Aligning training with clinical reality: linking case-mix and self-reported confidence to entrustable professional activities in physician-staffed EMS

Background Emergency medical services (EMS) physicians must manage a broad spectrum of high-acuity prehospital emergencies. However, current training pathways in Germany are not explicitly competency-based and provide limited structured exposure to low-frequency, high-stakes scenarios. Entrustable professional activities (EPAs) offer a framework to align training with real-world clinical demands. This study aimed to identify key prehospital tasks suitable for an EPA-based curriculum.Methods We conducted a multi-method descriptive study combining (1) a retrospective analysis of 4,078 prehospital EMS physician records (Nuremberg, 2017-2021) to assess case-mix and procedural frequencies and (2) an online survey of 134 bavarian EMS physicians assessing self-reported confidence across emergency domains. Tasks were categorized on the basis of frequency and confidence levels and mapped to candidate EPAs.Results Nontraumatic emergencies were dominated by cardiovascular and neurological conditions, whereas traumatic cases involved primarily extremity injuries. The most frequent interventions were intravenous access, oxygen administration, and ECG acquisition; invasive procedures were rare. Physicians self-reported high perceived confidence in resuscitation, airway management, and analgesia and lower perceived confidence in paediatric, neonatal, obstetric, and mass-casualty scenarios. Physicians with an anaesthesiology background descriptively reported higher perceived confidence across several domains; no inferential testing was performed. Tasks characterized by either high frequency with low confidence or low frequency with high stakes were identified as key targets for EPA development.Conclusion These findings identify patterns of clinical exposure and self-perceived confidence in the studied EMS context and suggest domains that may warrant further investigation in broader settings. They may inform the preliminary development of candidate EPA-based training frameworks in physician-staffed EMS systems. However, the findings do not demonstrate actual competence deficits, unsafe practices, patient safety effects, or the effectiveness of EPA-based curricula.Clinical trial number Not applicable.