Behavioral Specification of the Entrustment Process

摘要

Never trust anything that can think for itself if you can't see where it keeps its brain. JK Rowling, Harry Potter and the Chamber of Secrets;Judging Competence Consider the clinical educator in the following situation: An attending emergency medicine physician is responsible for a 65-year-old man with abdominal pain. The physician is legally required to see the patient and has ultimate responsibility for all care provided, but must decide how much autonomy to grant a second-year resident in managing the patient's diagnosis and treatment. What factors should the attending consider to make this entrustment decision? The competence of the learner involved in patient care is the chief concern; however, research suggests that clinical educators do not make systematic use of formal assessment opportunities to judge learners' preparedness to provide care1 and rarely base their feedback to trainees on direct observations of actual performance.2 Instead, supervisors report using a variety of indirect methods to assess competence, including verbal case presentations,3,4 input from colleagues and staff,1 trainees' self-assessments,1,3 and general trainee characteristics, such as number of years of postgraduate training.1,3 A wealth of literature on interpersonal trust in occupational settings confirms this strategy, indicating that (1) people seek evidence that others have the capability and willingness to perform according to expectations; and (2) when personal experience with the trainee in the entrustment decision is limited, individuals use proxies for direct observation to judge trustworthiness.5;Managing Risk In our example, the attending emergency medicine physician is supervising a second-year orthopedic resident with whom he has not worked before. He is unfamiliar with this “off-service” resident's experience in emergency medicine and asks his colleagues for their input. The colleagues report nothing unusual about the resident, who seems professional, but they express concern about her ability to handle undifferentiated patients. The attending physician has previously regretted granting autonomy to residents from other disciplines and prefers to avoid risks to patient safety. He therefore makes a conservative entrustment decision, opting to follow up with the patient much more quickly and thoroughly than he would if the resident had been familiar to him and/or had trained in emergency medicine. This attending physician's approach exemplifies “increased oversight” as the general strategy supervisors use to manage entrustment concerns. Oversight may include double-checking or more closely monitoring the work of trainees, or, in extreme cases, assuming direct control over patient care.6 In our (J.A.K.) observations of emergency medicine educators, we have observed 3 styles of managing trainee oversight: the loner, the director, and the teacher. The loner takes complete control of the situation, with the entrustment decision offering the trainee little to no independence, even in relatively safe settings. The director partially entrusts care to the trainee, but restricts the learner's autonomy to tasks with simple decision-making demands. The teacher views competency shortfalls as learning opportunities, responding to entrustment concerns by using questions or other prompts to draw the trainee's attention to a missed consideration or procedural step. Although these styles may characterize an educator's typical approach to supervision, a given supervisor likely adopts more than 1 style, depending on the level of the learner and the situation.7 Investigations of trust in other occupational settings suggest that entrustment is not necessarily an all-or-none act but a combination of approaches that dynamically alter the social distance between people.5;Linking Competency Judgments to Oversight Strategies Let us return to our example. Over the course of her rotation, the orthopedics resident in our story has gained competence in her app