Entrustable professional activities (EPAs) seek to translate essential physician competencies into clinical practice. Until now, it is not known whether EPA-based curricula offer enhanced assessment and feedback to trainees.This study examined program directors' and senior residents' justifications for entrustment decisions and what role generic, cross-specialty competencies (such as communication skills, collaboration, and understanding health care systems) play in these decisions.Entrustment decisions for all Dutch obstetrics and gynecology residents between January 2010 and April 2014 were retrieved from their electronic portfolios. Justifications for entrustment were divided into 4 categories: the resident's experience, his or her technical performance, the presence of a generic competency, and training. Template analysis was used to analyze in depth the types of justifications, which play a role in entrustment decisions.A total of 5139 entrustment decisions for 375 unique residents were extracted and analyzed. In 59% of all entrustment decisions, entrusting a professional task to a resident was justified by the experience of the resident. Generic competencies were mentioned in 0.5% of all entrustment decisions. Template analysis revealed that the amount of exposure and technical skills are leading factors, while the quality of the performance was not reported to be of any influence.Entrustment decisions only rarely are based on generic competencies, despite the introduction of competency frameworks and EPAs. For program directors, a leading factor in entrustment decisions is a resident's exposure to an activity, and the quality of a resident's performance appears to play only a minor role.