Entrustment Unpacked: Aligning Purposes, Stakes, and Processes to Enhance Learner Assessment

Abstract

Educators use entrustment, a common framework in competency-based medical education, in multiple ways, including frontline assessment instruments, learner feedback tools, and group decision making within promotions or competence committees. Within these multiple contexts, entrustment decisions can vary in purpose (i.e., intended use), stakes (i.e., perceived risk or consequences), and process (i.e., how entrustment is rendered). Each of these characteristics can be conceptualized as having 2 distinct poles: (1) purpose has formative and summative, (2) stakes has low and high, and (3) process has ad hoc and structured. For each characteristic, entrustment decisions often do not fall squarely at one pole or the other, but rather lie somewhere along a spectrum. While distinct, these continua can, and sometimes should, influence one another, and can be manipulated to optimally integrate entrustment within a program of assessment. In this article, the authors describe each of these continua and depict how key alignments between them can help optimize value when using entrustment in programmatic assessment within competency-based medical education. As they think through these continua, the authors will begin and end with a case study to demonstrate the practical application as it might occur in the clinical learning environment.

Exploring how feedback reflects entrustment decisions using artificial intelligence

“…We used a dataset of feedback narratives each paired with an assigned ES level, generated during low‐stakes, high frequency directly observed clinical encounters of clerkship‐year medical students 29 . We first examined whether each feedback narrative contained words or phrases associated with its ES level.…”

“…We used a dataset of feedback narratives each paired with an assigned ES level, generated during low-stakes, high frequency directly observed clinical encounters of clerkship-year medical students. 29 We first examined whether each feedback narrative contained words or phrases associated with its ES level. To do this, we employed a deep neural network (DNN)-a machine language methodology that has been viewed as the most capable of mimicking complex cognition.…”

What do student experiences of programmatic assessment tell us about scoring programmatic assessment data?

“…In this issue of Medical Education, Jackson et al present results of a survey of applicants to a large UK medical school demonstrating structural obstacles faced by SED students in preparing for the medical school application process. 5 The authors found that SED students had less access to clinical shadowing experiences, fee-based courses for admission test preparation, and formal (school-based) interview preparation, all of which were associated with offers of admission to the medical school. This should not be surprising, but of course the obstacles faced by the SED begin long before university; children of affluent parents enjoy both tangible and intangible benefits in a lifelong preparation of a medical school application: private schools, tutors, enrichment experiences, summer camps, travel, application-ready international service experiences and summer research opportunities.…”

“…This has become a common bugbear in health professions assessment. In unpacking entrustment decisions, Kinnear and colleagues highlight how discrepancies can arise in the perceived stakes and purpose of assessments 5 . Even when learners theoretically appreciate the breaking of the formative/summative dichotomy into a continuum of stakes, they cannot seem to shake traditional conceptions that all assessment counts.…”

Entrustable Professional Activities: Reflecting on Where We Are to Define a Path for the Next Decade

“…35,36 In the former article, they note the tension in using assessment data to perform the double duty of providing formative feedback to trainees as well as inform summative decisions about performance. 35 In the latter article, they question whether written comments in assessment should even be asked to serve both purposes, arguing that the lexicon used to help trainees develop is not necessarily the same as that used to report their performance to others. 36 They posit opportunity should be made for both uses.…”