Abstract: Competency-based medical education (CBME) is one of the core features of the third generation of medical education reform. The entrustable professional activity (EPA) framework is a valuable assessment method. EPAs aim to assess medical students' clinical competency for specific roles by observing their behaviors. Ideally, it should be conducted in the workplace, but numerous challenges exist, prompting some scholars to propose implementing EPAs based on simulation. Currently, simulation-based EPA assessment is a relatively novel research field, with studies focusing on acceptability, reliability, and validity, and influencing factors. Simulation-based EPA assessment has high acceptability and provides learners with a psychologically safe environment; in terms of validity, it can effectively differentiate learners across different competency levels; regarding reliability, inter-rater consistency is higher in simulated settings than in clinical settings, although the correlation between simulation-based and workplace-based assessment results remains controversial; entrustment decisions are influenced by factors such as raters' understanding of ″entrustment″, scenario authenticity, and the diversity of clinical tasks. Although current evidence remains limited, simulation offers clear advantages for EPA assessment: it provides a controlled, low-risk environment that can effectively address issues such as lack of standardization and patient safety concerns in workplace-based assessment. Nonetheless, challenges persist, including high costs, technical constraints, and the need for robust standard-setting. Simulation-based EPA assessment primarily serves to standardize competence verification and enable low-stakes training and evaluation, offering learners a safe space for practice. In contrast, workplace-based EPA assessment remains the ultimate basis for entrustment decisions. The two modalities are complementary. Future research should further explore simulation-based EPA assessment to enhance the scientific rigor and operational feasibility of competence evaluation, thereby advancing the development of competency-based medical education.

Key words: Education, medical, Medical simulation, Entrustable professional activities, Competence, Research progress