen enough of the resident’s work to generalize, and recorded with enough specificity that a future reader can reconstruct the basis for the decision. This has operational consequences. Assessment must be embedded into the workflow rather than bolted on afterward, ideally captured immediately after a case or shift while observations are fresh. Faculty development must treat entrustment rating as a teachable, coachable skill, with calibration exercises in which multiple raters score the same performance and reconcile their differences. Programs must also resist the seduction of automation that merely counts forms, and instead build review processes that sample and score the narrative content of assessments using validated instruments.

For residents, the stakes of getting this right are personal and immediate. Trainees respond to the feedback culture they inhabit. When they perceive that ratings are arbitrary, they learn to game the system, requesting assessments at convenient moments and from lenient raters. When they perceive that ratings are extensive, practiced, and accurate, feedback becomes a form of coaching rather than surveillance, and the EPA framework starts to do what it was designed to do: tell a resident, in concrete behavioral terms, what they can already be trusted to do alone and what they must still work on under supervision. The commentary’s synthesis suggests that programs which invest in all three pillars will not only produce better data but will change the day-to-day conversation between teachers and learners.

As competency-based medical education continues its march through surgical training, the lessons of this exchange between the Kabbash study and Lipman’s commentary extend well beyond general surgery. Every specialty adopting EPAs faces the same temptation to measure volume instead of value. The evidence now accumulating points toward a more demanding but more defensible standard: build an assessment system that is comprehensive enough to be representative, rehearsed enough to be reliable, and specific enough to be true. Only then can a statement of entrustment mean what it claims, and only then can the programs that certify surgeons honestly say that readiness for independent practice was demonstrated, not assumed.

Subject of Research: Quality and validity of faculty feedback in entrustable professional activity-based assessment of surgical residents

Article Title: The best EPAs are extensive, practiced and accurate

Article References: The best EPAs are extensive, practiced and accurate. (n.d.). https://doi.org/10.1007/s44186-026-00577-5

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00577-5

Keywords: entrustable professional activities, surgical education, general surgery residency, workplace-based assessment, faculty feedback, competency-based medical education, Qual score, rater calibration, resident training, American Board of Surgery, feedback quality, surgical competency committees

The research, led by Kaitlin Pardue and colleagues in the Department of Surgery, was published in Global Surgical Education, the Journal of the Association for Surgical Education. The team set out to test a simple but urgent premise: because sternotomy is a high-risk procedure that general surgery residents encounter infrequently, simulation may be the most practical way to close the experience gap without compromising patient safety.

The procedural stakes are considerable. Opening the sternum requires precise midline division of the bone with a sternal saw, and deviations can damage underlying structures, complicate closure and increase the risk of postoperative wound complications. Prior surveys of general surgery residency program directors have documented limited cardiac surgery exposure during training, and many trainees report low comfort levels with the procedure — a pattern the Oklahoma group sought to address directly.

In the study, 25 learners consented and completed a baseline sternotomy on the training model before receiving any instruction. The majority of participants were resident trainees, making up 72 percent of the cohort, and 60 percent were male. Notably, none of the participants had ever performed a sternotomy prior to the simulation, and the group reported strikingly low baseline preparedness, averaging just 1.2 on a 5-point scale.

The training protocol was deliberately straightforward. After the baseline attempt, participants viewed a standardized instructional video demonstrating proper technique, then repeated the procedure on the simulator. Surveys administered before and after the initial sternotomy, and again at the completion of the simulation, measured self-assessed preparedness and anxiety using a 5-point Likert scale.

Objective scoring was built into the simulator itself. Artificial sternums were marked with a colored grading scale that allowed a 30-point accuracy assessment, capturing how closely trainees adhered to the ideal midline path. In addition, de-identified video recordings of each attempt were scored by blinded faculty reviewers on a 4-point technique scale, adding an independent, human evaluation of procedural skill alongside the anatomical accuracy measure.

The results were unambiguous. Accuracy scores on the sternum model rose from an average of 15.64 at baseline to 22.36 after training on the 30-point scale, a statistically significant improvement (p=0.006). Blinded faculty technique scores climbed from 2.08 to 3.48 on the 4-point scale (p<0.0001), indicating that the gains were visible not just in the cut itself but in the overall quality of the trainees’ operative technique.

The psychological benefits were just as striking. Ninety-six percent of participants reported improvement in preparedness following the simulation exercise, with an average increase of 1.3 points on the preparedness scale. Self-reported anxiety scores also fell significantly, dropping from 3.72 before the exercise to 2.76 afterward (p=0.001). The authors note that reducing anxiety in a controlled, nonthreatening environment may be a key mechanism by which simulation prepares trainees for real clinical scenarios.

The research was supported in part by a grant from the OUHSC College of Medicine’s Jerry Vannatta, MD Academy of Teaching Scholars, and the authors report no financial conflicts of interest. The study received ethical approval from the Human Investigation Committee of the University of Oklahoma (IRB# 15961), and informed consent was obtained from all participants.

The investigators conclude that, given the rare and high-risk nature of sternotomy, simulation offers an excellent opportunity to build both skill and confidence in surgical trainees — and may serve as a metric for assessing competence. While this was a pilot study and further work is needed to determine whether simulator gains translate into durable clinical competency, the findings suggest that a relatively simple, reproducible model combined with directed teaching could become a standard part of preparing the next generation of surgeons for one of the most demanding openings in the operating room.

The educational challenge at the heart of this study reflects a broader shift in how surgical training is conceived. Traditional apprenticeship models, in which residents learn by graduated exposure to real operations, assume that trainees will encounter each critical procedure often enough to progress from observation to supervised performance to independence. For procedures like median sternotomy, that assumption increasingly fails. Cardiac surgery volumes are concentrated in specialized centers, general surgery residents rotate through cardiothoracic services for limited periods, and the operation itself is often reserved for the most experienced members of the team because of the stakes involved. The result is a structural gap between what trainees are expected to be ready for and what they have actually practiced.

Simulation has emerged as the most widely endorsed response to this kind of exposure gap, and the evidence base supporting it has matured considerably over the past two decades. Systematic reviews of skills transfer after simulation-based surgical training have concluded that simulator-acquired skills do carry over to clinical settings, particularly when the training model reproduces the key perceptual and motor demands of the real procedure. For sternotomy, those demands include stabilizing the saw against a rigid, unforgiving structure; maintaining a strictly midline trajectory along the sternal symphysis; adjusting force as the saw traverses the denser manubrium and body of the bone; and halting the division at exactly the right moment to avoid plunging into the mediastinum. A model that lets trainees rehearse these elements repeatedly, without any risk to a patient, addresses precisely the components of the procedure where error is most costly.

The Oklahoma team’s simulator was not developed in a vacuum. Prior work in cardiac surgery education, including published efforts to build median sternotomy simulation models specifically for surgical training, has demonstrated growing interest in reproducing this single high-stakes step outside the operating room. What distinguishes the present study is its pairing of a physical, reproducible model with a structured instructional sequence and a dual scoring system. The combination matters because simulation alone, without deliberate instruction and objective feedback, tends to reinforce whatever habits a trainee brings to the task. The standardized video shown between the baseline and post-training attempts ensured that improvement reflected learning of correct technique rather than mere familiarity with the model.

The colored grading scale embedded in the artificial sternums deserves particular attention as a methodological feature. By scoring accuracy on a 30-point scale directly on the bone itself, the investigators created an assessment that is objective, inexpensive, and immediately interpretable. A deviated cut is visible in the artifact it leaves behind, which mirrors the clinical reality that a non-midline sternotomy is apparent to the operative team the moment the bone is divided. This kind of built-in assessment also points toward competency-based approaches to surgical education, in which progression is tied to demonstrated performance on defined tasks rather than to time served or case counts alone. A program director could, in principle, use a sternotomy simulator score as one element of a broader portfolio of procedural readiness.

The anxiety findings add a dimension that is often underemphasized in technical skills research. Self-reported anxiety fell from 3.72 to 2.76 on the five-point scale, a statistically significant decrease that accompanied the objective performance gains. The relationship between anxiety and surgical performance is well recognized: elevated stress degrades fine motor control, narrows attention, and impairs decision-making, particularly in trainees who are performing a procedure for the first time. Allowing a first attempt to occur in a low-stakes setting, where an imperfect cut has no consequence, may interrupt that cycle. By the time a trainee holds a sternal saw over a patient, the procedure is no longer a first exposure, and the psychological load of the moment is correspondingly reduced.

The clinical consequences of a poorly executed sternotomy help explain why this particular step merits dedicated training. Deviations from the midline can leave asymmetric bone edges that complicate wire closure and sternal reapproximation, and sternal wound complications, including dehiscence and mediastinitis, are among the most serious morbidities following cardiac operations. Off-midline cuts may also lacerate underlying pleura or vascular structures. Because these complications carry substantial morbidity and cost, investments in preclinical rehearsal of the incision are consistent with broader quality and safety priorities in cardiothoracic care.

As a pilot study, the work has limitations that the authors themselves acknowledge and that frame the agenda for future research. The cohort of 25 learners was small and drawn from a single institution, and the absence of any prior sternotomy experience among participants, while ideal for measuring learning curves, means the simulator’s value for more advanced trainees remains untested. The study measured immediate post-training performance rather than retention, leaving open the question of how durable the gains are over weeks or months. Most importantly, demonstrating improved simulator performance is not the same as demonstrating improved clinical competency, and translational studies linking simulator scores to supervised performance in actual operations would strengthen the case for widespread adoption.

Nevertheless, the pattern of results across three independent measures — anatomical accuracy, blinded technique scoring, and self-reported preparedness — converges on a consistent conclusion. The magnitude of the improvements, achieved with a single instructional session and a reproducible model, suggests an efficient educational intervention that could be implemented without elaborate resources. For a procedure that most general surgery residents will rarely, if ever, perform before being expected to assist with or perform it, that efficiency is the central argument for making sternotomy simulation a routine component of surgical preparation.

Subject of Research: A sternotomy simulation program to improve surgical trainees' performance and preparedness

Article Title: Splitting hairs: improving sternotomy performance and preparedness among trainees using a novel simulation program

Article References: Pardue, K., Davis, R., Trimble, J., Harter, M., Wood, F., Scott, R., & Lees, J. (2026). Splitting hairs: improving sternotomy performance and preparedness among trainees using a novel simulation program. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 174. https://doi.org/10.1007/s44186-026-00581-9

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00581-9

Keywords: sternotomy, surgical simulation, surgical education, general surgery residency, trainee preparedness, technical skills, cardiothoracic surgery, pilot study, competency assessment, medical training, anxiety reduction, patient safety