Competency-based medical education (CBME) emphasizes achievement of performance outcomes rather than time in training. Entrustment, a central construct within CBME, has been conceptualized as an active choice by clinical supervisors regarding the degree of supervision to offer a trainee and reflects their underlying cognitive processing of the trainee’s clinical performance. 1 , 2 3 , 4 5 , 6
In assessing an EPA, a supervisor makes an in-the-moment judgment about whether a trainee is “entrustable” within a situated, workplace-based assessment context. In making this decision, supervisors have been shown to consider multiple factors, including those related to themselves, the trainee, the supervisor–trainee relationship, the task, and the context. 7–15 16 , 17 18–22
Supervisors engage certain observational and decision-making processes in making assessment decisions, collectively referred to as their rater cognition. 23 23–25 26 , 27
In this study, we aimed to characterize how supervisors conceptualize entrustment and make decisions about trainees during EPAs related to gastrointestinal endoscopy. We chose endoscopy because it is a skill performed by many specialists (gastroenterologists, surgeons, and primary care physicians); it includes technical, cognitive, and nontechnical elements; it encompasses both simple diagnostic (e.g., colonoscopy) and complex therapeutic procedures (e.g., endoscopic mucosal resection); and it is performed in both adult and pediatric contexts. 28 , 29
Method
We conducted an interview-based study using a constructivist grounded theory approach to explore how clinical supervisors conceptualize endoscopic entrustment and how they perceive making formative, in-the-moment entrustment decisions in the workplace. The interviews followed a semistructured guide (Supplemental Digital Appendix 1 at https://links.lww.com/ACADMED/B219
We purposively sampled endoscopy supervisors from multiple specialties (adult and pediatric gastroenterology, surgery, and primary care), geographic regions, and experience levels, with the goal of enrolling a broad cross-section of endoscopists. We purposively sampled some participants who held educational roles within gastroenterology or endoscopy-focused organizations (e.g., the American Society for Gastrointestinal Endoscopy and the Canadian Association of Gastroenterology), and we specifically selected others not in education leadership roles to explore alternative viewpoints. We recruited study participants using an invitation email, which we sent to 49 potential participants. We continued recruitment until theoretical sufficiency (i.e., the point at which we deemed our depth of understanding was sufficient and where additional interviews did not result in further modification to our framework). 30
Analysis
All interviews were conducted by phone, audio-recorded, and transcribed verbatim between April and November 2019. Consistent with the tenets of constructivist grounded theory, we began data analysis alongside interviews. 31 , 32 9 , 14
Reflexivity
Our study team comprised scientists with expertise in assessment and feedback interactions (R.B., S.G., C.M.W.), as well as qualitative research (S.G.). Three of the researchers were also clinicians (T.J., S.G., and C.M.W.). The coders possessed clinical training in gastroenterology and graduate training in health professions education research (T.J.), as well as graduate training in psychology (G.A.M.), which produced generative divergences that led to a comprehensive analytic process. The primary coder (T.J.) kept memos throughout data collection and analysis and wrote additional memos after team meetings to clarify emerging ideas.
This study was approved by the Hospital for Sick Children Research Ethics Board (Toronto, Canada).
Results
We recruited 29 participants total, including the 2 pilot supervisors. Given that the pilot interviews did not generate data significantly different from the remainder of the cohort, they were included in the analysis. Eight participants (27.6%) were women and 21 (72.4%) were men; 18 (62.1%) practiced in the United States and 11 (37.9%) in Canada. Their experience in supervising endoscopic trainees ranged from less than 1 year to 36 years. Participants practiced (and supervised trainees) in a range of specialties, including adult gastroenterology (10, 34.5%), pediatric gastroenterology (9, 31.0%), general surgery (7, 24.1%), and primary care (3, 10.3%). Interviews were between 21 and 60 minutes long and generated 369 pages of transcript data. Our analysis identified 3 major themes, which we outline below.
Participants describe entrustment in degrees and perceive their level of entrustment as fluctuating over time
Participants described their view of entrustment as varying in degrees. Although the sense of entrustment having levels or degrees was universal, how participants conceptualized entrustment was variable.
Some participants described progressively entrusting rudimentary components of an endoscopic procedure before being able to entrust more advanced skills and, ultimately, the procedure in its entirety:
My review of EPAs is that [entrustment] is a progressive metric. Progressive metric means that if you take a [procedure], if you break it down into steps, and you say [these are the constituent steps] ... that allow people to understand where they fall in the continuum of procedure development. (Participant [P]19)
One participant described a system with multiple binary decisions regarding whether the participant entrusted a trainee to perform a procedure under direct, indirect, or absent supervision (“... each of those decisions has to be a yes/no” [P4]). Another participant proposed a similar system including the additional levels of whether they entrusted trainees to perform procedures on “their long-standing patients” or “[their] family member” (P14).
Other participants perceived their degree of entrustment as manifesting in their level of preparedness to take over from a trainee under their supervision:
There are sometimes in cases, if it’s a third-year resident that’s done 100 of them or is really proficient at it, I may not put gloves on or a gown on until they seem like they’re struggling. I’ll just say, “I’ll see how far they can get on their own.” Then, there are others that there’s no way, I would put the gown on right away and kind of be right there at the bedside. (P22)
These ways of conceptualizing entrustment appeared to function on relatively sliding scales, given many participants also described their judgments of a particular trainee as fluctuating over time, without clear relationships to a trainee’s training level. These fluctuations were perceived to occur due to situational factors related to the patient, procedure, or trainee:
I see [entrustment] as a continuum that has sort of a sinusoidal pattern. It’s a learning process, meaning that there may be moments where the resident, you feel you could entrust them. And then when they are challenged cognitively again by either a higher level or new circumstance or another twist that maybe overloads them, then maybe they need a little bit more support.... And then they can be entrusted again depending on the circumstances, so that over time they build a sort of overall improvement in the skill or the activity that is being entrusted. But it can vary from situation to situation. So it’s not like every single time they do it they improve, and they improve, and they improve, and once they become entrustable they are permanently entrustable. I think that it can vary. (P7)
As demonstrated in these quotes, entrustment appears to be conceptualized as a matter of degree and as a decision that fluctuates back and forth, dependent on numerous factors in the situated assessment setting.
Participants perceive entrustment decisions in one context as influencing their decisions within and across contexts
Some participants noted that within the realm of endoscopy, their entrustment decisions about a trainee in one instance influenced their entrustment decision about another endoscopic skill. Take, for example, the following representative discussion about entrustment decisions in colonoscopy and polypectomy (2 discrete endoscopic skills):
I think in someone who’s really shown me that they have those sort of baseline [endoscopic] skills that I’m much more likely to allow them to take the next step and be comfortable with [other endoscopic skills]. But if I see someone who can’t advance the endoscope or can’t loop reduce, I’m a lot more likely to take over and probably not allow them to do a polypectomy. (P2)
Some participants also perceived entrustment as transferrable across different types of procedural contexts. Speaking of the surgical and endoscopic context, one participant reported “a tremendous degree of overlap between technical skills” and that “a trainee that’s entrusted in one technical skill likely would be entrusted in another” (P3).
Certain participants also described transferring entrustment decisions across medical and procedural contexts, such as in this discussion of entrusting a trainee to endoscopically manage a bleeding ulcer:
I knew that they were quite competent outside of the endoscopy unit in regard to their knowledge and how to appropriately approach the situation we were in. So I felt completely comfortable allowing them to do the entire procedure. (P2)
Other participants expressed that a decision to not entrust a trainee in the medical context could extend to the endoscopic context based on a perceived lack of reliability, which they felt they could infer from a trainee’s previous suboptimal medical management of a patient:
I think it just goes down to those domains that we’ve talked about, which are reliability and truthfulness. I think someone who I can’t trust to get a good enough history, who I can’t trust to manage a patient appropriately ... that would definitely impact my entrustment [decision] for the endoscopic procedure. (P15)
In this vein, participants rationalized the influence of their entrustment decision in one context on another context as being due to a “preconceived notion” from one setting “pass[ing] over into another arena” (P25), reflecting trainee-related personal or professional factors that manifest in both settings (e.g., “lack of insight” [P25]).
Despite the prior theme suggesting that entrustment may fluctuate, participants perceived that their previous entrustment decisions and other interactions could influence future entrustment decisions both within procedural domains and across clinical contexts. Some indicated that this influence may relate to certain trainee factors (e.g., reliability or insight) manifesting with relative consistency as trainees perform different tasks. The particular factors that participants considered and how these become synthesized in entrustment decisions are described next.
Participants synthesize static and dynamic factors when making entrustment decisions
Participants reported synthesizing a medley of factors in making procedural entrustment decisions. Although the general categories of factors were common across participants, individual participants reported unique combinations of factors that were personally important to them. They also assigned different weights to their personal factors in their ultimate decisions.
The list of factors that participants considered could be categorized as related to the trainee, supervisor, supervisor–trainee relationship, patient, procedure, and environment. They could also be divided into static and dynamic categories. By static, we refer to factors that persisted between training encounters over long periods of time and appeared to influence a supervisor’s baseline frame of reference for entrustment decisions. By dynamic, we refer to factors situated within any specific assessment setting that appeared to change from one training encounter to the next. Participants described synthesizing a unique combination of dynamic factors against their personal baseline informed by static factors in making entrustment decisions (Figure 1 ). As illustrated in Figure 1 , static factors informing supervisors’ baseline frame of reference for entrustment can be conceptualized as the location of the fulcrum along a seesaw, which influences the baseline propensity of the seesaw to fall to one side or another, whereas the synthesis of dynamic factors can be conceptualized as the application of various forces along the seesaw board. Combined, these factors influence a supervisor’s decision to entrust or not, as represented by the side to which the seesaw falls.
Figure 1: Entrustment decision-making seesaw. Static factors were perceived to influence a supervisor’s baseline frame of reference with respect to entrustment (represented by the location of the seesaw fulcrum). Salient dynamic factors were then incorporated with this baseline (represented by the application of various forces along the seesaw board), resulting in an ultimate entrustment decision. Participants described variably synthesizing static and dynamic factors related to the trainee, supervisor, supervisor–trainee relationship, patient, procedure, and environment in making endoscopic entrustment decisions. Static factors include the supervisor’s own competence, disposition, and prioritization of trainee learning; the culture of the institution and specialty; and legal considerations. Dynamic factors include level of training, professional attributes, and skills of trainee; mental workload of supervisor; supervisor–trainee familiarity; complexity and risk of procedure; composition and quality of team; time constraints; and patient age, acuity, comorbidity, comfort, pathology, and safety.
Static factors.
Participants frequently considered static factors. For instance, participants’ own self-assessed competence in the procedure was noted as influencing their decision making:
When I started doing colon procedures, and I had not done very many or I was still myself on my learning curve, I wasn’t really in a position where I felt comfortable entrusting any part of that procedure to a resident because I wasn’t comfortable with it myself. (P4)
Some participants noted their frame of reference was related to their own ability to recognize and manage complications, so that they were confident they could “get the trainee out of trouble” (P9):
I think the more you are comfortable that you can rescue a situation, quite frankly, and maybe that’s recognizing it before it happens, the more comfortable you are with your own ability to see that something could go wrong, [the more likely you are to entrust]. (P21)
Some participants also described how their baseline willingness to prioritize trainee learning relative to 1 or more competing demands influenced the likelihood they would entrust. For instance, some supervisors were less likely to entrust procedures that they perceived “[don’t] matter” to trainee learning due to the perception that the trainee did not require competency in that procedure for their future practice and, therefore, the risk of making an entrustment decision was not justified (P4). In a similar fashion, others reported being less likely to entrust due to competing legal considerations:
For example, the pregnant patient who needs an [endoscopic procedure], and in those situations, it just comes down to liability, and just recognition that there are certain situations that we just need to do as attendings. No matter how good the trainee might be, I’m potentially putting them in a difficult situation. (P27)
Participants who practiced in the pediatric setting reported feeling less likely to entrust trainees, due to a “hands-on” and “paternalistic” culture, which they attributed to being “cautious or protective of the patients” (P13). Several participants also reported that their institutional culture of having to “supervise the entire colonoscopy from insertion to removal of the scope” (P4) left them unable to entrust in practice:
I think in a sense we’re told to baby them more and not consider them “the” provider. And so, by definition, that makes me the provider.... I think culturally at our institution, if an error happened or a complication occurred, that would more be my doing.... I would not blame the fellow. I would say I was the one who missed that I needed to step in, or change something, or not trust them to do it. (P21)
Several participants also alluded to a supervisor’s general tendency to entrust; they typically attributed this to the “temperament, personality, and personal characteristics of the [supervisor] that go into whether they let [a trainee] continue to try something” (P21).
Dynamic factors.
While static factors seemed to influence participants’ baseline frame of reference for entrustment decisions, participants also reported attending to multiple performance dimensions dynamically. The particular factors supervisors prioritized and combined in decision making varied across supervisors and supervision encounters. Participants described considering the net influence of these dynamic factors (as represented by the application of a force to the seesaw board in Figure 1 ) against their baseline frame of reference (as represented by the location of the fulcrum along the seesaw in Figure 1 ), which led to their ultimate decision to entrust or not (as represented by which side the seesaw ultimately falls to in Figure 1 ).
As an example, one participant reported considering multiple dynamic factors (i.e., a trainee’s personal and professional attributes, training level, technical and nontechnical skills, and the nature of the supervisor–trainee relationship) against a static factor (i.e., their own competence):
Factors specific to the trainee are their attitude ... their level of experience, their knowledge of their own limitations, and their willingness to ask for help and kind of respond to feedback, and also their technical abilities and clinical judgment. And I think with respect to the trainees, also the relationship of the supervisor and the trainee.... And then with respect to the supervisor.... It’s their own kind of comfort level of the supervisor in terms of the actual procedure being performed and their level of experience. (P4)
Another participant reported considering a different combination of dynamic factors, including a particular trainee’s technical skills, the quality and composition of the care team (e.g., presence of an anesthetist), and the patient’s acuity, in addition to a different static factor (i.e., institutional culture):
The environment in the room does make a difference in the way you entrust because there’s often a whole variety of other behaviors, and performances, and strengths, or weaknesses in the room, and they influence what you’re entrusting. You think it’s a very focused [technical] issue, but if you’re entrusting them to supervise as well as perform the procedure, there’s a lot of distraction and interruption that a [trainee] needs to be prepared to deal with. And so, the environment of who is there, the acuity of the patient, the support staff available, presence or not of anesthesia, a lot of these other components influence how much you’re entrusting someone when you give them that privilege, so that would influence a decision. Within a department, I don’t think there’s a lot more outside other than I’m sure some departments have a laissez-faire attitude towards fellows’ independence, and others, perhaps like ours, have a ... much more conservative approach. (P8)
To summarize, participants considered static factors, which were relatively constant between training encounters and appeared to influence their baseline frame of reference in making entrustment decisions. Further, they described integrating performance dimensions dynamically in a fashion that was variable between supervisors and training encounters. They conceptualized their entrustment in a trainee as a matter of degree and perceived that it could fluctuate over time. Despite this framework, participants also described entrustment decisions in one context as influencing their entrustment decisions in another context, potentially owing to certain trainee factors manifesting across contexts.
Discussion
In our study, participants reported conceptualizing entrustment as fluctuating in degrees across trainees and assessment scenarios. With the same trainee, they also reported that one entrustment decision can influence future decisions both within and across procedural and clinical contexts. In forming their final entrustment decisions, they described considering a unique combination of static factors (i.e., those that tend to persist across training encounters and often years) that appeared to set their frame of reference, and they also described attending to performance dimensions that fluctuated dynamically between training encounters.
Our participants each engaged in an idiosyncratic cognitive process where different static and dynamic factors were synthesized in entrustment decisions. These factors were related to the trainee, supervisor, supervisor–trainee relationship, patient, procedure, and environment—categories consistent with what has been reported in the literature. 3 , 5 , 7 , 9 , 33 5 , 13 , 34 , 35 23 , 36 , 37
Our finding that supervisors conceptualize entrustment as varying in degree and evolving over time aligns with entrustment in the formative setting, where supervisors make in-the-moment decisions while weighing multiple, often competing, factors. 2 2 38 39
Our participants’ justification of why their entrustment decisions could transfer between contexts (e.g., clinical, endoscopic, surgical) centered on certain trainee characteristics (e.g., technical skills, knowledge, reliability) that they believed manifested across contexts. This finding echoes descriptions of initial trust, where entrustment decisions are based on first impressions rather than prolonged observations, as well as the assimilation effect, where prior trainee performance influences current rater judgment. 3 , 40 41 , 42
Our findings have several implications for academic medicine. Despite how quickly CBME training and assessment systems have been adopted, a recent critical narrative review demonstrated that much of the evidence pertaining to the core assumptions about CBME was mixed and derived from a limited range of research designs (i.e., quantitative analyses). 43 44
Our findings also have implications for procedural training specifically. Given that procedural experience facilitates trainee learning and that entrustment facilitates procedural experience, optimizing training conditions to favor entrustment may also facilitate learning. 45 , 46
Our study has limitations worth mentioning. First, participants were not situated within an actual assessment setting and thus could have been describing hypotheticals prone to recall biases. To mitigate this limitation, we asked participants to select and reflect on specific, real-life training experiences during our study interviews. Second, we used only 1 set of procedural skills (i.e., endoscopy) to study procedural entrustment more broadly, and therefore, our findings may not generalize to other procedural skills.
Conclusions
Procedural entrustment appears to be a complex process in which supervisors idiosyncratically synthesize static and dynamic factors to produce situated entrustment decisions. In selecting who assesses EPAs and in which context they are assessed, programs might consider the list of static and dynamic factors we identified, with the goal of optimizing them in ways that facilitate trainees’ learning and ultimate achievement of entrustment. Further studies of how these factors interact to influence supervisors’ decision-making processes have the potential to inform CBME faculty development practices, as well as competency committee practices when aggregating faculty entrustment decisions.
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