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