Learning from Experience: A Systematic Review of Early Multi-Institutional EPA Studies Across U.S. Medical Specialties

OBJECTIVE: To evaluate the design, implementation strategies, and outcomes of early multi-institutional studies evaluating newly implemented Entrustable Professional Activities (EPAs) across U.S. residency and fellowship programs to inform future EPA implementation.

DESIGN: PubMed, Embase, and Scopus were searched for peer-reviewed U.S.-based multi-institutional or national studies evaluating EPA implementation in residency or fellowship training. Single-institution studies, undergraduate medical education studies, and non-U.S. publications were excluded. Screening and data extraction were performed independently and in duplicate.

SETTING: Graduate medical education programs in the United States.

PARTICIPANTS: Residency and fellowship programs, faculty assessors, and trainees participating in multi-institutional EPA implementation or evaluation studies.

RESULTS: Of 121 records identified, 5 studies met inclusion criteria. Studies published between 2020 and 2025 represented general surgery, pathology, anesthesiology, endocrine surgery, and pediatrics. Study duration ranged from 2 to 36 months, with participation ranging from 6 to 28 programs in pilot studies and 23 programs in one multi-institutional pediatric evaluation study. EPA assessments ranged from 698 to 25,503 per study. EPA implementation was feasible, with entrustment ratings increasing with trainee level. Digital platforms improved evaluation capture. Common barriers included variable faculty engagement, workflow friction, sampling bias from voluntary completion, and redundant evaluation systems.

CONCLUSIONS: Early multi-institutional EPA studies demonstrate feasibility but reveal consistent implementation challenges. Future EPA implementation efforts should prioritize workflow integration, digital assessment platforms, and faculty development to support sustainable competency-based assessment.