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

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.

The concept of entrustable professional activities (EPAs) has recently emerged. It connects competencies with practice^2,3  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).

Since Aristotle, philosophers and researchers have identified conditions that must be met before someone trusts another person and is willing to be vulnerable for the associated risks,^4,5  which can be summarized in 4 words: Ability, Integrity, Reliability, and Humility (table 1).

Entrustment decisions combine traditional assessment of ability with the right to execute an EPA without supervision (or with indirect supervision only). EPA-based entrustment decisions thus reflect the stepwise acceptance of a trainee to become part of the medical or specialty community. However, distinctions between ad hoc and summative entrustment decisions must be made (table 2).

Being evaluated on an EPA means that the learner is being judged on his or her readiness to provide care under a specified level of supervision that decreases, as trainees increase in their competence and skills. A 5-level rating scale has been proposed: at Level 1, the trainee is ready to be present and observe; at Level 3, the trainee is ready to act under indirect supervision; and at Level 5, the trainee is ready to provide supervision to junior learners.²  Each of the 5 levels has direct consequences for the trainee and for patient care. EPA decisions imply the acceptance of risks related to patient safety. Balancing thoughtful challenges for learners and adequate supervision is necessary.

All residents must be evaluated using each specialty's competency specific milestones. Using an EPA rating scale of supervision is not in conflict, but can be aligned with milestones which also usually have 5 anchor levels. The figure illustrates how competencies and milestones can be combined into an EPA in actual practice.⁶  In this example, the key competencies for an EPA decision are MK, ICS, and PBLI.

• 1

  Determine 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.

• 2

  Reframe 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.

• 3

  Clinical competency committees can include these features in discussions of residents' readiness for promotion and graduation.

• 4

  Make 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.

• 1

  Use guidelines to assist the process⁷ of defining and elaborating EPAs for curriculum development and to integrate entrustment as a core approach to assessment.

• 2

  Implement 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.

• 3

  Build high-stakes summative entrustment decisions based on information from multiple sources (eg, short practice observations, multisource feedback, knowledge/skills tests).

• 4

  True 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.