Applying Entrustable Professional Activities Across Emergency Medicine Medical Education Fellowships: A Cross‐Institutional Commentary

The recent development of entrustable professional activities (EPAs) for emergency medicine (EM) medical education (MedEd) fellowships by Villa et al. [1] represents a significant milestone in the movement toward competency-based education in academic medicine training. These 16 EPAs, developed through a modified Delphi consensus process, provide a much-needed framework for establishing uniform expectations for MedEd fellowships across institutions and offer a common language for assessing fellows' readiness for independent educational practice. Previous literature has focused on implementing EPAs within undergraduate medical education and residency training structures, with limited focus on fellowships [2-4]. Additionally, many EPAs have been focused on improving clinical training rather than solely focusing on educational standards. However, implementation in the real-world setting of diverse fellowships with unique structures, resources, and cultures raises an important question: how can a national framework be meaningfully adopted across locally distinct programs? To explore this question, we conducted a cross-institutional mapping exercise among three EM MedEd fellowship programs—Virginia Commonwealth University (VCU), Thomas Jefferson University, and UMass Chan Medical School. These fellowships vary in structure, scope, and available resources, but share a commitment to developing future clinician-educators. Our goal was to examine how each program's current activities align with these EPAs, identify areas of overlap or divergence, and assess the feasibility of adopting this new outcomes-based framework. We reviewed the 16 EPAs outlined in the original article and mapped current fellowship competencies to each one. The mapping process was conducted in three deliberate stages to promote both local accuracy and cross-institutional consistency. First, each fellowship independently identified all formal and informal learning activities within its curriculum, drawing from program handbooks, rotation objectives, and course syllabi. These activities were then mapped to the 16 published EM MedEd EPAs by at least two program leaders at each site. Next, each site conducted an internal reconciliation step, classifying activities as “fully aligned,” “partially aligned,” or “not aligned” with specific EPAs. Finally, representatives from all three institutions shared results, reviewing each EPA and discussing discrepancies until full consensus was achieved. This collaborative adjudication ensured shared interpretation and reproducibility across programs. Our findings, summarized in the accompanying table, demonstrate a high degree of natural alignment with the proposed EPAs, underscoring the relevance and utility of the framework. For instance, all three programs address key EPAs such as “Creating an academic CV,” “Serving as a mentor to learners,” and “Applying evidence-based teaching methods to didactic instruction” through structured assignments, mentorship activities, and participation in master's-level coursework. However, differences emerged in the implementation of EPAs that depend heavily on institutional infrastructure or administrative exposure. For example, one site noted that while its fellows consistently engaged in curriculum design and teaching evaluations (EPA 5 and EPA 7), there was limited structured exposure to “Performing program evaluation” (EPA 14) because administrative data access required institutional approvals not uniformly granted to fellows. Another program identified a curricular gap in “Assessing quality of MedEd research” (EPA 13), leading to the introduction of a monthly education scholarship journal club. This variability was also seen to be influenced by the presence of institutional research infrastructure. In contrast, a third site embedded fellows in program evaluation committees early in the fellowship year, providing a longitudinal experience. Additionally, some fellowships offered protected time and formal assignments, while others relied more heavily on informal mentorship or learner-directed experiences. These variations illustrate how shared EPAs can prompt targeted curricular refinement and mutual learning among institutions, while highlighting varied approaches to the fellowships’ distinct mission and operational reality. Several key themes emerged from our collective experience. First, the EPA framework was flexible enough to accommodate local variation while still promoting competency-based alignment. Rather than requiring a major curricular overhaul, the EPAs served as a clarifying lens through which existing activities could be evaluated, refined, or validated. Second, the mapping process itself proved to be a powerful tool for curricular self-assessment. Programs were able to identify gaps—such as the lack of formal feedback milestones for scholarly projects—and make immediate enhancements to better support fellow development. For example, one program identified a gap in structured feedback milestones for scholarly projects, while another noted limited exposure to administrative program evaluation—illustrating both common challenges and site-specific differences. Third, we found that successful engagement with the full range of EPAs was closely tied to program duration and institutional resources. The presence of longitudinal training structures and dedicated academic time facilitated robust engagement with more complex competencies. This model may not suit all fellowships, but it highlights the importance of resource allocation. Fourth, we recognized that EPA titles alone are insufficient to ensure consistent expectations or assessment. Shared tools, milestone descriptors, and rubrics are needed to guide developmental progression and enable meaningful feedback across programs. Finally, we identified a clear opportunity for national collaboration. A shared repository of curricular materials, assessment tools, and mentoring strategies would promote consistency, reduce duplication, and elevate the overall quality of MedEd fellowship training. Preliminary feedback from fellows suggested that explicitly linking activities to EPAs clarified expectations and influenced project choices, reinforcing the framework's value for both learners and training programs. One fellow described the EPA alignment as “a roadmap that finally connected the dots.” They reflected that before the mapping exercise, fellowship tasks often felt discrete—teaching 1 week, developing curricula the next. With the EPAs, these activities were reframed as interconnected competencies leading toward independent educator identity. Another fellow noted that seeing their progress across the EPAs during mentorship meetings “made invisible growth visible,” reinforcing confidence and providing structure for goal-setting. This alignment not only enhanced fellows' self-assessment but also helped programs articulate the broader value of fellowship training beyond individual projects. Several limitations warrant mention. This commentary reflects only three self-selected EM MedEd fellowships, which may limit generalizability and introduce selection bias toward programs already invested in competency-based education. The mapping process relied on descriptive consensus rather than standardized assessment metrics, and we did not measure fellows' competency development quantitatively. Additionally, the absence of outcome data and potential variation in the interpretation of EPAs across programs should be acknowledged. Nonetheless, these early experiences highlight both the promise and the practical challenges of implementing a shared competency framework. In conclusion, our cross-institutional application of the EPA framework illustrates its adaptability, relevance, and potential to drive curricular alignment across diverse EM MedEd fellowships. This initial mapping effort not only confirmed the value of the EPAs but also highlighted areas for growth—particularly in shared assessment strategies such as milestone-based assessment tools, fellow development rubrics, and structured feedback. Inter-fellowship collaboratives or virtual communities of practice could facilitate benchmarking and peer review, similar to models used in other specialties. Through continued collaboration and reflection, the EPA framework can become a foundational driver of excellence and equity in the training of future medical educators. Looking ahead, broader collaboration across programs—such as through Society for Academic Emergency Medicine (SAEM) or Council of Residency Directors in Emergency Medicine (CORD) initiatives or shared national databases or tools for standardization—would promote transparency, reduce redundancy, and may provide a path toward more consistent implementation. Included in the MHPE program curriculum. Assignment in the MHPE program Internally—Clinical Competency Committee and Program Evaluation Committee Externally—inter-institutional research teams, CORD MedEd Community of Practice, ACEP Education Committee, MERC The data that support the findings of this study are available from the corresponding author upon reasonable request.