The Challenge of Defining Entrustable Professional Activities in Orthopaedics

The leadership of JBJS has been consistent over many years in vetting manuscripts to ensure that readers are given orthopaedic information that is accurate and trustworthy. It may be that, sometimes, reviewers and editors do not agree with the logic or findings of a well-presented manuscript; however, all published manuscripts should be truthful and rigorous in defining the methods and results. Like many of the professional journals in the medical field, JBJS relies on peer review to judge the quality of manuscripts and to recommend publication, revision, or rejection. Peer review is a very important step in the delivery of scientific information to our readers, enabling them to trust information to be reliable enough to use in patient care or research. The orthopaedic readership trusts JBJS because they know that the possibility of falsehood and error within published manuscripts is small. We are publishing an article in the AOA Critical Issues in Education channel of JBJS Open Access (“Entrustable Professional Activities in Orthopaedics”) that some reviewers felt strongly had flaws that could not be corrected and therefore should not be published. Other reviewers and members of the editorial board felt that the topic of the manuscript was important and timely, and despite the acknowledged shortcomings, the manuscript was worthy of publication after revision. Another argument for publication was the importance of having a manuscript on this topic appear in a JBJS journal to promote better research methodology on the issue in the near future and to catch up with other medical specialties that are ahead of orthopaedics in teaching and using the tool that is the core focus of this manuscript. The topic of the article is Entrustable Professional Activities (EPAs), which are core tasks that faculty trust that a trainee—a resident or fellow—can do competently with minimal or no supervision. As the training of orthopaedic residents shifts toward competency-based metrics, rather than time-based learning, the performance of EPAs can be used to assess the ability of trainees to master knowledge and skill and, ultimately, to act as independent providers. The manuscript is from a respected group of orthopaedic educators from the University of Toronto. Their research was guided by a worthy question, and the methodology was rigorous although possibly skewed in EPA selection, especially regarding some of the EPAs that were not included in the manuscript. As part of their research method, the authors applied an evaluative process that resulted in the inclusion of only 1 EPA for the hand and wrist, 1 for the elbow, and 4 non–sports-related EPAs for the shoulder and proximal part of the humerus. The authors defended this process, maintaining that the main conclusion was correct and that residency directors could find ways to add EPAs for areas that were not included or were underrepresented. The authors also outlined in great detail how local program directors can create their own EPAs for use in their own training programs. In the final analysis, after several revisions (and some increase in the number of EPAs), the editors felt that the manuscript should be published to start the conversation about EPAs in orthopaedic training and spur new research that can build on this initial JBJS Open Access article. Although the manuscript may have deficiencies, it does not lack scientific integrity. In conclusion, the readership and future leaders in orthopaedic education will weigh in and have the final say on this topic.

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