Only as Strong as the Weakest Link: Resident Perspectives on Entrustable Professional Activities and Their Impact on Learning.

Core to competency-based medical education (CBME) is the use of frequent low-stakes workplace-based assessments. In the Canadian context, these observations of performance are framed around entrustable professional activities (EPAs). We aimed to explore residents' real-world perspectives of EPAs and their perceived impact on learning, because assessments perceived to be "inauthentic," or not truly reflective of their lived experiences, may interfere with learning. Using constructivist grounded theory, we conducted 18 semistructured interviews in 2021 with residents from all programs that had implemented CBME at one tertiary care academic center in Canada. Participants were recruited via email through respective program administrators. Data collection and analysis occurred iteratively, and categories were identified using constant comparative analysis. Residents were strikingly polarized, perceiving EPAs as either a valuable opportunity for professional growth or as an onerous requirement that interfered with learning. Regardless of what view participants held, all perspectives were informed by: (1) the program administration and the perceived messaging from program to residents; (2) faculty assessors and their perceived degree of engagement, or "buy-in" with the EPA system; and ultimately (3) learner behavior. We theorized from these findings that all 3 aspects must be working in tandem for the assessment system to function as intended. From the learners' perspective, there exists a dynamic, interdependent relationship between the 3 CBME stakeholders. As such, the perceived value of the EPA assessment system can only be as strong as the weakest link in the chain.