Entrustable professional activities (EPAs) are a recent addition to the competency-based medical education model that undergirds the current physician training continuum. EPAs are real-life, core professional or workplace activities that a professional is entrusted to perform once she or he has attained a sufficient level of competency.1–4 More succinctly, EPAs “translate competencies into clinical practice.”3 That is, they describe the authentic clinical activities in which learners demonstrate their competence. These clinical activities are broad enough to be applied across different clinical contexts and specialties. Most recently, the EPA framework has been applied to undergraduate medical education (UME) with the development of 13 Core EPAs for Entering Residency (Core EPAs), which aim to delineate the activities that entering residents might be expected to perform on day one of residency without direct supervision.5
While the EPA framework allows for innovative teaching, learning, and assessment across the spectrum of medical education, the Core EPAs also present new opportunities and challenges for UME faculty educators who participate in the assessment–entrustment continuum at varying levels of engagement. At one end of this continuum are the faculty who primarily interact with learners in the workplace. During each encounter, these faculty make decisions about what they trust learners to do independently. In this capacity, they are well suited to assess learner performance through direct observations; these decisions eventually may inform entrustment decisions. On the other end of the continuum are the educators who review all available data to make summative entrustment decisions. Acknowledging the critical need for faculty development for a heterogeneous group of educators who will be involved in entrustment decision making, in 2014, the Association of American Medical Colleges established the Core EPAs pilot, which included the creation of an interinstitutional concept group to focus specifically on faculty development. The purpose of this article is to provide a critical synthesis of the EPA literature and to describe a shared mental model for faculty development6–8 that this concept group developed, which encompasses a foundational conceptual framework for entrustment, to better prepare faculty and to align faculty development efforts in teaching, assessment, and entrustment judgments.
Trust, Trustworthiness, and Entrustment: Constructing a Mental Model for Entrustment
ten Cate and colleagues9 proposed that trust is an interdependent endeavor between learner and supervisor, an exercise in “relational autonomy” that involves a receptivity to “being vulnerable to the actions of a trustee.” Entrustment, then, constitutes a socially complex, shared endeavor for both learner and supervisor.10 That is, the learner demonstrates her or his entrustability to influence supervisors’ decisions to confer entrustment. As such, the EPAs create a workplace-based context for the development and assessment of learner competence through core professional activities across different roles.11 Because the workplace environment is also a “shared performance space,” both learners and clinical faculty educators engage in the entrustment experience, partnering in the pursuit of trust.12
Trust is key to determining learner competence and independence.1–6 Further, this trust judgment is an intuitive and observational assessment that is both complex and multifactorial.6–16 Trust is the “gatekeeper” to increased levels of learner participation in the clinical workplace.17 This is significant because it is through gradually increasing clinical responsibilities and ongoing participation in the clinical “zone of proximal development”18 that the learner develops competence and demonstrates entrustability to achieve an entrustment determination from supervising faculty. Supervisor/learner interactions and relationships then constitute a valuable currency of entrustment within the workplace.
Trustworthiness has emerged as a multidimensional concept that is essential to making decisions of entrustment.3,19 O’Neill’s20 model of trustworthiness includes aspects of competence, honesty, and reliability, each of which is connected to the others in the expression of trustworthiness. Kennedy and colleagues19 described a four-dimensional model of trustworthiness that included the following: (1) clinical knowledge and skills, (2) discernment or the awareness of one’s own knowledge limits, (3) conscientiousness or the comprehensiveness of data gathering and diligence in follow-up, and (4) truthfulness or the level of honesty in one’s interactions with a supervisor. Together, these dimensions shape the expression of trustworthiness. ten Cate3 interpreted the notion of trustworthiness through a broader set of features that impact entrustment decisions. These included (1) attributes of the learner, (2) attributes of the supervisor, (3) the supervisor/learner relationship, (4) the situational context for entrustment, and (5) the level of complexity of the EPA. Supervisory style,21 fluency in the language of medicine,19 supervisors’ clinical skills abilities, and differing comparability points of reference (most notably self)22 are additional characteristics proposed to affect entrustment decisions. Trustworthiness, then, is a trait that both the learner and supervisor shape through their relationships and interactions; the learner demonstrates trustworthiness for the purposes of achieving entrustment, and likewise the clinical faculty member role models trustworthiness to catalyze and advance learners’ clinical participation, to create a positive workplace environment, and to optimize learning.17,23,24
The ultimate goal of an entrustment decision is to “predict learners’ future behaviors and assess their potential to competently care for patients.”17 Making these types of decisions requires the development of faculty members’ observation skills and ability to analyze and interpret learners’ observed behaviors. Clinical faculty supervisors also must possess a heightened level of self-awareness, experience, and clinical skills expertise to effectively participate in the entrustment of learners.17,22
Based on this critical synthesis of the EPA literature, we identified the following four dimensions as constructs for a shared mental model for Core EPA faculty development: (1) observation skills in authentic work environments (workplace-based assessments), (2) feedback and coaching skills, (3) self-assessment skills (including reflective practice) that ensure the appropriate role modeling of desired behaviors and attitudes, and (4) peer guidance skills developed through a community of practice that inculcates a transformative EPA culture.
Faculty Development to Foster Observation Skills in Authentic Settings
Steinert and colleagues25 described the value of experiential learning in faculty development programs, which is applicable to teaching the Core EPAs. They also posited that “immediate relevance and practicality are key.” Along those same lines, workplace-based assessments have gained prominence in the literature as an effective model for driving learning related to the EPAs.26,27 In this context, workplace-based assessments serve to define critical data points to aid faculty in making high-stakes entrustment decisions, given that such decisions fundamentally include multiple evidence-informed assessments of learners’ performance in authentic settings.
Observations in workplace settings are particularly important in teaching and assessing the Core EPAs as they allow faculty the opportunity to promote and assess the attributes of trustworthiness in learners.27 Learners are exposed to complex, unpredictable tasks in the workplace, and their performance may fluctuate, which can challenge their sense of competence.28 Taking time to observe learners who are deeply engaged in authentic patient activities can help build trust between the learner and faculty supervisor. Learners will likely be more willing to seek help from a faculty supervisor who has taken the time to observe her or him and share in the patient care experience.29
Workplace observations to drive attainment of entrustment according to the Core EPAs should be focused on identifying and addressing learners’ needs in real time. This enables a trusting relationship in which the learner is comfortable disclosing uncertainties and areas of weakness. Observations of learners engaged with patients provide additional opportunities for faculty to identify and discuss any inconsistencies between the information gathered and the information presented or documented by the learner. Likewise, these types of focused observations may provide valuable information as to how conscientiously the learner follows through on any observed gaps in patient care. Thus, teaching and assessing the Core EPAs in the workplace calls for faculty development that promotes direct observation and workplace-based assessment skills. These need to occur in the context of strong, trusting partnerships between faculty and learners to facilitate the assessment of trustworthiness and the critical development of entrustability.
Faculty Development to Foster Feedback and Coaching Skills
Clinical faculty who have the opportunity to directly assess learners are uniquely suited to participate in workplace-based assessments, including real-time entrustment decisions. Each real-time assessment data point collected over a longitudinal period of time has the potential to inform high-stakes, summative entrustment decisions. Each one also offers an opportunity to improve learner performance, if those observations can be translated into specific, appropriately timed, face-to-face feedback encounters.30 Educators have recognized the importance of feedback in improving performance, and both observation and feedback are essential to the acquisition of expertise.31 To this end, the literature includes descriptions of multiple educational interventions to improve faculty members’ skills in peer observation, feedback delivery, and clinical teaching communication.32–36
Recently, the emphasis in the feedback literature has shifted from a focus on feedback delivery to an exploration of the factors that influence learner responsiveness to feedback, which is a necessary step towards acceptance and incorporation of feedback. Eva and colleagues37 found that learner factors, such as confidence, experience, and fear of not appearing knowledgeable, may affect learners’ interpretation and uptake of feedback. Furthermore, the importance of feedback-seeking behavior in learners has been highlighted, and specific tips to encourage this behavior may be translated to EPA teaching and assessment program development.38 Finally, our emerging understanding of the relationship of emotion to motivation and learning in medical education has important implications for Core EPA performance assessment and should be considered when designing feedback systems.37–39
Faculty development efforts that aim to improve the ability of clinical faculty to engage in meaningful conversations with learners about their observed performance, and to coach them in their pursuit of entrustment, should incorporate not only feedback delivery methods but also foundational training regarding the factors that impact learner responsiveness and acceptance. However, even with motivated faculty and receptive learners, the effectiveness of feedback also may depend on the culture of the learning environment. Thus, faculty development efforts should include systems and curricula that are specifically designed to promote trusting learner–supervisor relationships, thereby placing faculty in a longitudinal coaching role.40,41
Faculty Development to Foster Self-Assessment, Role Modeling, and Reflective Practice
Eva and Regehr42 noted that self-assessment is an essential skill for learners and practitioners in the health professions. This is especially true for faculty educators engaged in the UME entrustment process as they serve as frontline role models of the skills, behaviors, and attitudes that promote trustworthiness. Studies indicate, however, that self-assessments are often inaccurate when they focus solely on unguided reviews.42 Sargeant and colleagues43 suggested that what is needed is “informed self-assessment,” a process which uses external and internal data sources to generate an appraisal of one’s own abilities. Schumacher and colleagues44 described a similar construct in “self-directed self-assessment,” which is dependent on an individual’s ability to identify and seek out multiple external sources of information to create a more robust self-assessment. This type of self-assessment is complex because of the potential for different interpretations of information, internal and external contextual influences and tensions, and assorted responses to information.43 Faculty need the skills to identify high-quality, internal and external data sources regarding their own abilities and heightened self-awareness training to be able to adequately interpret and apply the solicited feedback.
Just-in-time reflection in practice is another facet of self-assessment.42,45 Reflection in practice underpins discernment and, in combination with help-seeking behavior, is an essential skill set for faculty entrustment role models as well as for trustworthy learners. Reflection must supplement self-assessment to support the learning necessary for increasing levels of entrustment for both the faculty educator and learner. All faculty involved in entrustment decision making will likely need ongoing training to hone these skills and processes that will be tailored to their specific contributions to the entrustment decision. Faculty demonstrating these behaviors within their own practices can serve as exemplary role models for learners and peer coaches for faculty educators to foster buy-in and instill a desire to develop informed self-assessment.
Faculty Development as a Community of Practice
Wenger46 defines communities of practice as “groups of people who share a concern or a passion for something they do and learn how to do it as they interact regularly.” Translating the complexities of entrustment decision making into the educational roles and responsibilities of faculty educators brings unique challenges because entrustment decision making is as much a cognitive task as it is a social task. Establishing communities of practice around the Core EPAs simultaneously provides a built-in network of peer support, coaching, and guidance for clinical educators while socializing cultural and educational constructs of entrustment. Creating a community of entrustment provides a context for “social learning”47,48 through ongoing interaction, collaboration, and shared guidance. It likewise provides a context for “legitimate peripheral participation”48—that is, all clinical faculty who are involved at all levels of entrustment decision making are able to make valuable contributions to the entrustment process. Steinert and colleagues25 underscored the role of a community of peers both as role models to enable the ongoing exchange of information and ideas and as a professional network of “collegial support to promote and maintain change.” Thus, the establishment of communities of entrustment is essential to the ongoing development, support, and socialization of faculty as entrustment educators and decision makers.
UME as a Unique Entrustment Environment
The current UME clinical learning environment is still one of relatively brief exposures for learners to a wide variety of clinical faculty and residents from multiple specialties in many different settings. Although this variety presents the opportunity for rich workplace-based assessments, it also may hinder the formation of longitudinal learner–supervisor relationships that facilitate effective feedback, coaching, and ultimately informed learner assessment. As medical schools begin to build more longitudinal clinical and coaching experiences for medical students, these experiences must occur simultaneously with faculty development efforts to optimize the potential for “entrustment partnerships” to form.
Hauer and colleagues17 suggested that junior faculty do not yet possess the necessary experience and skills to effectively contribute to entrustment decisions. This suggestion seems to run counter to current educational practices in UME. Junior faculty, residents, and fellows all supervise and teach medical students and contribute to entrustment decisions. This group of educators also makes important observations regarding learners’ conscientiousness, truthfulness, and discernment in their educational environments. Although it is important for all faculty who contribute to entrustment decisions to have a shared mental model for entrustment, faculty development efforts should specifically target the unique needs of faculty based on their role. For example, faculty who primarily participate in workplace-based assessments and make informal, snapshot entrustment decisions with every teaching encounter may require different skill development than faculty who assess learners over an extended period of time or those who make summative entrustment decisions.
Ultimately, an entrustment system that both maximizes safe patient care and optimizes trainees’ learning must clearly define the role and value of all educators’ contributions to entrustment, given the understanding that contributions from a diverse set of faculty render a more comprehensive and detailed picture of the learner. Such a system needs to explicitly address the expectations for and the development of all educators to ensure that they make competent entrustment decisions that are appropriate for both the faculty member’s role and the learner’s indicated level of supervision. Engaging junior faculty and other physician trainees is essential to the sustainability of the entrustment community of practice. As junior educators progress in their careers, they will be better able to contribute their entrustment expertise to their learners and peers, thus creating a renewable and sustainable entrustment community.
Within the evolving Core EPA entrustment framework, making entrustment decisions may prove more challenging in the UME environment than in the graduate medical education environment. For example, the majority of faculty in residency training programs typically reside in one clinical department, allowing for the physical community of practice to more easily coalesce. In UME, however, faculty members are distributed across many clinical departments and increasingly across multiple institutional sites, neither of which readily supports a physically cohesive community of practice. Additionally, UME faculty may assign medical students to more peripheral roles in patient care activities which could limit learners’ opportunities to participate in some of the Core EPAs. Finally, UME faculty from across specialties spend less time with individual medical students, which may limit supervisor–learner continuity and the establishment of longitudinal entrustment partnerships to the same degree that they develop in graduate medical education settings.
In summary, our conceptual understanding of entrustment continues to evolve across the continuum of medical education. To codify our understanding of the role of faculty development and faculty development research across the assessment–entrustment continuum, we have developed a list of recommendations and research questions (see Lists 1 and 2). These provide a road map for ongoing inquiry and examination of faculty development practices related to the Core EPAs and for future directions in Core EPA faculty development research. Although UME faculty development for the Core EPAs remains in its beginning stages, a critical synthesis of the EPA literature has revealed the following dimensions for faculty development: (1) observation skills in authentic settings (workplace-based assessments), (2) feedback and coaching skills, (3) self-assessment and reflection skills, and (4) peer guidance skills developed through a community of practice.
Defining a cogent, comprehensive entrustment framework for UME educators warrants further study. The framework we have described can assist in creating effective strategies, processes, and methods for meaningful faculty engagement in teaching and assessing the Core EPAs. It can likewise serve to more clearly delineate the shared role of trust and trustworthiness in medical student training. Our recommendations for ongoing faculty development efforts and future directions in faculty development research highlight the many opportunities and challenges accompanying the implementation of the Core EPAs in UME (see Lists 1 and 2). As more medical schools engage in the systematic development and assessment of the Core EPAs, these lists will both expand and contract as existing questions find answers and new questions and recommendations arise.
Faculty Development Recommendations From the Core Entrustable Professional Activities for Entering Residency Faculty Development Concept Group
- Develop and disseminate a shared mental model for entrustment for educators in undergraduate medical education (UME).
- Pair faculty and learner development to better inculcate a culture of shared entrustment, reciprocal feedback-seeking behaviors, and meaningful learner–educator partnerships.
- Structure medical school curricula to support longitudinal observations and relationships to foster trust.
- Clearly define the guidelines and behaviors necessary for effectively fulfilling the dual roles of UME educators to ensure both patient safety and learner development.
- Reduce variability in faculty members’ assessments of learners through informed self-assessment training and practice for faculty.
- Create multiple opportunities for faculty to engage in deliberate practice to integrate informed self-assessment and feedback-seeking behaviors as continuous performance improvement.
- Align faculty rater skills development with programs to advance faculty clinical skills development.
- Develop communities of practice for all faculty educators who teach and assess the Core Entrustable Professional Activities for Entering Residency.
Future Directions for Faculty Development Research From the Core Entrustable Professional Activities for Entering Residency Faculty Development Concept Group
- What are the roles, contributions, and training for junior faculty, residents, and fellows engaged in entrustment judgments related to the Core Entrustable Professional Activities for Entering Residency (Core EPAs)? What are the best approaches to develop and support junior entrustment educators?
- What are the contributions to Core EPA entrustment judgments and the necessary training needs for faculty educators who solely engage in “brief interactions” with medical students?
- How do we assess the baseline understanding of clinical faculty regarding the definition and conceptualization of the Core EPAs and entrustment? How does this understanding change with training?
- What is the “core content” of Core EPA teaching and assessment? What is the impact of teaching this core content on faculty performance?
- What level of systems support, in terms of time, compensation, and acknowledgment, will be necessary to achieve the level of faculty development required for educators in undergraduate medical education (UME)?
- What types of systems are needed for high-stakes entrustment decisions to balance patient safety and learner development?
- What are the barriers in the current UME educational environment to meaningful engagement for UME educators in the entrustment process?
- How do we involve faculty in the design and implementation of entrustment assessment tools?
- What are the specific knowledge, skills, and attitudes necessary for faculty to effectively make summative entrustment decisions?
Acknowledgments: The authors wish to thank the Association of American Medical Colleges and the Core Entrustable Professional Activities for Entering Residency Faculty Development Concept Group members: Jamie Noble, MD, MS, Columbia University College of Physicians and Surgeons; Allison Ownby, PhD, MEd, University of Texas Health Science Center at Houston McGovern Medical School; Eve Colson, MD, MEd, Yale School of Medicine; Greg Trimble, MD, Virginia Commonwealth University School of Medicine, Inova Campus; Angie Thompson-Busch, MD, PhD, Michigan State University College of Human Medicine; Jefry Biehler, MD, Florida International University Herbert Wertheim College of Medicine; Yoni Amiel, MD, Columbia University College of Physicians and Surgeons; and Jan Bull, MA, Association of American Medical Colleges.
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