Use of graded responsibility and common entrustment considerations among United States emergency medicine residency programs

Abstract

Purpose: The Accreditation Council for Graduate Medical Education (ACGME) requires all residency programs to provide increasing autonomy as residents progress through training, known as graded responsibility. However, there is little guidance on how to implement graded responsibility in practice and a paucity of literature on how it is currently implemented in emergency medicine (EM). We sought to determine how EM residency programs apply graded responsibility across a variety of activities and to identify which considerations are important in affording additional responsibilities to trainees.Methods: We conducted a cross-sectional study of EM residency programs using a 23-question survey that was distributed by email to 162 ACGME-accredited EM program directors. Seven different domains of practice were queried.Results: We received 91 responses (56.2% response rate) to the survey. Among all domains of practice except for managing critically ill medical patients, the use of graded responsibility exceeded 50% of surveyed programs. When graded responsibility was applied, post-graduate year (PGY) level was ranked an “extremely important” or “very important” consideration between 80.9% and 100.0% of the time.Conclusion: The majority of EM residency programs are implementing graded responsibility within most domains of practice. When decisions are made surrounding graded responsibility, programs still rely heavily on the time-based model of PGY level to determine advancement.

Guiding Fellows to Independent Practice

“…In the absence of—or even despite—validated checklists and faculty development, varied understanding and interpretation of the ACGME definitions of direct and indirect supervision can also affect entrustment ratings of fellows. Regardless of increased emphasis on competency-based metrics to guide entrustment and advancement of procedural independence, some faculty still determined the ability of EM residents to perform critical care procedures by year of training in one study, although competency and barriers to resident autonomy were not described 11 . Resident-sensitive quality measures in specific illnesses were used to examine pediatric resident entrustment decisions at a large children's hospital and have yet to be investigated at the fellowship level 12 …”

“…Regardless of increased emphasis on competency-based metrics to guide entrustment and advancement of procedural independence, some faculty still determined the ability of EM residents to perform critical care procedures by year of training in one study, although competency and barriers to resident autonomy were not described. 11 Resident-sensitive quality measures in specific illnesses were used to examine pediatric resident entrustment decisions at a large children's hospital and have yet to be investigated at the fellowship level. 12 We believe that these areas of progressive clinical autonomy deserve further study and must include PEM fellows' attitudes toward specific levels of supervision.…”

“…There is already strong evidence for assignment of supervision levels via PD and clinical competency committee assessments of clinical performance. 11 Simulation education provides learners with additional experiences in rare procedures, resuscitation leadership, team work, and communication skills, with less direct supervision. As the overall number of critically ill children who require resuscitation and procedures is relatively low, the use of simulation for procedural and resuscitation leadership competency in fellowship may add additional perspectives toward a fellows' need for supervision when allowed to practice more independently.…”

“…Bidirectional feedback between fellows and faculty on expectations, skill level and autonomy bear some promise, along with the milestones and the opportunity to use entrustable professional activities to guide fellow responsibilities. There is already strong evidence for assignment of supervision levels via PD and clinical competency committee assessments of clinical performance 11 . Simulation education provides learners with additional experiences in rare procedures, resuscitation leadership, team work, and communication skills, with less direct supervision.…”