Making prospective entrustment decisions: Knowing limits, seeking help and defaulting

Abstract

Introduction Many studies focused on entrustment have not considered prospective entrustment decisions, where clinical competency and entrustment committees determine how much supervision trainees will require in the future for tasks occurring in not completely known contexts. The authors sought to explore factors that influence and determine prospective entrustment decisions made by members of such committees in graduate medical education (GME) and undergraduate medical education (UME). Methods The authors conducted a constructivist grounded theory study with 23 faculty participants from GME and UME clinical competency and entrustment committees in the United States between October 2020 and March 2021. Interviews sought to explore factors and considerations participants weigh in making prospective entrustment decisions about trainees. Data collection and analysis occurred in an iterative fashion, ensuring constant comparison. Theoretical sampling was used to confirm, disconfirm and elaborate on the evolving results. Results Trainees' ability to know limits and seek help is the foundation of participants' prospective entrustment decision making. Most participants, however, describe a presumption of trainee readiness to progress and describe commonly making default prospective entrustment decisions unless ‘red flags’ in performance are present. Although participants desire sufficient and trusted data about trainee performance to inform decisions, they often lack it. Finally, the perceived permanence and consequences of prospective entrustment decisions influence how participants weigh other factors contributing to prospective entrustment decisions. Conclusion Trainees' ability to know limits and seek help appears to be the foundation of prospective entrustment decision making. Training programmes should strive to collect and employ robust data supporting and questioning the presence of these attributes.

Comparing Entrustment Decision-Making Outcomes of the Core Entrustable Professional Activities Pilot, 2019-2020

“…Our findings highlight substantial challenges in making prospective determinations about readiness of graduating medical students for indirect supervision in the Core EPAs framework at the scale of entire medical school classes. 7,8,33,45 Results also suggest important gaps in readiness for a subset of Core EPAs (ie, EPAs 4, 8, 10, 11, and 13). 45 Among next steps suggested by these results are improvement in curriculum and assessment specific to these EPAs at participating schools; further improvements in systems for programmatic assessment and data curation; and consideration of revision of what are considered Core EPAs on a specialty-specific basis for incoming interns.…”

Optimising prospective entrustment: Defaulting on default progression

“…Email: jacob.pearce@acer.org Roberts and colleagues' critical realist analysis of student perspectives on programmatic assessment adds to an important and growing body of research. [1][2][3][4] They find that the requirement to balance "the complex relationship between learner agency, assessment structures and the DOI: 10.1111/medu.14852…”

“…In the article, Making Prospective Entrustment Decisions: Knowing Limits, Seeking Help, and Defaulting , Schumacher et al 3 paint a concerning picture of clinical competency committees (CCCs) which have inadequate data and default to progress trainees (prospective entrustment) in the absence of red flags. The authors effectively highlight the resultant threat to patient safety in the graduation of trainees who may not have the requisite competencies to prospectively entrust independent practice.…”

“…We must seek to either revise or remove elements of our programs of assessment that are not providing useful data and ask what elements are the most contributory to effective decisions and coaching feedback. Schumacher et al 3 have identified elements which help identify a trainee's ability to know limits and seek help as foundational. Other studies have identified value in narrative over numeric assessment data 12 and the importance of having tools which focus on both the trees (e.g.…”

“…In the article, Making Prospective Entrustment Decisions: Knowing Limits, Seeking Help, and Defaulting, Schumacher et al 3 This slide backwards in CCC decision-making is a major threat to the fidelity of implementation of CBME overall and its resultant success as an educational change intervention. CCC progression decisions, the act of prospective entrustment, is arguably the most critical element in a competency-based training program.…”