Entrustment as Assessment: Recognizing the Ability, the Right, and the Duty to Act

摘要

The Challenge Competency- and milestone-based frameworks are designed to improve assessment of learners on broad domains, such as professionalism, communication, or medical knowledge. In practice, marking trainees on competency scales has been found to be difficult.1 In addition, these assignments often do not directly translate to judgments to trust trainees to work effectively in an unsupervised fashion. By the end of training, programs must ensure that residents can provide high-quality, safe patient care without supervision.;What Is Known The concept of entrustable professional activities (EPAs) has recently emerged. It connects competencies with practice2,3 via assessment focused on specific clinical activities rather than on general competencies. The primary question in EPA-based assessment is “Can we trust the trainee to execute EPA X without supervision?” followed by “Why or why not?” often involving 1 or more competencies. Examples of EPAs with the predominant relevant competencies are (1) providing anesthesia in an ASA-4 patient (medical knowledge, collaboration); (2) lumbar puncture in a child (technical skill, collaboration, communication); and (3) chairing a family meeting in rehabilitation medicine (communication, health advocacy, professionalism, leadership). Rip Out Action Items Program directors should: 1Ensure that faculty, residents, and staff understand EPA concepts and how EPAs are established in your program.2Emphasize the “E” for entrustable within the EPA concept: supervisors make ad hoc entrustment decisions every day when working with residents.3Incorporate both ability and trust conditions—integrity, reliability, humility—in summative entrustment decisions.4Start small with a few EPAs; link these EPAs to your speciality's competencies and milestones; build from the literature; collaborate with faculty and trainees.;How You Can Start TODAY 1Determine if your specialty has defined EPAs for practice. If specialty-specific EPAs are not available, begin discussions about the most relevant EPAs for your program.2Reframe existing evaluations for key entrustment decisions and deliberately assign levels of required supervision. Readiness for indirect supervision or unsupervised practice should include the specific EPA-related ability and the 3 other trust conditions: integrity, reliability, and humility.3Clinical competency committees can include these features in discussions of residents' readiness for promotion and graduation.4Make residents aware of the EPAs, as these are defined, and that supervisors will judge them regarding levels of supervision, first ad hoc and later in a summative sense. Residents should also know that the general qualities of integrity, reliability, and humility will be considered in these entrustment decisions.;What You Can Do LONG TERM 1Use guidelines to assist the process7 of defining and elaborating EPAs for curriculum development and to integrate entrustment as a core approach to assessment.2Implement faculty development starting with the clinical competency committee. EPAs and levels of supervision often feel more natural to clinicians compared to competency-based rating scales. However, clinicians' frames of reference may differ when judging residents' readiness for unsupervised practice.3Build high-stakes summative entrustment decisions based on information from multiple sources (eg, short practice observations, multisource feedback, knowledge/skills tests).4True summative entrustment decisions for EPAs require that the public (regulators, insurers, and patients) understand that physicians-in-training can be ready to bear full responsibility for specific tasks. Be an advocate for a new view on certification and licensing.