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Trust Is a Two-Way Street

Sklar, David P., MD

doi: 10.1097/ACM.0000000000001046
From the Editor
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Editor’s Note: The opinions expressed in this editorial do not necessarily reflect the opinions of the AAMC or its members.

As I prepared for an upcoming shift in the critical care wing of our emergency department, I checked to see which resident was assigned to work with me. I did this partly out of curiosity and partly to help me adjust my approach, based upon my experience with the resident. In this case, I noticed that the resident was Tom, a senior resident, who had recently presented a challenging case at our morbidity and mortality conference (M&M). (Identifying details here and later have been changed.) Tom reported that four young patients had arrived simultaneously in critical condition from a car crash. His patient arrived in cardiac arrest and, despite prolonged resuscitative efforts, died.

The focus of the presentation and discussion that followed concerned problems with communication between the faculty attending and the resident (Tom) during the cardiac arrest. Tom felt uncomfortable stopping the resuscitation without an order from the faculty attending, who, however, was too busy with the other patients to give advice to Tom. In the presentation I sensed that Tom had felt abandoned as he struggled to make the difficult decision about ending the resuscitation. While I sympathized with the faculty member, who was attempting to care for multiple critically injured patients and coordinate the consultants, I also understood Tom’s perspective. As I recalled this M&M presentation, I decided that I would need to be particularly sensitive if we had any patients who were experiencing a cardiac arrest or near-arrest on our upcoming shift.

We began our shift with a mix of ill and injured patients—two young men stabbed in the chest during a fight, a middle-aged woman in septic shock, and an elderly woman with a stroke. Everything went smoothly, and Tom and I seemed to have established a comfortable working relationship.

Then we had a patient with cardiac arrest. The patient arrived suddenly, without warning, a man who had been sent to X-ray and returned to his bed not breathing and in cardiac arrest. The team of doctors and nurses who had been caring for the man informed us that he had been talking moments before going to X-ray. They accompanied him into the resuscitation area and watched as we performed CPR and gave medications to stimulate his heart. Tom took charge and I watched from a few feet away as he directed the nurses, students, respiratory therapists, and other physicians in a carefully orchestrated resuscitation effort. When after a half hour it was apparent that the patient was not going to survive, I suggested to Tom that we stop the resuscitation, and he agreed. I went to talk to the family in the waiting area, while Tom and the others took a breather, tried to figure out what had happened, filled out paperwork, and struggled to compose themselves for their other patients.

When I returned, I complimented Tom on his leadership and his excellent performance of numerous procedures. He seemed satisfied and even energized by his role in managing the arrest, and we had a good discussion about what might have led to the unfortunate event. I made a mental note that I would specifically comment upon this case when I filled out Tom’s evaluation.

The shift was winding down when an ambulance delivered a woman who described an episode of coughing and vomiting blood. She had previously had ulcers and was currently taking anti-inflammatory medications for arthritis. The connection between these two pieces of her medical history suggested a recurrent ulcer, although she had never experienced bleeding from her ulcer before and was not in any pain. All of her vital signs—her breathing, pulse, blood pressure, temperature—were normal, and Tom and I suspected that the bleeding had stopped and would not cause her further problems. I began typing some notes as Tom continued his exam. That was when I heard the woman retching, gasping, and vomiting. I turned away from the computer to observe blood pouring from the woman’s mouth. The blood flow was so rapid and intense that she could not breathe. In a matter of seconds she was in cardiac arrest and we began CPR. Tom looked at me helplessly as he began to direct the resuscitation.

“Tom, I will run this one,” I said, “and you try and get an airway. That’s what I think she needs most right now. It may not be possible to intubate her due to the blood pouring out, but try to suction out what you can and do your best to establish an airway.”

Tom nodded his agreement. I directed the nurses and another resident, who had come to help, to administer blood and a variety of medications as we continued CPR. We stopped for a few seconds to allow Tom to suction and attempt to intubate the patient. He suctioned out blood clots and struggled to see the epiglottis as blood covered his laryngoscope bulb. After a few more seconds of suctioning he announced a tentative success. He had placed the tube in the trachea and we began to administer oxygen. The patient soon had a pulse and blood pressure and we stopped CPR. We were all still shaken from the sudden turn of events and the horror of all the blood on the floor and stretcher. But our patient was alive. The ICU team arrived, observed the situation for a moment, and quickly transported the patient to their unit.

Later as I reviewed the night with Tom, I asked him how he felt. “Those cardiac arrests were hard. I guess eventually you get used to it,” he said.

“No, those were particularly difficult. I don’t think I have ever gotten used to the situation when someone who is talking to you dies in front of your eyes,” I said. “But you did everything that could have been done. And you did it all well. Maybe our lady will make it.”

He sighed. I wondered if he was reflecting on that other case he had presented at our M&M. “Well thanks,” he said. “Thanks for … being there.”

Later, as I filled out Tom’s evaluation, I tried to apply the concept of an entrustable professional activity (EPA),1 which involves the integration and application of competencies to professional activities, including an assessment by the supervisor of his or her willingness to trust the trainee at a certain level of independence for practice in the future. An EPA thus requires identification of a discrete professional activity and a supervisor who is present and clinically engaged and who has sufficient understanding of criteria and options for entrustment decisions.

Much of the recent work on EPAs has been on identifying and clarifying descriptions of professional activities and clinical problems that could serve as EPAs. In Tom’s case the EPA could be considered the management of a cardiac arrest patient. That is a specific problem that requires the coordination of numerous competencies such as medical knowledge of pharmaceutical agents and pathophysiology, patient care concerning airway management and performance of CPR, communications involving nurses and other residents, and systems-based care in understanding how to follow up and analyze the cause of a sudden deterioration that ultimately required resuscitation and team leadership.

One advantage of the EPA concept is that it recognizes the interconnection of the competencies that occurs when dealing with most clinical problems and allows the assessor to discuss how the problems were managed. The EPA approach encourages a judgment about the level of supervision required for the student or resident, based upon the supervisor’s observations. The level could range from a very limited role for a novice student all the way up to an autonomous independent practice or leadership role for a graduating resident. In this case, I felt that Tom had demonstrated a high level of competence and autonomy in the care of the cardiac arrest patients, and that I would be comfortable entrusting him with almost independent management of such cases in the future. Eventually, as Tom performed other EPAs, the program director and a competency committee could make a decision about his overall readiness for independent practice. I felt that Tom and I had shared in the care of our cardiac arrest patients, and that I had been able to assess his performance and entrust him with significant responsibilities that he had carried out well.

In a previous editorial2 I described how I understand the definitions and connections between EPAs and other assessment concepts such as competencies and milestones, but I did not specifically address the element of trust, which I will now discuss.

The decision to trust initially requires an assessment of a learner’s performance in dealing with a specific clinical problem and then a judgment about how much that individual can be trusted to share the care responsibilities involved. Both steps are subjective, and in this issue of Academic Medicine there are two articles3,4 that provide guidance about how to improve the consistency of assessment of a resident’s performance of professional activities and the subsequent entrustment decision. Calaman et al3 describe the development and validation of videos to help faculty learn how to make consistent assessments of learners’ performance levels on EPAs. These videos demonstrate various levels of expertise in handing off responsibilities for a patient to someone else. The videos could also be helpful in training faculty who would assess performances of this EPA (i.e., a handoff) in actual patient care activities.

Once the assessment of performance is made, it is important to decide how much responsibility to entrust to the student or resident. Rekman et al4 introduce meaningful entrustment scales to aid in creating consistent descriptions of entrustment assessments. Both these articles make clear that as we further develop the concept of EPAs, we will need to make sure that we have consistent language to describe the EPA, the performance, and the entrustment decision.

An essential part of the EPA process requires faculty supervision and engagement in the care process. Faculty have always had to make judgments about what a student or resident could do safely in the patient care environment and which activities the faculty member should perform with the resident assisting or observing. The EPA process makes this shared process more explicit. Carraccio et al,5 in our current issue of Academic Medicine, emphasize the integration of faculty supervision and resident performance and how they combine to deliver a certain level of quality of care. Weak resident performance or weak faculty supervision can lower the quality of care provided to the patient. Carraccio et al build upon the concept of a quality equation first introduced by Kogan et al6 that combines the performance of the residents with the supervision by faculty to result in a specific quality of care to patients. The idea is to recognize the important value of the faculty–learner supervisory relationship to the overall quality of care provided to patients in the educational environment. The EPA concept, with its emphasis on the learner’s workplace assessment and entrustment for certain activities, reinforces the dual educational and quality-of-care aspects of a faculty–learner supervisory relationship.

While much of the discussion of EPAs has emphasized defining the specific activities of the learners, little has been written on the actual entrustment process. How does a faculty member decide whether to allow a resident to “run” a resuscitation of a cardiac arrest patient, such as described in the case I presented above? Is the decision based upon the individual resident’s previous experience, the nature of the case, and/or the faculty member’s level of confidence at being able to assist the resident? In his initial description of entrustment, ten Cate1 noted that

trust in the judgment of a supervisor implies a personal involvement in the outcome of the activity of the trainee. If this is your trainee, his or her accomplishments are part of your accomplishments.

In our current issue ten Cate et al7 expand on this idea of trust and judgment and further define and describe the entrustment process. They describe three models for how entrustment decisions are made: presumptive trust, initial trust, and grounded trust.

Presumptive trust is the delegation of clinical care decisions to a student or resident based upon certain of that individual’s attainments, such as completion of medical school, board certifications, or training year level. Presumptive trust occurs before a relationship has developed between the supervisor and the learner.

Initial trust occurs when the faculty member and learner begin working together and get to know each other and there is an informal negotiation of the level of trust between them based upon first impressions and initial experience.

Grounded trust occurs after the relationship has matured and the faculty member can base the trust decision upon concrete past experience and anticipate the weaknesses and gaps that may require support. My relationship with Tom was a grounded trust relationship based upon previous work with him as a resident, the observations I had made at various educational conferences, and his case study at the M&M conference, which had raised some red flags about cardiac arrest care and termination of resuscitative efforts. I entrusted him with the management of the first cardiac arrest patient with close supervision, and I entrusted him with the intubation of the second patient. But I also maintained a constant participatory, supervisory role that allowed me to step in at any moment.

Yet as I considered both the Carraccio and ten Cate articles concerning entrustment, something seemed to be missing. Didn’t Tom also have to trust me? Isn’t entrustment something mutual, where both the resident and the faculty member have to make a decision about trust? And if the resident does not trust the faculty member to help when events spin out of control, what effect would that have on the resident’s behavior? Tom had clearly felt a lack of support in his previous case, which he had described at the M&M conference, and that experience had likely led him to question whether he could trust his future faculty supervisors. I recognized this, and made sure to communicate my engagement and commitment in our two cardiac arrest cases. While I believe that most faculty do attempt to provide the needed support for residents, there are times when they may give mixed messages, such as saying “Call me if you need any help,” which suggests that the call is a sign of weakness rather than a desired collaboration around a mutual desire for quality patient care. Residents learn quickly which faculty they can count on when they are confused, overwhelmed, or just need a boost of confidence. These are the faculty members who encourage telephone calls and difficult questions and have the commitment to quality care described by Carraccio et al.5 Trust is a two-way street, and passage on this street is earned and not automatically given.

As we work to further define the concept of entrustment in medical education, we need to begin to understand how trust develops between residents, students, and faculty. What do students and residents need to know, do, or show to their faculty, and what do the faculty need to know, show, and do for their learners?

The Association of American Medical Colleges published its Compact Between Resident Physicians and Their Teachers in 2006.8 This document’s principles are a good start in helping faculty assess and, if necessary, improve their commitment to the education of residents and their supervision in patient care activities. The document states that one of the core commitments of faculty is to

provide resident physicians with opportunities to exercise graded, progressive responsibility for the care of patients, so that they can learn how to practice their specialty and recognize when, and under what circumstances, they should seek assistance from colleagues.

The document goes on to urge residents to

secure direct assistance from faculty or appropriately experienced residents when confronted with high-risk situations or with clinical decisions that exceed their confidence or skill to handle them alone.

Is that enough to create trust? I don’t think so. I think we could do more. Trust develops over time between two people who get to know each other and understand each others’ strengths, weaknesses, and values. It is part of a relationship and cannot be switched on and off at a moment’s notice. I was fortunate that I had eight continuous hours with Tom so that we could work on numerous patients together before we had our most challenging cases. How often do we think about the development of a relationship with a resident when we are considering how much to trust that resident? Relationship building requires time and commitment, and if we believe trust to be an essential element of clinical education, we must create learning environments that allow for trusting relationships to develop over time between faculty and their students or residents. We must recognize the fundamental tension between the opportunity for learners to make mistakes and learn during clinical care and the need to avoid mistakes that harm patients while we provide the highest-quality care. Bidirectional trust and faculty commitment are critical mediators in resolving this tension. In this issue of Academic Medicine, Fitzsimmons et al9 describe an interesting example of how faculty in an anesthesia department negotiated this challenging tension in developing a trusting relationship with a resident with a learning disability and how they found the balance between the resident’s educational needs and the safety of patients.

The concept of entrustment can be a valuable addition to our understanding of learners’ clinical education and assessment if we can honestly and consistently embrace all of its implications for quality care. These implications may lead us to reconsider current practices and habits in areas such as overnight supervision of residents and faculty involvement in ambulatory clinics with residents, involvement that varies considerably by specialty. As we develop the concept of entrustment and link it with patient care quality, we may find that education and clinical care goals begin to come closer together. In this way, improvements in one will result in improvements in the other, and excellent clinical education quality will truly equal excellent patient care quality.

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References

1. ten Cate O. Trust, competence, and the supervisor’s role in postgraduate training. BMJ. 2006;333:748–751
2. Sklar DP. Competencies, milestones, and entrustable professional activities: What they are, what they could be. Acad Med. 2015;90:395–397
3. Calaman S, Hepps JH, Bismilla Z, et al. The creation of standard-setting videos to support faculty observations of learner performance and entrustment decisions. Acad Med. 2016;91:204–209
4. Rekman J, Gofton W, Dudek N, Gofton T, Hamstra SJ. Entrustability scales: Outlining their usefulness for competency-based clinical assessment. Acad Med. 2016;91:186–190
5. Carraccio C, Englander R, Holmboe ES, Kogan JR. Driving care quality: Aligning trainee assessment and supervision through practical application of entrustable professional activities, competencies, and milestones. Acad Med. 2016;91:199–203
6. Kogan JR, Conforti LN, Iobst WF, Holmboe ES. Reconceptualizing variable rater assessments as both an educational and clinical care problem. Acad Med. 2014;89:721–727
7. ten Cate O, Hart D, Ankel F, et al. Entrustment decision making in clinical training. Acad Med. 2016;91:191–198
8. Association of American Medical Colleges. Compact between resident physicians and their teachers. https://www.aamc.org/download/49820/data/residentcompactpdf.pdf. Accessed October 11, 2015
9. Fitzsimons MG, Brookman JC, Arnholz SH, Baker K. Attention-deficit/hyperactivity disorder and successful completion of anesthesia residency: A case report. Acad Med. 2016;91:210–214
© 2016 by the Association of American Medical Colleges