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 mixed-methods 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 based on frequency and confidence levels and mapped to candidate EPAs.Results Non-traumatic emergencies were dominated by cardiovascular and neurological conditions, while traumatic cases primarily involved extremity injuries. The most frequent interventions were intravenous access, oxygen administration, and ECG acquisition; invasive procedures were rare. Physicians reported high confidence in resuscitation, airway management, and analgesia, but lower confidence in pediatric, neonatal, obstetric, and mass-casualty scenarios. Anaesthesiology background was associated with higher confidence across several domains. Tasks characterized by either high frequency with low confidence or low frequency with high clinical risk were identified as key targets for EPA development.Conclusion Current EMS physician training in Germany does not fully align with real-world clinical demands. Integrating EPAs based on case-mix and competence gaps may improve training transparency, supervision, and patient safety. Simulation-based approaches appear essential for low-frequency, high-stakes scenarios in prehospital emergency care.