The medical education community is currently seeing a move toward entrustment or entrustable professional activities (EPAs)—in essence determining when a learner can be entrusted to perform an unsupervised activity.1 As the literature mounts in this field, institutions are beginning to discuss how to best adapt their curricula to this format.
As a keen educationalist and very much a junior educator, I would like to raise some concerns in the hope to better understand the value of the entrustment-based approach.
First, what do we exactly mean by trust? Trust is a subjective term. In addition, the movement toward competency-based education was made to objectify the training structure. If trust in essence is subjective, multiple supervisors will assume different stances in their judgment of a given trainee's readiness for practice at a given level of supervision, which is a move away from an objective approach to the training experience. Second, having worked in both Eastern and Western nations, trust has different connotations.2 In the East, trust is earned based on a personal relationship. In the West, trust is granted almost automatically from the start, unless an event occurs that hinders this. Hence, do entrustment decisions take into consideration the different meanings of trust globally? And what does trust look like as learners move from East to West and vice versa?
Entrustment decisions are also made in a temporal context. As I am in the latter stages of my training, I and the faculty attending physicians supervising me may come across complex and unusual patient cases, and it is not clear whether or how entrustment decisions are affected accordingly. That is the very nature of the field we are in. I also have observed that what occurs in my seniors' day-to-day practice is not what would be expected by a new starter. If I take the first EPA example of history and examination for entering residency, in view of ever-increasing work demands, I would have to say my mentors have rarely undertaken a complete history or examination. This is not a fault of their own but a consequence of the pressured system we work in, as well as the abundance of technology that aids in diagnosis. Therefore, it seems that there may be a mismatch between what we expect of learners and what physicians in practice do in reality (essentially a fine case of “do as I say not as I do”).
To date, we have limited evidence to suggest that entrustment will enhance education and clinical outcomes in the long term. Therefore, I wonder, pragmatically, what are we trying to achieve?
