Tensions in Assessment: The Realities of Entrustment in Internal Medicine

Abstract

Purpose A key unit of assessment in competency-based medical education (CBME) is the entrustable professional activity. The variations in how entrustment is perceived and enacted across specialties are not well understood. This study aimed to develop a thorough understanding of the process, concept, and language of entrustment as it pertains to internal medicine (IM). Method Attending supervisors of IM trainees on the clinical teaching unit were purposively sampled. Sixteen semistructured interviews were conducted and analyzed using constructivist grounded theory. The study was conducted at the University of Toronto from January to September 2018. Results Five major themes were elucidated. First, the concepts of entrustment, trust, and competence are not easily distinguished and sometimes conflated. Second, entrustment decisions are not made by attendings, but rather are often automatic and predetermined by program or trainee level. Third, entrustment is not a discrete, point-in-time assessment due to longitudinality of tasks and supervisor relationships with trainees. Fourth, entrustment scale language does not reflect attendings’ decision making. Fifth, entrustment decisions affect the attending more than the resident. Conclusions A tension arises between the need for a common language of CBME and the need for authentic representation of supervision within each specialty. With new assessment instruments required to operationalize the tenets of CBME, it becomes critically important to understand the nuanced and specialty-specific language of entrustment to ensure validity of assessments.

Exploring how feedback reflects entrustment decisions using artificial intelligence

“…Ideally, supervisors make entrustment decisions that grant a trainee an appropriate degree of independence to match their level of competence 3 . Yet, as educators apply the framework of entrustment, evidence of how entrustment‐based assessment provides trainees' guidance for achieving educational goals remains less clear 4–7 . Supervisors' feedback from entrustment‐granting clinical encounters may provide trainees with guidance on how to achieve higher entrustment, which may, in turn, capture trainees' learning needs.…”

“…3 Yet, as educators apply the framework of entrustment, evidence of how entrustment-based assessment provides trainees' guidance for achieving educational goals remains less clear. [4][5][6][7] Supervisors' feedback from entrustment-granting clinical encounters may provide trainees with guidance on how to achieve higher entrustment, which may, in turn, capture trainees' learning needs. This interaction between supervisors' entrustment decisions and trainees' learning needs has yet to be demonstrated empirically.…”

Reframing the O-SCORE as a Retrospective Supervision Scale Using Validity Theory

“…Indeed, the use of entrustability scales in practice has been met with confusion, concern, and criticism. 4 Since then, ten Cate et al and others have suggested a number of refinements and corrections, including the need to disentangle ''retrospective'' and ''prospective'' assessments. [5][6][7] In this Perspectives article we pick up on this distinction between retrospective and prospective assessment using assessment validity as our framework and the O-SCORE as our example.…”

Exploring resident perceptions of initial competency based medical education implementation

“…A recent study by Melvin et al focusing on the tension and realities of entrustment suggested that it was important to understand the complexity and specialty-specific language of entrustment in order to provide effective assessments to learners. 35 Residents' perceptions that anything less than the highest rating was a "wasted EPA observation" highlighted an interesting disconnect around the programmatic assessment aspect of the core components framework. This highlights residents' perceptions that EPA assessments are solely a type of summative assessment, rather than having a largely formative purpose as they were intended, which has been echoed by other residents as well.…”