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 research team, led by Michel S. Kabbash, examined Entrustable Professional Activity, or EPA, micro-assessments submitted to general surgery residents over the 2023 to 2025 academic years. EPAs are a cornerstone of competency-based medical education, a reform movement that shifted training away from time-based benchmarks and toward demonstrated ability to perform trusted professional tasks. Rather than judging a resident on a single high-stakes examination, EPA micro-assessments capture frequent, low-stakes observations of real clinical work — in this study, the management of three bread-and-butter surgical conditions: gallbladder disease, appendicitis, and inguinal hernia. Each micro-assessment includes a narrative comment in which the supervising faculty surgeon explains what the resident did well, what needs work, and how to improve.

The central hypothesis was straightforward: faculty who file more EPA evaluations might simply be more engaged in assessment overall, and that engagement might translate into higher-quality written feedback. To test it, the researchers needed an objective way to score feedback quality, which is notoriously difficult to quantify. They turned to the QuAL rubric — the Quality of Assessment for Learning instrument — which rates short workplace-based comments on a zero-to-five-point scale across three dimensions: evidence, meaning whether the comment cites specific observed behaviors; suggestion, meaning whether it offers actionable guidance; and connection, meaning whether it links the observation to the suggestion in a coherent way. The QuAL score was developed specifically to rate the kind of brief, free-text comments that dominate modern assessment platforms, giving the study a validated yardstick rather than a subjective impression of quality.

Two independent raters scored all of the narrative feedback, and the agreement between them was strong, with an interrater reliability of 0.85 — a figure that lends considerable statistical credibility to the quality ratings. In total, the team analyzed 661 EPA micro-assessments submitted by 26 faculty members. The median QuAL score across all comments was 3 on the six-point scale, and the median comment length was 60 words. Those two numbers turned out to be tightly linked: word count correlated positively with QuAL score, with a Spearman correlation coefficient of 0.81 and a p-value below 0.001. In plain terms, longer comments were substantially more likely to contain concrete evidence, useful suggestions, and a logical bridge between the two.

The volume question at the heart of the study also resolved in favor of the prolific evaluators. Faculty who submitted fewer than 25 evaluations during the study window produced feedback with a median QuAL score of 2.88, while those who submitted 25 or more reached a median of 3.25, a statistically significant difference with a p-value of 0.034. Faculty experience in the study cohort ranged widely, from one to 37 years in practice, and that variable mattered too. To disentangle the effects of volume, length, and experience — which naturally cluster together in busy senior surgeons — the researchers used regression modeling based on generalized estimating equations, a statistical approach suited to clustered data in which one faculty member contributes many assessments. The results held up: the number of evaluations submitted, the word count of the narrative feedback, and the number of years a faculty member had been in practice were each independently associated with higher-quality feedback, all with p-values below 0.05.

Why would frequent assessors write better comments? The study itself points toward targets for faculty development rather than offering a definitive psychological explanation, but the broader medical education literature suggests plausible mechanisms. Assessment is a skill, and like operative technique it improves with deliberate, repeated practice. A faculty member who completes dozens of EPA evaluations each year is repeatedly forced to articulate what competent performance looks like, to distinguish acceptable from excellent work, and to translate clinical observations into educational language. That repetition may build a kind of assessment fluency. Experience in practice likely compounds the effect: a surgeon 20 years into a career has seen a wider spectrum of resident performance and can draw on a richer mental library of specific examples, corrective strategies, and developmental trajectories when writing a comment.

The strong correlation between word count and quality deserves particular attention, because it cuts both ways. On one hand, it suggests a simple lever for improvement: programs that encourage faculty to write more substantive comments — moving beyond a terse sentence toward the 60-word-plus territory where evidence, suggestion, and connection can actually fit — may see measurable gains in feedback quality. On the other hand, length alone is not the goal. A rambling 200-word comment with no actionable suggestion would score poorly on the QuAL rubric regardless of its heft. The correlation indicates that in real-world practice, the faculty who write longer comments tend to be the ones including the specific ingredients that make feedback useful, not merely padding their text. Brevity, in the context of EPA micro-assessments, appears to come at a genuine educational cost.

The findings arrive at a moment when competency-based medical education is expanding globally and EPA-based assessment is becoming the default architecture for postgraduate training in many specialties. That transition has created an enormous appetite for faculty assessment data, and programs often measure engagement by counting submissions. This study adds an important nuance to that accounting: quantity and quality are not independent, and the faculty members who contribute the most data points may also be supplying the most educationally valuable ones. For program directors, that reframes low-volume assessors not merely as a data gap but as a quality gap — their residents may be receiving thinner, less actionable guidance precisely where more feedback structure is needed.

The practical implications for faculty development are concrete. The authors explicitly frame their results as identifying targets for improving EPA narrative feedback, and the data suggest where to aim: faculty early in their careers and faculty with low submission volumes are the groups most likely to produce lower-scoring comments. Interventions could include rater training workshops that model high-quality narrative comments, prompts embedded in assessment platforms that encourage evaluators to cite specific observed behaviors and pair them with concrete next steps, and departmental norms that treat assessment volume as a professional expectation rather than an optional courtesy. Previous work in the medical education literature has shown that faculty development programs can improve the quality of written evaluations, and this study provides the volume, length, and experience variables that such programs can monitor as markers of progress.

There are, as with any single-institution study, limits to how far the conclusions travel. The analysis covered 26 faculty members at one academic department, focused on three common surgical conditions, and relied on a six-point quality rubric that, while validated, cannot capture every dimension of what makes a comment transformative for a learner — including the trust and relationship between teacher and trainee that researchers call the educational alliance. The data underlying the study are not publicly available, and the observational design cannot prove that writing more evaluations causes better feedback, however strongly the regression suggests the association. Still, the core message is hard to ignore: in the ecosystem of surgical training, the surgeons who show up most often as assessors, write the most substantive comments, and carry the deepest wells of clinical experience are the ones producing feedback that best equips residents to grow. For a profession built on apprenticeship, that is a finding worth acting on.

Subject of Research: Quality of faculty narrative feedback in Entrustable Professional Activity assessments of general surgery residents

Article Title: Does more mean better? Evaluating faculty-to-resident feedback in general surgery

Article References: Kabbash, M. S., Fieber, J. H., Shaw, C. M., Cochran, A. A., Sarosi, G. A., & Falcone, J. L. (2026). Does more mean better? Evaluating faculty-to-resident feedback in general surgery. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 154. https://doi.org/10.1007/s44186-026-00563-x

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00563-x

Keywords: surgical education, entrustable professional activities, feedback quality, resident assessment, competency-based medical education, general surgery, faculty development, QuAL rubric, narrative feedback, micro-assessment, medical education, workplace-based assessment

The study, published in Global Surgical Education, the journal of the Association for Surgical Education, analyzed 1,071 Entrustable Professional Activity assessments completed by faculty for general surgery trainees between July 2023 and June 2025. Entrustable Professional Activities, or EPAs, are defined units of professional work — such as performing an operation, managing a critically ill patient, or coordinating pre-operative care — that supervisors rate on an entrustment scale ranging from watching the resident to granting full independence. The framework was adopted nationally in general surgery as part of the profession’s shift toward competency-based medical education, replacing time-based measures with direct observations of what a resident can actually be trusted to do.

The research team, led by Gabrielle Moore of the University of Utah Spencer Fox Eccles School of Medicine, applied mixed-effects ordinal regression models to the assessment data. This statistical approach is well suited to the structure of the dataset because it accounts for the fact that multiple assessments are nested within the same residents and the same faculty evaluators, and because entrustment ratings are ordered categories rather than continuous numbers. The models examined how the odds of receiving a higher entrustment rating changed with the presence of narrative feedback, post-graduate year, case complexity, the phase of care being assessed, and the demographics of both trainees and evaluators.

The headline finding was stark. Of the 1,071 assessments, 896 — 83.7 percent — contained narrative feedback, while 175, or 16.3 percent, had none at all. But residents rated at higher levels of entrustment for a given activity were significantly less likely to have received written comments: the odds ratio was 0.44, meaning the odds of receiving narrative feedback were less than half for those at higher entrustment levels compared with those rated lower, a difference that was highly statistically significant. In other words, the trainees who most impressed their supervisors got the least written explanation of why.

The pattern has a plausible psychological explanation, though the study design cannot prove causation. Faculty may feel that a resident performing at an expected or advanced level needs no justification, while a struggling trainee prompts a written note. Alternatively, supervisors may simply be more motivated to document concerns than to document excellence. Either way, the result runs against one of the central promises of the EPA framework — that every entrustment decision should be accompanied by actionable, individualized feedback that tells the trainee what to do next. Without narrative comments, a high entrustment rating is a verdict without a rationale, and a resident cannot easily convert it into improvement.

The analysis also mapped how entrustment varies across the arc of training and the texture of clinical work, and here the results were more reassuring. The likelihood of a higher entrustment rating increased significantly with post-graduate year, peaking in the senior stages of residency — evidence that the assessment system tracks genuine progression rather than assigning ratings at random. Trainees operating on straightforward cases were nearly twice as likely to earn higher entrustment than those in complex cases, with an odds ratio of 1.94. That gradient makes sense: a routine procedure offers fewer opportunities for things to go wrong and fewer moments where a supervisor must intervene, but it also raises the question of whether the rating reflects the resident or the operation.

Phase of care mattered even more dramatically. Assessments conducted before and after operations were far more likely to carry high entrustment ratings than those conducted intraoperatively: the odds ratio was 4.94 for pre-operative assessments and 3.04 for post-operative assessments, both statistically significant. The operating room, it turns out, is the hardest place to earn trust — unsurprising, given that intraoperative performance unfolds in real time under pressure, with the attending surgeon literally scrubbed in and sharing responsibility for the patient on the table. But the finding also hints that faculty may find it easier to delegate cognitive and coordinative tasks, such as planning and post-operative management, than to hand over the scalpel.

One of the most consequential results concerns fairness. Previous research in surgical education has documented demographic disparities in operative autonomy and assessment, including gender differences in entrustment and in the language faculty use to describe trainees. This study, however, found no difference in entrustment based on trainee or faculty demographics once post-graduate year and case complexity were controlled for statistically. That is an important methodological caveat: raw differences between groups can disappear when the model properly accounts for how much training a resident has had and how difficult their cases are. The finding offers cautious reassurance that the EPA system, at least in this sample, is rating the work rather than the person — though the authors and the broader literature agree that continued surveillance is warranted as implementation matures.

The study arrives at a moment when EPAs are moving from pilot projects to routine practice in American surgical training. A national pilot published in Annals of Surgery in 2023 documented the early implementation experience, and subsequent work has examined the validity of EPA ratings, the quality of the narrative comments attached to them, and the gaps between what faculty think they are communicating and what residents actually hear. Earlier studies have found that intraoperative EPA feedback often focuses narrowly on technical performance and provides limited guidance, and that the quality of narrative comments varies widely across evaluators. The new findings add a structural dimension to that critique: it is not only what faculty write that matters, but whether they write anything at all — and who ends up on the receiving end of the silence.

The authors’ conclusion is direct: efforts should be made to ensure that all residents receive actionable feedback along the continuum of their training. In practical terms, that could mean requiring a narrative comment for every EPA assessment regardless of entrustment level, building prompts into the mobile assessment platform that ask faculty to justify high ratings, or using faculty development workshops — an approach already shown to improve the utility of narrative evaluations in other specialties — to train supervisors in giving feedback that is specific, growth-oriented, and useful to trainees at every stage. The mobile platform through which the American Board of Surgery delivers EPA assessments could, in principle, make a comment field mandatory rather than optional.

For the surgical profession, the stakes extend beyond individual trainees. Entrustment decisions ultimately feed into certification and into the public promise that a newly independent surgeon can be trusted with patients’ lives. If the highest-rated residents are the least documented, programs lose a rich source of validity evidence — the written reasoning behind the judgment — at exactly the point where it is most valuable. The study’s dataset of 1,071 assessments across multiple institutions provides a solid foundation for that concern, and its statistical controls for training level and case complexity make the feedback gap difficult to dismiss as an artifact. The next step, the authors suggest, is ensuring that trust, once earned, is always explained.

Subject of Research: The relationship between entrustment levels and assessment factors in Entrustable Professional Activity evaluations of general surgery residents

Article Title: The relationship between entrustment and EPA assessment factors in general surgery residency training

Article References: Moore, G., Hegeholz, D., Sun, T., Weaver, M. L., Ward, E. P., Mabes, E. S., & Jaiswal, K. (2026). The relationship between entrustment and EPA assessment factors in general surgery residency training. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 157. https://doi.org/10.1007/s44186-026-00559-7

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00559-7

Keywords: entrustable professional activities, general surgery residency, entrustment, narrative feedback, surgical education, competency-based medical education, operative assessment, post-graduate year, case complexity, faculty evaluation, resident training, assessment validity