Five themes emerged consistently throughout the interviews. One involved the relationship between, on one hand, the EPAs that residents actually performed and, on the other, the residents' and attendings' views of residents' ability to competently perform those EPAs. The other four themes aligned with the predefined groups of factors affecting entrustment (factors related to the resident, to the attending, to the clinical context, and to the task itself).
Working, related to supposed level of ability.
Residents were comfortable with the training program's expectations. They did not think that executing activities with more supervision than they thought they needed hampered their learning, but they usually did not perceive performing above their expected level of competence as uncomfortable or unsafe either.
Yes, it happens sometimes that I receive supervision on activities I have done by myself many times before. Your supervisor is your trainer and assessor, so I understand. Also, they can give you pointers on how to improve your skills. (Resident, PGY1)
I think it is a good thing that supervisors watch you perform occasionally. You might think you are doing fine, and that you do not need any supervision any more, but that might just be the point where you start making mistakes. (Resident, PGY4)
Yes, sometimes I do perform activities on a higher level, but since there is always supervision around, these are opportunities for me to grow. (Resident, PGY4)
You learn to work independently, especially in the second year of training [done in community hospital]. When I do not feel competent, when I do not trust myself, I just tell my boss I need help. When you ask for supervision, you always receive it. (Resident PGY4)
Factors affecting entrustment.
As mentioned, we were able to place all factors (that, according to our 20 interviewees, determine the amount of trust that supervisors have in their trainees) within the four groups we hypothesized were important. Table 2 gives an overview of the 30 factors that faculty and residents identified during the interviews.
A. Factors in the trainee. Both residents and faculty stated that the attendings' mere acquaintance with the trainee and his or her level of training were important for making decisions to trust residents with EPAs. In fact, attendings' acquaintance with the resident was mentioned in 19 of the 20 interviews. We calculated, on average, 3.55 comments regarding this factor per interview—more than for any other topic, except “working proficiency” (three interviewees repeatedly mentioned clinical skills as a core factor, but only one of the residents mentioned this, and then only twice). Knowing the resident does not necessarily mean that a faculty member will always trust him or her, and recent experiences with residents weigh heavily in faculty's entrustment decisions.
If I have worked several times with the same resident, I am better able to determine the level of competence of that resident and whether he is capable enough to execute activities. (Faculty, intermediate level)
I call my supervisor and tell him I think I can handle the case, but if he has never seen me work … I think that makes it hard for him to determine whether or not he can trust me. (Resident, PGY1)
Faculty also consider the quality and comprehensiveness of the trainee's plan to be important. This consideration includes an estimation of the trainee's preparation and insight into potential patient complications that may occur in choosing one clinical plan over another plan.
When a resident consults me, I value the quality of his plan highly when making a decision in the amount of trust I give. Having little to add to his plan gives me confidence that he can handle the case. (Faculty, intermediate level)
I think it is important for my supervisors to hear me present the case in an orderly and complete way, which shows them I know what I am doing. (Resident, PGY4)
For faculty, competence is not entirely dependent on the year of training. Interviewees acknowledged learning curve differences among residents.
Residents' competencies can differ within their year of training, especially in the first year of training. When a resident has worked at an intensive care unit prior to starting residency training I tend to put more trust in him than if he would have started residency training straight after medical school. Also, some residents evolve faster while others need more time to master skills. (Faculty, intermediate level)
In general, faculty assume more independence in senior residents, as these residents are supposed to be ready to graduate soon and become certified specialists. For junior residents, attendings state that the clinical experience, such as managing acute care patients prior to residency, is important.
If a first-year resident has already worked at an ICU for two years, I will probably let him execute activities, such as arterial line access, more independently than a first-year resident who entered the program straight after medical school. (Faculty, intermediate level)
If residents state that they do not feel confident, they generally receive supervision, whether or not a faculty member trusts a resident to execute an activity.
When a resident asks me to assist him, I will, even if I do not think it is really necessary. (Faculty, senior level)
Sometimes, your supervisor will ask you if you want him to come; when you admit you do, there is never any discussion, he will come, no questions asked. (Resident, PGY4)
Attendings consider whether a resident is aware of his or her limitations to be very important.
This resident performs well, but I sometimes have trouble assessing what I can trust him to do. He does not seem to know when he needs to call for help. (Faculty, intermediate level)
I think it is important that my supervisor can trust that I will call before I get into trouble. (Resident, PGY4)
The supervisor's knowledge of the trainee's clinical skills and working manners is also important.
This resident is very skilled and knows what he is doing. (Faculty, senior level)
Clearly, supervisors' knowledge of the resident's competencies and attitudes weighs on their judgment. We have the impression that the mere lack of acquaintance leads to fewer independent responsibilities and more scrutiny and that, conversely, the mere fact that the supervisor knows the resident generally leads to more readily granted responsibilities.
B. Factors in the supervisor. All residents mentioned that characteristics of the supervisor, such as their general experience and specific expertise, can affect entrustment decisions.
There are differences among supervisors; I think it has to do with their experience. For example, a more senior boss has more experience in assessing residents and will have fewer problems letting a resident perform certain tasks independently than would a junior supervisor. (Resident, PGY1)
I think a supervisor who has recently lost a patient in a similar case will just come, if only for his own confidence. (Resident, PGY4)
I made a deal with him: “You can watch or try once, and you have to tell me what you see.” He failed to do both. I had poor judgment; it was misplaced trust on my side. That situation had its effect later on. A week later, he again was my junior resident, and thinking back, I believe I did not let him do as much as I would normally have allowed him to do. (Resident, PGY5)
Attendings stated that whether or not they actually oversee a procedure is not always balanced against trusting the resident, but it also depends on the responsibility they feel for both the patient and the residents they train.
You just have to be there for your resident, even though you know he can probably handle the case just fine. (Faculty, intermediate level)
As a supervisor, you are responsible for what goes on in your practice. (Faculty, intermediate level)
The amount of trust can be influenced by the attitude of the supervisors toward clinical training.
It is necessary for a resident's confidence to perform on his own sometimes. I usually peek through the OR window to make sure he is doing well, so I'm there without the resident realizing I am. (Faculty, senior level)
C. Circumstances. Attendings state that entrustment decisions also depend on the clinical environment, including the quality and availability of the team surrounding the resident.
It is also important whether or not my resident gets enough support from other team members. (Faculty, senior level)
It makes a difference whether the junior who is with me on call is in his first or in his third year; faculty members know that. (Resident, PGY5)
After 11 pm, an attending can take call either at home or in the hospital. Decisions on whether or not to entrust residents with clinical tasks are affected by the attendings' whereabouts.
It depends on where I am. In this particular situation, if I am at home I will come to the hospital. If I am already here, I would tell my resident to call me when he needs me. (Faculty, junior level)
I live too far away to go home when I am on call. And since I am already here … it's easy to just be there and see how my resident is doing. (Faculty, junior level)
It makes a difference where my supervisor is. If he is at home, he will have to decide if he can trust me to perform on my own, whether or not it is necessary to postpone execution of activities for 15 minutes or so. If he is here already … it's easier, he will be here whether it is really necessary or not. (Resident, PGY4)
Residents also stated that the time of day and mere convenience can each be a factor in the amount of trust that an attending places in them.
This may sound strange, but also the time of day…. It can make a difference when you call your supervisor at 11 pm, when he is still awake and alert, or in the middle of the night. When you wake him, I think sometimes he might be less eager to come. (Resident, PGY4)
It's contradictory sometimes. For example, during the day, you receive full supervision on a spinal needle placement on an ASA 2 patient who comes in for an ACL reconstruction, and in the middle of the night I find myself managing an ASA 3 patient without supervision. (Resident, PGY4)
D. Type of activity. Both faculty and residents stated that the condition of the patient, the team, and discrete steps of the EPA are important in entrusting decisions.
For such a complicated case I will just come, the risks are too high. (Faculty, intermediate level)
I think the most important [thing] for my boss is the case, how the patient is doing. (Resident, PGY4)
We explored when and why attending anesthesia specialists decide to trust residents to execute critical patient-care tasks. Residents' and attendings' expectations differ with regard to what is expected from residents, what residents actually do, and what residents think they can do safely.
Attendings generally agree more on the levels of responsibility residents should have at the beginning and end of training than in their views about how much responsibility residents should have in the intervening years (PGY2–4). One surveyed faculty member would not fully entrust any resident with any EPA at any stage. It is tempting to speculate on the reasons for these differences among faculty, but any suggestions would need further analysis. Our impression is that overbearing attendings may lead residents to be more hesitant, resulting in attendings trusting residents less, whereas open and engaging attendings likely give the resident space to grow and think, resulting in greater trust. More in-depth studies are needed to substantiate this speculation.
Residents, especially trainees in PGY1, 2, and 3, estimate their own abilities higher than attendings consider justified. Interestingly, PGY1 residents reported that, in the last three months, they had been assigned responsibilities beyond the level that attendings on average indicate as justified for this stage. The residents themselves see few problems with this situation, as they also perceive their abilities to usually meet or exceed those necessary to perform these assignments. To determine whether residents overestimate their abilities or not is difficult. Successfully and independently executing a critical activity that exceeds one's expected ability, if no complications occur, may boost residents' self-efficacy.18 Self-confidence is needed to stimulate further development, and it may be natural, even educationally necessary, for trainees to overestimate their ability somewhat. However, the supervisor's judgment to limit independent execution of EPAs is critical if a trainee's overconfidence may compromise patient safety (e.g., when airway intubations take longer than they should, thoracic epidurals overshoot the epidural space, or central lines require several needle punctures).
We found substantial differences among surveyed attendings' views of which activities residents should be able to handle across varying stages of training. Factors related to individual residents, the clinical circumstances, or the nature of the EPA affect differences across EPAs, but factors related to the supervisor seem especially important for individual EPAs (Figure 2). This greater importance could reflect the supervisor's estimation of the difficulty or complexity of the EPAs and his or her estimation of the risk to patients.
Through the interviews, we identified 30 factors that influence entrustment decisions. All of these factors fit within the four categories we defined in an earlier study13: factors related to the resident, supervisor, clinical circumstances, and patient-care task. Given the expected levels of proficiency at different stages of training, the multitude of factors involved helps explain the differences among the attendings' entrustment decisions.
The appropriate amount of trust attendings should place in a resident in a particular year of training cannot be determined in a generalized sense but must be individually customized to the trainee. In fact, supervisors must judge the interplay of factors related to the (1) resident, (2) the EPA, and (3) the clinical circumstances, including the facilities and the available clinical support of the microsystem.19,20 Table 2 may therefore serve as a first step in developing an entrustment decision support model and checklist. Sufficient acquaintance with the resident, the resident's stage of training, the availability of other personnel, the difficulty of the task, the risk of complications, and the condition of the patient all seem important. These factors may appear self-evident; however, they presently create much ambivalence and anxiety among faculty, and not understanding these factors and their interplay could potentially lead to much ambiguity and patient harm. For example, the finding that the quality of patient care is inadvertently compromised during the time of the year when more inexperienced residents are employed in hospitals allows hospital leaders to act on that information.21
We suggest that these factors may be operationalized in a robust manner and give faculty the tools to make better decisions when faced with deciding whether to entrust residents with clinical activities.
We recognize several limitations to the study. We confined our study to a single Dutch anesthesia training program, and thus our findings need to be replicated in other clinical settings to determine external generalizability. Further, qualitative studies involving interviews bear an inherent risk of subjectivity because the interviewer can influence the nature of the interview, and other researchers may find different themes. To minimize these risks, we structured our interviews with a carefully scripted interview guide, and we identified relevant factors using factor analysis and theme saturation. We assessed only six EPAs, and assessing other clinical domains might yield additional factors, but these would most likely overlap with the factors we identified above.
To our knowledge, this is the first time a study has assessed the opinions of individual faculty and trainees on entrustment decisions. Dijksterhuis and colleagues14 conducted a related, focus-group study among obstetrics–gynecology faculty and trainees, but our study yields factors on a more detailed, generalizable, and actionable level. Dijksterhuis and colleagues make a conceptual distinction between levels of competence and degrees of independence, whereas we consider the level of competence a measure of the trainee. In another study of internists and emergency medicine physicians, Kennedy and colleagues15 used a similar methodology but from a different angle. Their questions was not, “When do supervisors entrust responsibility?” but, rather, “When do trainees ask for help?” They found that factors in the resident, factors in the supervisor, and the nature of the clinical question (i.e., those related to the EPA) determine the requests. Requesting help from an attending and deciding to trust a resident are intimately related, and we feel the Kennedy and colleagues' study supports our findings. In another recent qualitative study, Ginsburg and colleagues22 interviewed 19 experienced internal medicine attendings on qualities of outstanding, average, and problematic residents. They came up with eight clusters of factors, based on a grounded theory approach, that are similar to our findings (Table 2, “Factors in the trainee”), but they also uncovered additional resident qualities, such as work ethic, leadership skills, and impact on staff. These factors do not overlap with ours but, rather, seem to supplement them. This indicates that further studies will be helpful to complete the picture of factors that affect decisions to entrust critical care to trainees.
Finally, we hope this study will help to improve postgraduate training. The study's findings fit into the competency-based postgraduate training models that have emerged in recent years.2,13,20,23–25 Construct assessments that address both trainee competence and patient safety are necessary. Current methods of assessing clinical competence, which use duration of training as a major criterion, may not be sufficient. Assessments should include both measuring the amount of trust attendings place in residents and understanding why they do so. Understanding entrustment decisions and including them in assessing and promoting trainees will lead to physicians who are competent, safe, and trustworthy.6,24
Future studies might include a more in-depth analysis of the mechanisms that determine supervisors' decisions to entrust residents with patient-care tasks. These studies might aim to validly measure these decisions or to understand whether and how entrustment decisions can play an important part in assessing trainees. If entrustment decisions can be better validated, they may lead to more formalized statements of awarded responsibility that could be included as milestones in a trainee's competency portfolio.13,26 Such an advance could accelerate the development of a competency-based training program. These programs support patient and provider educational outcomes, and they are more influenced by the quality of care and the providers' actions than the mere educational content or duration of the training program.
This study was exempt from ethical approval by the ethical review board of the University Medical Center Utrecht, Utrecht, the Netherlands (See also “Method / Ethical considerations,” above).
Conflicts of interest:
Some of the results of this study were orally presented at the 2009 meeting of the Association for Medical Education in Europe (Malaga, Spain) and the 2009 Annual Meeting of the American Society of Anesthesiologists (New Orleans, Louisiana).
1AAMC policy guidance on graduate medical education: Assuring quality patient care and quality education. Acad Med. 2003;78:112–116.
2Leung WC. Competency based medical training: Review. BMJ. 2002;325:693–696.
3Konrad C, Schüpfer G, Wietlisbach M, Gerber H. Learning manual skills in anesthesiology: Is there a recommended number of cases for anesthetic procedures? Anesth Analg. 1998;86:635–639.
4de Oliveira Filho GR. The construction of learning curves for basic skills in anesthetic procedures: An application for the cumulative sum method. Anesth Analg. 2002;95:411–416.
5Sites BD, Gallagher JD, Cravero J, Lundberg J, Blike G. The learning curve associated with a simulated ultrasound-guided interventional task by inexperienced anesthesia residents. Reg Anesth Pain Med. 2004;29:544–548.
6Ten Cate O. Trust, competence and the supervisor's role in postgraduate training. BMJ. 2006;333:748–751.
7Vygotsky LS. Chapter 6: Interaction between learning and development. In: Cole M, John-Steiner V, Scribner S, Souberman E, eds. Mind in Society: The Development of Higher Psychological Processes. Cambridge, Mass: Harvard University Press; 1978:79–91.
8Cantillon P, Macdermott M. Does responsibility drive learning? Lessons from intern rotations in general practice. Med Teach. 2008;30:254–259.
9Kennedy TJ, Regehr G, Baker GR, Lingard LA. Progressive independence in clinical training: A tradition worth defending? Acad Med. 2005;80(10 suppl):S106–S111.
10Vermunt JD, Verloop N. Congruence and friction between learning and teaching. Learn Instr. 1999;9:257–280.
11Ten Cate O, Snell L, Mann K, Vermunt J. Orienting teaching toward the learning process. Acad Med. 2004;79:219–228.
12Ten Cate O. Entrustability of professional activities and competency-based training. Med Educ. 2005;39:1176–1177.
13Ten Cate O, Scheele F. Competency-based postgraduate training: Can we bridge the gap between theory and clinical practice? Acad Med. 2007;82:542–547.
14Dijksterhuis MG, Voorhuis M, Teunissen PW, et al. The assessment of competence and progressive independence in postgraduate clinical training. Med Educ. 2009;43:1156–1165.
15Kennedy T, Regehr G, Baker GR, Lingard L. Preserving professional credibility: Grounded theory study of medical trainees' requests for clinical support. BMJ. 2009;338:b128.
16Scheele F, Teunissen P, Van Luijk S, et al. Introducing competency-based postgraduate medical education in the Netherlands. Med Teach. 2008;30:248–253.
18Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice-Hall; 1986.
19Mohr J, Batalden P, Barach P. Integrating patient safety into the clinical microsystem. Qual Saf Health Care. 2004;13(suppl 2):ii34–ii38.
20Long DM. Competency-based residency training: The next advance in graduate medical education. Acad Med. 2000;75:1178–1183.
21Haller G, Myles PS, Taffé P, Perneger TV, Wu CL. Rate of undesirable events at beginning of academic year: Retrospective cohort study. BMJ. 2009;339:b3974.
22Ginsburg S, McIlroy J, Oulanova O, Eva K, Regehr G. Toward authentic clinical evaluation: Pitfalls in the pursuit of competency. Acad Med. 2010; 85:788–786.
23Ten Cate O, Snell L, Carraccio C. Medical competence: The interplay between individual ability and the health care environment. Med Teach. In press.
24Carraccio C, Wolfsthal SD, Englander R, Ferentz K, Martin C. Shifting paradigms: From Flexner to competencies. Acad Med. 2002;77:361–367.
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25Carraccio CL, Benson BJ, Nixon LJ, Derstine PL. From the educational bench to the clinical bedside: Translating the Dreyfus developmental model to the learning of clinical skills. Acad Med. 2008;83:761–767.