Development of Nested Entrustable Professional Activities: A Delphi Consensus Study in General Surgery

Background: Entrustable professional activities (EPAs) are widely used in competency-based medical education; however, most EPAs reflect skills expected later in training, limiting their ability to capture incremental progression among mid-level residents. This lack of granularity obscures meaningful development toward autonomy, undermines resident motivation, and delays identification of struggling learners. We describe a framework of nested EPAs in surgery-defined as smaller, discrete, professional tasks embedded within core EPAs-to address gaps in assessing mid-level trainee progression. This model can be adapted across medical specialties facing similar assessment limitations. Objective: To describe the development of nested EPAs using surgery as a reproducible model for other specialties. Methods: In 2024, we created descriptions for nested EPAs using a systematic process. We developed 160 narratives across 10 nested EPAs, organized into 4 performance domains: anatomy, surgical technique, potential errors, and operative steps, each with 4 levels of increasing autonomy (10×4×4). Second, we performed a Delphi consensus study to finalize the nested EPAs and associated narratives (80% agreement for consensus). The Delphi panel included 15 surgical experts (5 women and 10 men) from 8 surgical subspecialties, affiliated with 1 general surgery residency program. The focus was on intraoperative nested EPAs. Results: In the first round, 136 of 160 items (85%) reached consensus, with 17 updated based on feedback and included in the second round along with 24 items that initially did not meet consensus. All 41 revised items (100%) achieved consensus in the second round. Conclusions: We demonstrated a model for developing nested EPAs.