When Do Supervising Physicians Decide to Entrust Residents?
Purpose Patient-care responsibilities stimulate trainee learning but training may compromise patient safety. The authors investigated factors guiding clinical supervisors' decisions to trust residents with critical patient-care tasks.
Method In a mixed quantitative and qualitative descriptive study carried out at University Medical Center Utrecht, Utrecht, the Netherlands, from March to September 2008, the authors surveyed attending anesthetists and resident anesthetists regarding when attendings should entrust each of six selected critical tasks to residents. The authors conducted structured interviews with both groups, using trigger case vignettes to solicit opinions on factors that affect entrustment decisions.
Results Thirty-two attending anesthetists and 31 residents answered the questionnaire (response rate 58%), and 10 participants from each group were interviewed. Attendings varied in their opinions regarding how much independence to give residents, particularly postgraduate year (PGY) 2, 3, and 4 residents. PGY1 residents reported working above their expected level of competence but estimate their own ability as sufficient, whereas PGY5 residents reported working below their expected level of competence. The authors classified factors that determine entrustment into four groups: characteristics of the resident, the attending, the clinical context, and the critical task.
Conclusions Residents' and attendings' opinions and impressions differ regarding what is expected from residents, what residents actually do, and what residents think they can do safely. The authors list factors affecting why and when supervisors trust residents to proceed without supervision. Future studies should address drivers behind entrustment decisions, correlations with patient outcomes, and tools that enable faculty to justify their entrustment decisions.
Deciding when a trainee is ready for unsupervised patient care is not easy. Early unsupervised care can impact the patient's safety, add to the cost of care, and increase liability for the supervisor and/or the organization. In contrast, not enough self-guided and independent decision making may negatively affect the trainee's learning curve and timely achievement of competence. In competency-driven postgraduate medical training, residents must combine learning new and critical materials with taking increasing responsibility for safe patient care. Learning cannot occur without a first time to independently perform procedures and make decisions. One way to approach this dilemma is to instate a number of critical procedure attempts residents must successfully complete before particular competency levels can be assumed. Another approach incorporates qualitative performance feedback, and given residents' different learning curves, this one is perhaps more defensible because supervisors decide to entrust a clinical or procedural responsibility to a resident deliberately and only after careful consideration—rather than automatically after a set amount of time. This crucial decision should be based on the trainee's phase of training, on a valid assessment of his or her competence for the specific task, and on patient acuity. However, a myriad of other factors also affect such decisions, and these are not well understood. To our knowledge, no valid instrument is available to robustly assess, given these varying factors, the level of independence that a trainee deserves.
Carrying out activities that are just at the edge of one's competence can stimulate maximum comprehension and a steep learning curve, but a paucity of studies support this phenomenon in clinical practice. An educational psychology term for doing something that is just beyond the learner's competence, or the gap between what the learner already can do and what he or she is about to learn to do, is "constructive friction." When supervisors entrust learners, including medical trainees, with only routine activities, learning is likely to be too slow or absent. Conversely, too much responsibility required at too early a stage may result in adverse effects for—in the case of medicine—both the patient and the trainee. Educational psychologists have labeled both of these situations "destructive friction."
Ten Cate introduced the concept of "entrustable professional activity" (EPA) to signify the professional tasks that medical trainees need to master during postgraduate training that require entrustment decisions by clinical supervisors. EPAs are useful units of analysis for establishing a competency-based curriculum. Ten Cate and Scheele used EPAs to define five levels of responsibility and proficiency (i.e., having limited knowledge, acting under close supervision, acting under supervision on call, acting independently, and supervising others). They postulated four groups of factors that may influence decisions regarding whether or when a trainee is ready to execute a critical activity independently (Figure 1). The first factor group focuses on the ability of the trainee. The second group, which can be especially hard to measure, includes factors relating to the personality of the supervisor. The third factor group encompasses the environment and circumstances (e.g., the time of day, facilities, and personnel present) in which the activities are executed. Finally, the fourth factor group entails the nature and complexity of the activity. The activity becomes more complex as several competencies are required in concert for successful and safe execution. Recently, a focus-group study conducted in a Dutch obstetrics–gynecology postgraduate training program confirmed the validity of these four factor groups. Three of these groups of factors (i.e., those pertaining to the trainee, the supervisor, and the clinical issue) align with a recent study of Kennedy and colleagues, which highlighted the drivers that encourage trainees to request clinical support. Clearly, none of these four factor groups act independently, but they do represent discrete and measurable constructs.
(Enlarge Image)
Figure 1.
Factors that determine whether attendings entrust residents with critical patient-care activities within the clinical learning environment.
We interviewed trainers and trainees, exploring when, and under which constraints, attending anesthetists entrust critical activities to anesthesia residents. We chose anesthesiology because this specialty contains many tangible entrustment decisions. Anesthesiology postgraduate training in the Netherlands is currently transitioning to new standard requirements, which derive from the CanMEDS competency model and are comparable to the six Accreditation Council on Graduate Medical Education competencies.
Abstract and Introduction
Abstract
Purpose Patient-care responsibilities stimulate trainee learning but training may compromise patient safety. The authors investigated factors guiding clinical supervisors' decisions to trust residents with critical patient-care tasks.
Method In a mixed quantitative and qualitative descriptive study carried out at University Medical Center Utrecht, Utrecht, the Netherlands, from March to September 2008, the authors surveyed attending anesthetists and resident anesthetists regarding when attendings should entrust each of six selected critical tasks to residents. The authors conducted structured interviews with both groups, using trigger case vignettes to solicit opinions on factors that affect entrustment decisions.
Results Thirty-two attending anesthetists and 31 residents answered the questionnaire (response rate 58%), and 10 participants from each group were interviewed. Attendings varied in their opinions regarding how much independence to give residents, particularly postgraduate year (PGY) 2, 3, and 4 residents. PGY1 residents reported working above their expected level of competence but estimate their own ability as sufficient, whereas PGY5 residents reported working below their expected level of competence. The authors classified factors that determine entrustment into four groups: characteristics of the resident, the attending, the clinical context, and the critical task.
Conclusions Residents' and attendings' opinions and impressions differ regarding what is expected from residents, what residents actually do, and what residents think they can do safely. The authors list factors affecting why and when supervisors trust residents to proceed without supervision. Future studies should address drivers behind entrustment decisions, correlations with patient outcomes, and tools that enable faculty to justify their entrustment decisions.
Introduction
Deciding when a trainee is ready for unsupervised patient care is not easy. Early unsupervised care can impact the patient's safety, add to the cost of care, and increase liability for the supervisor and/or the organization. In contrast, not enough self-guided and independent decision making may negatively affect the trainee's learning curve and timely achievement of competence. In competency-driven postgraduate medical training, residents must combine learning new and critical materials with taking increasing responsibility for safe patient care. Learning cannot occur without a first time to independently perform procedures and make decisions. One way to approach this dilemma is to instate a number of critical procedure attempts residents must successfully complete before particular competency levels can be assumed. Another approach incorporates qualitative performance feedback, and given residents' different learning curves, this one is perhaps more defensible because supervisors decide to entrust a clinical or procedural responsibility to a resident deliberately and only after careful consideration—rather than automatically after a set amount of time. This crucial decision should be based on the trainee's phase of training, on a valid assessment of his or her competence for the specific task, and on patient acuity. However, a myriad of other factors also affect such decisions, and these are not well understood. To our knowledge, no valid instrument is available to robustly assess, given these varying factors, the level of independence that a trainee deserves.
Carrying out activities that are just at the edge of one's competence can stimulate maximum comprehension and a steep learning curve, but a paucity of studies support this phenomenon in clinical practice. An educational psychology term for doing something that is just beyond the learner's competence, or the gap between what the learner already can do and what he or she is about to learn to do, is "constructive friction." When supervisors entrust learners, including medical trainees, with only routine activities, learning is likely to be too slow or absent. Conversely, too much responsibility required at too early a stage may result in adverse effects for—in the case of medicine—both the patient and the trainee. Educational psychologists have labeled both of these situations "destructive friction."
Ten Cate introduced the concept of "entrustable professional activity" (EPA) to signify the professional tasks that medical trainees need to master during postgraduate training that require entrustment decisions by clinical supervisors. EPAs are useful units of analysis for establishing a competency-based curriculum. Ten Cate and Scheele used EPAs to define five levels of responsibility and proficiency (i.e., having limited knowledge, acting under close supervision, acting under supervision on call, acting independently, and supervising others). They postulated four groups of factors that may influence decisions regarding whether or when a trainee is ready to execute a critical activity independently (Figure 1). The first factor group focuses on the ability of the trainee. The second group, which can be especially hard to measure, includes factors relating to the personality of the supervisor. The third factor group encompasses the environment and circumstances (e.g., the time of day, facilities, and personnel present) in which the activities are executed. Finally, the fourth factor group entails the nature and complexity of the activity. The activity becomes more complex as several competencies are required in concert for successful and safe execution. Recently, a focus-group study conducted in a Dutch obstetrics–gynecology postgraduate training program confirmed the validity of these four factor groups. Three of these groups of factors (i.e., those pertaining to the trainee, the supervisor, and the clinical issue) align with a recent study of Kennedy and colleagues, which highlighted the drivers that encourage trainees to request clinical support. Clearly, none of these four factor groups act independently, but they do represent discrete and measurable constructs.
(Enlarge Image)
Figure 1.
Factors that determine whether attendings entrust residents with critical patient-care activities within the clinical learning environment.
We interviewed trainers and trainees, exploring when, and under which constraints, attending anesthetists entrust critical activities to anesthesia residents. We chose anesthesiology because this specialty contains many tangible entrustment decisions. Anesthesiology postgraduate training in the Netherlands is currently transitioning to new standard requirements, which derive from the CanMEDS competency model and are comparable to the six Accreditation Council on Graduate Medical Education competencies.
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