It’s two o’clock in the morning. The phone rings, waking the on-call attending physician from what had been a sound sleep. A resident is calling to review a case she has been asked to evaluate in the emergency department. She feels the patient has stabilized and can be sent home with arrangements for outpatient follow-up, but must “clear” that decision with her supervising physician.
The resident, a qualified physician having graduated from a fully accredited medical school over two years ago, is now in the third year of specialty training. The attending physician has only a casual acquaintance with this particular resident, never having worked directly with her before, but is aware that she is generally considered to be very capable and reliable.
The patient’s presenting problem is neither unusual nor particularly complex. The information provided is complete. The attending physician asks a couple of further questions that are competently answered. Finally the attending asks, “so are you comfortable sending this person home, or would you like me to come in to review him with you?” The resident confirms that she is satisfied with the decision and doesn’t see a need for further review. They hang up. Both go back to bed. The attending physician may or may not get back to sleep.
This scenario, played out countless times in countless variations every day in teaching hospitals, illustrates the concept of entrustment. For entrustment to occur, the essential operative driver is trust.
Many definitions of trust are available, but the one that I think best captures the key elements relevant to the clinical setting is provided by Mayer et al (Acad Manag Rev 1995;20:709):
“The willingness of a party to be vulnerable to the actions of another party based on the expectation that the other will perform a particular action important to the trustor, irrespective of the ability to monitor or control that other party.”
So how does this occur? What allows the attending physician to accept “vulnerability” and trust in the judgment of the resident sufficiently to agree to a plan of action without personal verification? What, for that matter, allows any person to trust another?
There has been much written on this topic, dating back to ancient philosophy. Trusting, it seems, is a rather complex, distinctly human and highly personal interaction. It requires a relationship between the person who grants the trust (the trustor) and the one who is trusted (the trustee). The vulnerability that the trustor accepts is based a number of assumptions, but principally their assessment of two key attributes of the trustee: their capability, and their motivation to do the right thing. The whole matter is further complicated by the fact that trust is usually contextual, but may become unconditional. We begin by trusting a specific person within the limits of a certain task or scope of responsibility. We may, with continued experience and appropriate reinforcement, extrapolate and extend that sphere of trust. To do so, the trustor is required to judge broader attributes of the trustee, which will determine their willingness to extend trust further, to more complex situations.
In medical education, this is no abstract or purely philosophical issue. As illustrated by the scenario above, the concept of endowed trust has been, and continues to be, central to the provision of competent, safe care in our clinical teaching centres. In fact, it’s becoming increasingly complex in settings where the interaction between supervising physicians and trainees is more sporadic and truncated (as illustrated above), and where the sheer volume of cases requires efficient decision making. The concept of admitting patients to hospital for “observation” has become a thing of the past.
Moreover, as we move toward the concepts of Entrustable Professional Activities and Competency Based Assessment, our medical schools will be grappling with the challenge of developing methods by which these “entrustment decisions” can be made objectively within our increasingly busy and hectic workplaces.
This was the topic of a recent webinar provided by the Office of Faculty Development and featuring Dr. Olle ten Cate, widely regarded as the originator and major proponent of EPAs in medical education. Among the many insights he provided was a consideration of the key elements that should inform an entrustment decision. It begins with simple ability, which consists largely of knowledge and technical skills. Ability is relatively easy to observe and assess in brief encounters. It’s also fairly straightforward to simulate encounters so they can be practiced or tested, as with OSCEs. However, entrustment also involves a number of key elements that are much more complex and difficult to objectively assess, including integrity (truthfulness, honesty), reliability (consistency) and humility (awareness of limitations). These latter attributes defy objective quantification, can’t be reliably assessed in a single encounter, and are very difficult to simulate for practice or examination purposes. They require longitudinal observation, in a variety of clinical situations, carried out by appropriately oriented and consistent observers. They require, in fact, a continuing relationship between teacher and learner.
And so, to borrow a phrase from Hamlet, “there’s the rub”. Those continuing relationships, so essential to the development of trust, are notoriously difficult to establish in our current clinical clerkships and residency training programs, where teachers and learners collide almost randomly, de-linked by separate and independent schedules. What’s more, when they do come together, the number of learners, clinical volumes and primacy to expedite patient care makes it even more difficult to establish effective relationships. Paradoxically, the long abandoned apprenticeships and long, service-based clinical placements were, in some ways, much more suited to establishing the continuing workplace relationships that allowed this longitudinal, more holistic approach to assessment and entrustment decisions.
And so, what to do? We certainly can’t and shouldn’t attempt to turn back the clock. But can we learn from prior experience to develop a clinical workplace that better promotes more effective teacher-learner coordination, and therefore more valid entrustment decisions? Obviously there are no easy fixes, but a few observations are offered that may have some relevance:
Maximizing continuing contact between teacher-preceptors and learners is key. Coordination of assignments and call schedules is logistically challenging and would require coordination of multiple, currently siloed administrations, but would be well worth the effort, and should perhaps be seen as a priority and strategic direction for undergraduate and postgraduate programs. Integrated, community- based programs provide an environment much more conducive to establishing effective entrustment decisions. In this regard, Family Medicine programs are leading the way and may provide valuable guidance. Social programs and team building exercises involving trainees and faculty members, once a common component of training programs, may play a prominent role in building effective working relationships. We are, quite simply, more likely to trust people we know personally. Finally, it might well be time to reconsider the role of attending physician, and the assumption that the same individual can simultaneously manage a busy clinical service and provide effective educational supervision.
Clarity with respect to the scope of entrustment for each individual learner will facilitate decisions. In other words, teachers and learners need to be “on the same page” with regard to expectations. Dr. ten Cate refers to a “zone of proximal development” as the difference between what the learner has already mastered and the next level of proficiency. It’s important for both parties to not only understand the task for which entrustment is provided, but the level of proficiency or degree of resolution with respect to that task. This, of course, gets back to the issue of relationship and need for a greater level of understanding between trustor and trustee. It involves better communication regarding individual learner needs, and more targeted faculty development.
Transmission of learner information between programs is essential. We need to come to grips with our collective paranoia about “forward feeding” and develop effective means to get relevant and useful information about individual learner needs, goals and teaching requirements to the right people. Both learners and faculty must appreciate that the goal is to enhance the educational experience, not prejudice decisions. In this regard, the soon to be released Learner Handover Project initiated through the Future of Medical Education in Canada initiative and chaired by Dr. Leslie Nickell will provide a valuable contribution.
The concept of entrustment means we will occasionally (hopefully rarely) be required to say someone is not yet ready to take on a particular task, or advance within a program. We must be willing to engage these situations objectively and constructively. The development of key abilities essential to any discipline requires time, practice and immersion in the appropriate training environment. However, the attributes of integrity, reliability and humility can (and should) be identified early in the educational process. This provides an appropriate “division of labour” between undergraduate and postgraduate programs. Undergraduate programs, in addition to focusing on the development of appropriate foundational knowledge and skills, should ensure they are admitting and graduating individuals with the appropriate personal attributes to engage any field of medical practice. Postgraduate programs should be able to assume the individuals entering their programs are worthy of entrustment, and can concentrate on the development of discipline specific expertise.
Stephen R. Covey, the late educator and author of “The Seven Habits of Highly Effective People” describes trust as “the glue of life…the most essential ingredient in effective communication…the foundational principle that holds all relationships”. In the end, trust is about people, effective working relationships and open communication. Our challenge is to find ways to ensure this uniquely human, essential ingredient can develop and flourish despite the challenges of our increasingly complex and stressed clinical learning environments.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education