Defining Core Entrustable Professional Activities for Plastic Surgery: Results of a National Delphi Process
Authors: Esther A. Kim, MD, Lindsay A. Tao, BS., Carolyn B. Cafro, BS., Olle ten Cate, PhD
Background
•Competency-based medical education (CBME) emphasizes demonstrated ability in clinical practice
•Entrustable professional activities (EPAs):
•Discrete units of professional tasks that trainees can be entrusted to perform independently once competence is demonstrated
•EPAs operationalize CBME in real-world settings
•Plastic surgery lacks a validated, specialty-specific EPA framework
•The ACEPS EPA Task Force had already proposed a preliminary set of PRS-specific EPAs created using the nominal group technique and Equal rubric method
Aim
To refine and validate the 15 preliminary EPAs through a national Delphi consensus process
Methods
Study Design
•National Delphi consensus distributed to ACEPS members and all PDs APDs of ACGME-accredited PRS residencies
•Two survey rounds- Likert scale questions and free text
•Consensus predefined as ≥80% agreement
EPA Evaluation Domains
•Representativeness (primary for consensus)
•Clarity of wording
Frequency of resident exposure
Results
Participant Characteristics
•44 panelists (24% response rate)
•Broad subspecialty representation
•Highest for general reconstruction (57%), microsurgery (50%), breast (40%) though all subspecialties represented
•Wide distribution of years in practice
•<5 yrs: 20% | 5-15 years: 52% | 15 years: 28%
Delphi Round 1 Results
•13/15 EPAs reached consensus
•Highest agreement for:
•Surgeon as a manager and consultant (98%)
•Non-oncologic breast reconstruction (95%)
•Aesthetic surgery of the body (93%)
•Two craniofacial EPAs did not reach agreement
•Concerns of scope
Delphi Round 2 Results
•Narrative feedback guided revisions
•Participants received summarized feedback and had the opportunity to revise their response
•100% of EPAs reached consensus
Discussion
•High levels of agreement across a diverse expert panel support the validity and generalizability of proposed EPAs
•Initial lack of consensus for select EPAs highlights the tension between subspecialty breadth and universal competency expectations, reflecting variability in exposure rather than importance
•Implementation will require alignment with ACGME milestones, faculty engagement, and institutional assessment infrastructure
•As a consensus-based methodology, these findings require future validation in practice, including correlation with trainee performance and patient outcomes
Next Steps
•Q-sorting- ACEPS EPA Task force members met at PSTM 2025 to map pre-existing PRS subcompetencies to EPAs
•Entrustment level development- Defining entrustment levels from limited participation to practice ready
•National Pilot implementation- July 2027
Conclusion
This study establishes a consensus-driven, specialty-specific EPA framework for plastic surgery training. These findings provide a foundation for standardized competency-based assessment and future implementation across residency programs.
We thank the ACEPS EPA Task Force for their contributions:
Esther Kim, Olle ten Cate, Keith Brandt, Kim Bjorklund, Amanda Gosman, Scott Lifchez, Vu Nguyen, Peter Taub, Don MacKay, Aaron Mason, Mike Neumeister, David Tang
