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, 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