When Do Supervising Physicians Decide to Entrust Residents With Unsupervised Tasks?
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Patient Safety
When Do Supervising Physicians Decide to
Entrust Residents With Unsupervised Tasks?
Anneke Sterkenburg, MD, Paul Barach, MD, MPH, Cor Kalkman, MD, PhD,
Mathieu Gielen, MD, PhD, and Olle ten Cate, PhD
Abstract
Purpose using trigger case vignettes to solicit factors that determine entrustment into
Patient-care responsibilities stimulate opinions on factors that affect four groups: characteristics of the
trainee learning but training may entrustment decisions. resident, the attending, the clinical
compromise patient safety. The authors context, and the critical task.
investigated factors guiding clinical Results
supervisors’ decisions to trust residents Thirty-two attending anesthetists and 31 Conclusions
with critical patient-care tasks. residents answered the questionnaire Residents’ and attendings’ opinions and
(response rate 58%), and 10 participants impressions differ regarding what is
Method from each group were interviewed. expected from residents, what residents
In a mixed quantitative and qualitative Attendings varied in their opinions actually do, and what residents think
descriptive study carried out at University regarding how much independence to they can do safely. The authors list
Medical Center Utrecht, Utrecht, the give residents, particularly postgraduate factors affecting why and when
Netherlands, from March to September year (PGY) 2, 3, and 4 residents. PGY1 supervisors trust residents to proceed
2008, the authors surveyed attending residents reported working above their without supervision. Future studies
anesthetists and resident anesthetists expected level of competence but should address drivers behind
regarding when attendings should estimate their own ability as sufficient, entrustment decisions, correlations with
entrust each of six selected critical tasks whereas PGY5 residents reported patient outcomes, and tools that enable
to residents. The authors conducted working below their expected level of faculty to justify their entrustment
structured interviews with both groups, competence. The authors classified decisions.
Editor’s Note: A commentary on this article appears to approach this dilemma is to instate a term for doing something that is just
on pages 1399 –1400. number of critical procedure attempts beyond the learner’s competence, or the
residents must successfully complete gap between what the learner already can
D eciding when a trainee is ready for
before particular competency levels can
be assumed.3–5 Another approach
do and what he or she is about to learn to
do, is “constructive friction.” When
unsupervised patient care is not easy.
incorporates qualitative performance supervisors entrust learners, including
Early unsupervised care can impact the
feedback, and given residents’ different medical trainees, with only routine
patient’s safety, add to the cost of care,
learning curves, this one is perhaps more activities, learning is likely to be too slow
and increase liability for the supervisor
defensible because supervisors decide to or absent. Conversely, too much
and/or the organization. In contrast, not
entrust a clinical or procedural responsibility required at too early a stage
enough self-guided and independent
responsibility to a resident deliberately may result in adverse effects for—in the
decision making may negatively affect the
and only after careful consideration— case of medicine— both the patient and
trainee’s learning curve and timely
rather than automatically after a set the trainee. Educational psychologists
achievement of competence. In
amount of time. This crucial decision have labeled both of these situations
competency-driven postgraduate medical
training, residents must combine learning should be based on the trainee’s phase of “destructive friction.”9 –11
new and critical materials with taking training, on a valid assessment of his or
increasing responsibility for safe patient her competence for the specific task, and Ten Cate12 introduced the concept of
care.1,2 Learning cannot occur without a on patient acuity.6 However, a myriad of “entrustable professional activity” (EPA)
first time to independently perform other factors also affect such decisions, to signify the professional tasks that
procedures and make decisions. One way and these are not well understood. To medical trainees need to master during
our knowledge, no valid instrument is postgraduate training that require
available to robustly assess, given these entrustment decisions by clinical
Please see the end of this article for information varying factors, the level of independence supervisors. EPAs are useful units of
about the authors. that a trainee deserves. analysis for establishing a competency-
Correspondence should be addressed to Dr. ten based curriculum. Ten Cate and Scheele13
Cate, Center for Research and Development of Carrying out activities that are just at the used EPAs to define five levels of
Education, University Medical Center Utrecht, PO Box
85500, 3508 GA Utrecht, the Netherlands; edge of one’s competence can stimulate responsibility and proficiency (i.e.,
telephone: (!31) 88-755-7010; fax: (!31) 88-755- maximum comprehension and a steep having limited knowledge, acting under
3409; e-mail: t.j.tencate@umcutrecht.nl. learning curve,7,8 but a paucity of studies close supervision, acting under
Acad Med. 2010;85:1408 –1417. support this phenomenon in clinical supervision on call, acting independently,
doi: 10.1097/ACM.0b013e3181eab0ec practice.9 An educational psychology and supervising others). They postulated
1408 Academic Medicine, Vol. 85, No. 9 / September 2010Patient Safety
four groups of factors that may influence Purpose analysis. We compensated the respondents
decisions regarding whether or when a The aims of the study, an exploration of the with a €15 (#$22) gift certificate. We
trainee is ready to execute a critical dynamics of competency-based clinical constructed two versions of the
activity independently (Figure 1). The training, were (1) to investigate whether questionnaire: one for faculty members and
first factor group focuses on the ability of clinical faculty members have a general one for residents.
the trainee. The second group, which can conception about which EPAs they should
be especially hard to measure, includes entrust—and to what extent at each stage of For the questionnaires, we identified
factors relating to the personality of the the training—to residents, (2) to study through a literature review, and selected
supervisor. The third factor group whether the EPA framework is in accord through a consensus discussion, six
encompasses the environment and not only with residents’ feelings of self- critical EPAs that residents must master
circumstances (e.g., the time of day, efficacy for each EPA but also with the over the course of the anesthesiology
facilities, and personnel present) in which actual level of responsibility at which residency. Residents regularly perform
the activities are executed. Finally, the residents have been asked to work, and (3) the six chosen EPAs during the required
fourth factor group entails the nature and to explore the human factors that training program, and the American
complexity of the activity. The activity determine whether a faculty member trusts Board of Anesthesiology (ABA) lists all
becomes more complex as several a resident to perform a critical activity. six as core competencies necessary for
competencies are required in concert for completing the ABA certification
successful and safe execution. Recently, a requirements.17 Three senior
focus-group study conducted in a Dutch Method anesthesiology coauthors (C.K., P.B., and
obstetrics–gynecology postgraduate M.G.), all experienced in training
training program confirmed the validity Setting residents, came to a consensus on the
of these four factor groups.14 Three of We conducted the study between March complexity of each EPA. They ranked the
these groups of factors (i.e., those and September 2008 at the Department EPAs in order of increasing responsibility
pertaining to the trainee, the supervisor, of Anesthesiology of the University level from 1 to 6, taking into account
and the clinical issue) align with a recent Medical Center (UMC) Utrecht, Utrecht, both the complexity and the unique
study of Kennedy and colleagues, 15 the Netherlands. The department offers a nature of the task, the training
which highlighted the drivers that five-year postgraduate anesthesiology requirements residents needed to
encourage trainees to request clinical residency program in an academic complete the task, and each task’s
support. Clearly, none of these four hospital (four years) and community potential to harm the patient. The six
factor groups act independently, but they setting (one year). Residents, while on EPAs selected—(1) intubation of patient
do represent discrete and measurable call, work in pairs of a junior airway, (2) administering spinal
constructs. (postgraduate year [PGY] 1–3) and a anesthesia, (3) arterial line placement, (4)
senior (PGY4 or 5) resident. At night and central venous line placement, (5)
during weekends, senior residents anesthetic management of an American
We interviewed trainers and trainees, directly supervise their less experienced Society of Anesthesiologists Classification
exploring when, and under which colleagues. Both residents are supervised 1 (ASA 1) patient, and (6) administering
constraints, attending anesthetists entrust by an attending physician who is on call, thoracic epidural anesthesia—demonstrate
critical activities to anesthesia residents. but not necessarily on-site, and who may a sufficient amount of variance in required
We chose anesthesiology because this need as many as 25 minutes to arrive in competence, and all receive substantial
specialty contains many tangible the operating room. During weekday attention throughout the training program.
entrustment decisions. Anesthesiology shifts (Monday through Friday 8 AM until
postgraduate training in the Netherlands 11 PM) attending physicians are on-site. The questionnaire asked faculty members
is currently transitioning to new standard to identify which EPAs residents should
requirements, which derive from the master at what level of competency and at
Population
CanMEDS competency model and are what year of postgraduate training. We
comparable to the six Accreditation We invited all faculty anesthetists (n "
defined mastery as “ready for
Council on Graduate Medical Education 52) and residents (n " 56) at UMC
unsupervised practice,” as judged by the
competencies.16 Utrecht to participate in the study. We
faculty respondents themselves. Because
fully informed all the participants of both
this was an exploratory study, we aimed
the purpose and procedures of the study
to find out how faculty valued these
during a general staff meeting. We recruited
levels, so we did not provide strict
the clinicians through e-mail. We sent two
instructions beforehand. We asked the
reminder e-mails to nonresponders
respondents to indicate a level of
approximately two and three months,
assumed proficiency for each of the six
respectively, after the first invitation.
EPAs per PGY of training, using a 0 to 5
scale, based on the aforementioned five
Instruments and procedures levels of proficiency from our previous
All respondents received an electronic work13: 0 " the resident does not have
Figure 1 Factors that determine whether questionnaire which was first piloted with relevant knowledge or skills to perform
attendings entrust residents with critical several respondents and then refined. We the EPA, 1 " the resident should have
patient-care activities within the clinical gave each participant a code, and we knowledge but is not competent, 2 " the
learning environment. removed all identifiers from the data before resident should act only under direct,
Academic Medicine, Vol. 85, No. 9 / September 2010 1409Patient Safety
close supervision, 3 " the resident should members’ and residents’ answers. We consent form because we allowed
act only under supervision on call, 4 " used qualitative data analysis software participants to opt out at any time.
the resident should be able to act (MAXQDA, Berlin, Germany; version
independently, or 5 " the resident 2007) to analyze the interview transcripts.
should be able to supervise others. The analysis began by open coding, that Results
is, sorting and labeling the data by Characteristics of the respondents
The residents’ questionnaire required content. We attempted to place the data Of the 52 attending anesthetists involved
them to rate their self-efficacy for each into one of the four predefined categories in postgraduate training, 32 (62%)
EPA from 0 to 5, using a scale similar to described above (Figure 1). For example, completed the questionnaire. Nineteen
that of the attendings. We also asked the after the interviewer presented a case respondents (59%) were male, and 13
residents, again using a similar 1 to 5 vignette, one attending might say, “This (41%) were female. The mean age of the
scale, to indicate the highest level at patient is obese, has a beard … there are a attendings was 46 (range: 32–61; SD:
which they had performed the given lot of risks involved. I would definitely 8.8). Half of the attending anesthetists
activities in the last three months. come if a resident is young or not practiced general anesthesiology, whereas
experienced enough in my eyes.” We the others worked in subspecialties: 4
We invited a random sample of 10 would assign this comment the main (13%) worked in pediatric
supervising faculty members and 10 category code “Nature of the task” and anesthesiology, 3 (9%) in pediatric
residents to participate in follow-up the subcode “The risk of (severe) cardiothoracic anesthesiology, 4 (13%) in
interviews. A secretary picked names in complication,” plus the main code adult cardiothoracic anesthesiology, and
random order from an existing list. We “Factor in the resident” and subcodes 1 (3%) in intensive care. Three attendings
personally informed all participants “resident’s stage of training” and “resident’s (9%) were fellows. We categorized faculty
about the interview process and assured estimated experience.” A.S. did all initial respondents into three groups based on
their confidentiality. We offered coding. Then, all of us further refined the years of practice and experience in
interviewees a €50 ($75) gift certificate categories (e.g., what to include in postgraduate training with cutoff points
for completing the interview. A senior “circumstances”) through discussions. at 5 and 15 years. Thirteen faculty
anesthetist from a different academic After all the quotes were coded, we counted members (41%) were junior attendings
medical center who was not involved in them. We used the frequency of comments ($5 years of experience), 12 (37%) were
the UMC Utrecht residency training or and the fact that some interviewees clearly intermediate (5–15 years of experience),
supervision (M.G.) conducted in-person noted some reasons for trust as most and 7 (22%) were senior (%15 years).
interviews with faculty members. A important to create a rank order of
young physician trainee, not involved in importance within each of the four Of the 56 residents, 31 (55%) completed
the anesthesiology training program categories. the questionnaire. Of these, 12 (39%)
(A.S.), conducted in-person interviews were male, and 19 (61%) were female.
with the residents. The interviews were Ethical considerations
The mean age of the residents was 31
semistructured and lasted about 30 to 45 We minimized the potential harm to years (range: 24 –39; SD: 3.7). The study
minutes. We gave the same guidance to residents and faculty by having a junior population consisted of 7 PGY1 residents
both interviewers, and they both asked physician (A.S.), not employed in the (23%), 5 PGY2 residents (16%), 4 PGY3
the same questions in the same order. We hospital and not acquainted with the residents (13%), 9 PGY4 residents (29%),
used two emergency night case vignettes respondents, carry out the resident and 6 PGY5 residents (19%).
as triggers to explore factors that interviews. We employed a senior
influence entrustment decisions. In anesthesiologist (M.G.) not employed by All of the participants whom we initially
addition to the case vignettes, we the hospital, to carry out the faculty approached for interviews agreed to
presented to faculty members a list of all interviews. We ensured the confidentiality participate. Of the faculty members who
possible resident pairs, in each program of the interviewees and stressed the participated in an interview, 3 (30%)
year, and asked them to indicate, first, voluntary nature of the interviews. The were junior, 5 (50%) intermediate, and 2
which of the two residents they would interviews started with an explanation of (20%) senior. Six out of 10 (60%)
choose to perform a specific task and, the purpose of the study, and no provided anesthesia for general surgery, 2
second, what factors would make them interviewees indicated that their risk of (20%) for adult cardiothoracic surgery, 1
trust one resident over the other. The participating exceeded the benefits of this (10%) for general pediatric surgery, and 1
interviewers (A.S. or M.G.) audio-recorded study. Because we invited all eligible (10%) for pediatric cardiothoracic
the 20 interviews, and A.S. transcribed residents and faculty to participate, surgery. Three (30%) of the residents
them verbatim, removing all identifiers equitability was not an issue. All transcribed interviewed were PGY1, 5 (50%) were
from the transcripts. The interviewers interviews were coded before analysis and PGY4, and 2 (20%) were PGY5. Half of
(M.G. and A.S.) also took extensive field seen only by A.S., M.G., O.t.C., and a the residents who were interviewed were
notes during the interview process. secretarial assistant. We coded all junior, and the other half were senior
questionnaires before processing them. We residents. (The pediatric rotation in the
Data analysis sought informed consent at three fourth year concludes the junior stage of
The questionnaire data were analyzed moments: during a staff meeting, in a training, which explains why some PGY4
with statistical software (SPSS Inc., personal e-mail to each potential residents are still junior.)
Chicago, Illinois; version 15.0). We participant, and during an introductory
calculated frequencies, mean scores, and explanation preceding the interview. We We found no significant differences on any
the discrepancy scores between faculty did not have participants sign an informed parameters between the participating
1410 Academic Medicine, Vol. 85, No. 9 / September 2010Patient Safety
Figure 2 Percentages of attending anesthesiologists (n " 32) expecting residents to be ready for unsupervised practice by postgraduate year and by
entrustable professional activity (ASA 1 " American Society of Anesthesiologists Classification 1).
attendings and residents and the total still in training ready to execute particular pronounced with central venous line
pool of attendings and residents, but activities by themselves. But, as Figure 2 placement and arterial line placement in
there were slightly (nonsignificant) shows, at least one attending would PGY1. By the end of PGY5, there is
more female resident respondents and consider PGY2 residents ready to general concordance between what
slightly (nonsignificant) fewer senior independently execute five of the six EPAs. residents are asked to do in practice
attending respondents. and what the faculty expect them to be
able to do, as indicated in the
Expected levels of proficiency at Discrepancy among expectations, questionnaire; however, PGY5 residents
subsequent stages of training perceived abilities, and actual practice actually perform some EPAs (i.e.,
Figure 2 shows how the attendings’ Residents report performing EPAs at higher administration of spinal anesthesia and
expectations of residents’ proficiency levels than faculty members expect, administration of thoracic epidural
differ throughout the residents’ course of particularly in the early years of their anesthesia) at a lower level of
training. A large variation exists among training (Figure 3, Table 1). This potentially responsibility than expected. In general,
faculty regarding the competencies concerning discrepancy is most residents estimate their level of
expected in terms of both PGY and clinical
EPAs. The differences among the six EPAs
in degree of difficulty and risk (“intubation
of patient airway” being the least difficult
and risky, and “administration of thoracic
epidural anesthesia” being the most
difficult and risky) were confirmed by
systematic differences found; for example,
attendings consider residents ready to
independently perform arterial line
placement relatively early in their training
but do not feel they are able to administer
thoracic epidural anesthesia until much
later. Most faculty members consider
residents ready to execute the six target
EPAs (except administering thoracic
epidural anesthesia) independently from Figure 3 Mean proficiency levels: (A) How proficient attending anesthetists expect residents to
PGY3 and PGY4 onward; however, a few be, (B) the level at which residents think they think they can perform, and (C) the level at which
faculty never consider residents who are residents have actually been asked to perform.
Academic Medicine, Vol. 85, No. 9 / September 2010 1411Patient Safety
Table 1
Staff and Residents’ Indication of the Level of Responsibility by Year of
Training (1–5) at Which Residents Should Perform, Think They Can Perform,
and Have Been Performing
Residents’
self-reported
3-month
highest level
Residents’ own of task
Faculty expectation perceived ability execution
Postgraduate Standard No. of
Entrustable professional activity year Mean deviation (SD) residents Mean SD Mean SD
Intubation of patient airway 1 1.84 0.45 7 2.43 0.54 2.57 0.54
..........................................................................................................................................................................................................................
2 2.75 0.62 5 3.80 1.10 3.40 1.14
..........................................................................................................................................................................................................................
3 3.47 0.72 4 4.25 0.96 4.00 1.16
..........................................................................................................................................................................................................................
4 4.25 0.72 9 4.78 0.44 4.78 0.44
..........................................................................................................................................................................................................................
5 4.75 0.57 6 4.83 0.41 4.83 0.41
Administering spinal anesthesia 1 1.78 0.55 7 2.00 1.00 2.00 0.63
..........................................................................................................................................................................................................................
2 2.81 0.59 5 3.40 1.11 3.20 0.84
..........................................................................................................................................................................................................................
3 3.48 0.81 4 4.25 0.50 3.50 0.58
..........................................................................................................................................................................................................................
4 4.22 0.71 9 4.78 0.44 4.33 0.82
..........................................................................................................................................................................................................................
5 4.75 0.51 6 4.67 0.82 4.17 0.75
Arterial line placement 1 1.81 0.74 7 3.86 0.69 3.57 0.79
..........................................................................................................................................................................................................................
2 2.97 0.78 5 4.60 0.55 3.80 1.10
..........................................................................................................................................................................................................................
3 3.75 0.80 4 4.75 0.50 4.75 0.50
..........................................................................................................................................................................................................................
4 4.53 0.62 9 4.89 0.33 4.78 0.44
..........................................................................................................................................................................................................................
5 4.81 0.47 6 5.00 0.00 4.83 0.41
Central venous line placement 1 1.25 0.67 7 3.14 1.07 3.00 0.82
..........................................................................................................................................................................................................................
2 2.31 0.64 5 4.00 1.00 3.40 0.55
..........................................................................................................................................................................................................................
3 3.22 0.61 4 4.25 0.50 3.75 0.96
..........................................................................................................................................................................................................................
4 4.16 0.77 9 4.67 0.50 4.56 0.53
..........................................................................................................................................................................................................................
5 4.69 0.54 6 5.00 0.00 4.83 0.41
Anesthetic management of 1 1.72 0.52 7 2.29 1.11 2.83 0.75
..........................................................................................................................................................................................................................
American Society of
2 2.75 0.51 5 3.80 1.10 3.20 0.84
Anesthesiologists Classification ..........................................................................................................................................................................................................................
1 patient 3 3.35 0.80 4 4.00 0.82 3.50 0.58
..........................................................................................................................................................................................................................
4 4.28 0.68 9 4.89 0.33 4.43 0.54
..........................................................................................................................................................................................................................
5 4.78 0.49 6 4.83 0.41 5.00 0.00
Administering thoracic epidural 1 0.84 0.45 7 1.57 0.79 1.67 0.52
..........................................................................................................................................................................................................................
anesthesia 2 1.81 0.38 5 2.80 0.84 2.80 0.84
..........................................................................................................................................................................................................................
3 2.52 0.63 4 3.75 0.50 3.50 0.58
..........................................................................................................................................................................................................................
4 3.44 0.72 9 4.00 0.87 3.83 0.41
..........................................................................................................................................................................................................................
5 4.47 0.62 6 4.67 0.82 4.17 0.41
Mean values across EPAs 1 1.54 7 2.55 2.61
..........................................................................................................................................................................................................................
2 2.57 5 3.73 3.30
..........................................................................................................................................................................................................................
3 3.30 4 4.21 3.83
..........................................................................................................................................................................................................................
4 4.15 9 4.67 4.45
..........................................................................................................................................................................................................................
5 4.71 6 4.83 4.64
competence higher than the level at Interview results residents’ ability to competently
which attendings deem them competent Five themes emerged consistently perform those EPAs. The other four
to execute activities. In a few instances, throughout the interviews. One themes aligned with the predefined
residents feel they are instructed to perform involved the relationship between, on groups of factors affecting entrustment
an EPA above their level of competency one hand, the EPAs that residents (factors related to the resident, to the
(e.g., PGY1 residents managing an ASA 1 actually performed and, on the other, attending, to the clinical context, and
patient; Table 1). the residents’ and attendings’ views of to the task itself).
1412 Academic Medicine, Vol. 85, No. 9 / September 2010Patient Safety
I understand. Also, they can give you
Table 2 pointers on how to improve your skills.
(Resident, PGY1)
Factors That Determine Entrustment Decisions*
Factors mentioned by I think it is a good thing that supervisors
Residents Faculty Total watch you perform occasionally. You
Factors (n!10) (n!10) (n!20) might think you are doing fine, and that
you do not need any supervision any
Factors in the trainee 10 10 20 more, but that might just be the point
.........................................................................................................................................................................................................
Acquaintance with the resident 9 10 19 where you start making mistakes.
.........................................................................................................................................................................................................
Stage of training 7 10 17 (Resident, PGY4)
.........................................................................................................................................................................................................
Plan or overview of the case 7 8 15
......................................................................................................................................................................................................... Yes, sometimes I do perform activities on
Communication skills 9 5 14 a higher level, but since there is always
.........................................................................................................................................................................................................
Estimated experience 6 8 14 supervision around, these are
.........................................................................................................................................................................................................
Own request 9 4 13 opportunities for me to grow. (Resident,
.........................................................................................................................................................................................................
Knowledge of limitations and when to 6 6 12 PGY4)
call for help
......................................................................................................................................................................................................... You learn to work independently,
Prior work experience 4 6 10
......................................................................................................................................................................................................... especially in the second year of training
Apparent self-confidence 6 4 10 [done in community hospital]. When I
.........................................................................................................................................................................................................
Working proficiency 1 9 10 do not feel competent, when I do not
.........................................................................................................................................................................................................
General medical competence 3 6 9 trust myself, I just tell my boss I need
......................................................................................................................................................................................................... help. When you ask for supervision, you
Trustworthiness 2 7 9
......................................................................................................................................................................................................... always receive it. (Resident PGY4)
Reliability 0 7 7
.........................................................................................................................................................................................................
Medical knowledge 1 5 6
......................................................................................................................................................................................................... Factors affecting entrustment. As
Adherence to tasks 1 3 4
mentioned, we were able to place all
Factors in the supervisor 10 9 19 factors (that, according to our 20
.........................................................................................................................................................................................................
General experience and specific 10 5 15 interviewees, determine the amount of
experiences
......................................................................................................................................................................................................... trust that supervisors have in their
Sense of medical responsibility 5 9 14 trainees) within the four groups we
.........................................................................................................................................................................................................
Prior patient experiences 9 2 11 hypothesized were important. Table 2
.........................................................................................................................................................................................................
Sense of urgency 4 7 11 gives an overview of the 30 factors that
.........................................................................................................................................................................................................
Sense of educational responsibility 5 5 10 faculty and residents identified during the
.........................................................................................................................................................................................................
Subspecialty 0 3 3 interviews.
Circumstances 10 7 17
......................................................................................................................................................................................................... A. Factors in the trainee. Both residents
Number of qualified personnel 7 4 11
available and faculty stated that the attendings’
.........................................................................................................................................................................................................
Physical distance of the supervisor to 5 5 10 mere acquaintance with the trainee and
the patient his or her level of training were
.........................................................................................................................................................................................................
Legal issues involved 3 3 6 important for making decisions to trust
.........................................................................................................................................................................................................
Presence of competing medical tasks 3 2 5 residents with EPAs. In fact, attendings’
......................................................................................................................................................................................................... acquaintance with the resident was
Time of the day 2 0 2
......................................................................................................................................................................................................... mentioned in 19 of the 20 interviews. We
Conditions and equipment available 0 1 1
calculated, on average, 3.55 comments
Nature of the task 9 10 19 regarding this factor per interview—more
.........................................................................................................................................................................................................
Condition of the patient 9 9 18 than for any other topic, except “working
.........................................................................................................................................................................................................
Difficulty of the task 6 6 12 proficiency” (three interviewees
.........................................................................................................................................................................................................
The risk of (severe) patient 5 4 9 repeatedly mentioned clinical skills as a
complications core factor, but only one of the residents
* The numbers in bold indicate how many residents and how many faculty mentioned any Factors in the trainee, mentioned this, and then only twice).
any Factors in the supervisor, any Circumstances, or any item related to the Nature of the task. Knowing the resident does not
necessarily mean that a faculty member
will always trust him or her, and recent
experiences with residents weigh heavily
Working, related to supposed level of perceive performing above their in faculty’s entrustment decisions.
ability. Residents were comfortable with expected level of competence as
the training program’s expectations. uncomfortable or unsafe either. If I have worked several times with the
same resident, I am better able to
They did not think that executing Yes, it happens sometimes that I receive determine the level of competence of that
activities with more supervision than supervision on activities I have done by resident and whether he is capable
they thought they needed hampered myself many times before. Your enough to execute activities. (Faculty,
their learning, but they usually did not supervisor is your trainer and assessor, so intermediate level)
Academic Medicine, Vol. 85, No. 9 / September 2010 1413Patient Safety
I call my supervisor and tell him I think I Sometimes, your supervisor will ask you if Attendings stated that whether or not
can handle the case, but if he has never you want him to come; when you admit they actually oversee a procedure is not
seen me work … I think that makes it you do, there is never any discussion, he
always balanced against trusting
hard for him to determine whether or not will come, no questions asked. (Resident,
he can trust me. (Resident, PGY1) PGY4) the resident, but it also depends on the
responsibility they feel for both the
Faculty also consider the quality and patient and the residents they train.
Attendings consider whether a resident is
comprehensiveness of the trainee’s plan
aware of his or her limitations to be very You just have to be there for your
to be important. This consideration
important. resident, even though you know he can
includes an estimation of the trainee’s
probably handle the case just fine.
preparation and insight into potential This resident performs well, but I (Faculty, intermediate level)
patient complications that may occur in sometimes have trouble assessing what I
choosing one clinical plan over another can trust him to do. He does not seem to As a supervisor, you are responsible for
plan. know when he needs to call for help. what goes on in your practice. (Faculty,
(Faculty, intermediate level) intermediate level)
When a resident consults me, I value the
quality of his plan highly when making a I think it is important that my supervisor The amount of trust can be influenced by
decision in the amount of trust I give. can trust that I will call before I get into the attitude of the supervisors toward
Having little to add to his plan gives me trouble. (Resident, PGY4)
clinical training.
confidence that he can handle the case.
(Faculty, intermediate level) The supervisor’s knowledge of the It is necessary for a resident’s confidence
trainee’s clinical skills and working to perform on his own sometimes. I
I think it is important for my supervisors usually peek through the OR window to
to hear me present the case in an orderly
manners is also important.
make sure he is doing well, so I’m there
and complete way, which shows them I without the resident realizing I am.
This resident is very skilled and knows
know what I am doing. (Resident, PGY4) (Faculty, senior level)
what he is doing. (Faculty, senior level)
For faculty, competence is not entirely
Clearly, supervisors’ knowledge of the C. Circumstances. Attendings state that
dependent on the year of training.
resident’s competencies and attitudes entrustment decisions also depend on the
Interviewees acknowledged learning
weighs on their judgment. We have the clinical environment, including the
curve differences among residents.
impression that the mere lack of quality and availability of the team
Residents’ competencies can differ within acquaintance leads to fewer independent surrounding the resident.
their year of training, especially in the first
year of training. When a resident has
responsibilities and more scrutiny and It is also important whether or not my
worked at an intensive care unit prior to that, conversely, the mere fact that the resident gets enough support from other
starting residency training I tend to put supervisor knows the resident generally team members. (Faculty, senior level)
more trust in him than if he would have leads to more readily granted
started residency training straight after It makes a difference whether the junior
responsibilities. who is with me on call is in his first or in
medical school. Also, some residents
evolve faster while others need more time his third year; faculty members know
B. Factors in the supervisor. All residents that. (Resident, PGY5)
to master skills. (Faculty, intermediate
level) mentioned that characteristics of the
supervisor, such as their general After 11 PM, an attending can take call
In general, faculty assume more experience and specific expertise, can either at home or in the hospital.
independence in senior residents, as these affect entrustment decisions. Decisions on whether or not to entrust
residents are supposed to be ready to residents with clinical tasks are affected
graduate soon and become certified There are differences among supervisors; by the attendings’ whereabouts.
specialists. For junior residents, I think it has to do with their experience.
For example, a more senior boss has more It depends on where I am. In this
attendings state that the clinical
experience in assessing residents and will particular situation, if I am at home I will
experience, such as managing acute care have fewer problems letting a resident come to the hospital. If I am already here,
patients prior to residency, is important. perform certain tasks independently than I would tell my resident to call me when
would a junior supervisor. (Resident, he needs me. (Faculty, junior level)
If a first-year resident has already worked PGY1)
at an ICU for two years, I will probably let I live too far away to go home when I am
him execute activities, such as arterial line I think a supervisor who has recently lost on call. And since I am already here … it’s
access, more independently than a first- a patient in a similar case will just come, if easy to just be there and see how my
year resident who entered the program only for his own confidence. (Resident, resident is doing. (Faculty, junior level)
straight after medical school. (Faculty, PGY4)
intermediate level) It makes a difference where my supervisor
I made a deal with him: “You can watch is. If he is at home, he will have to decide
If residents state that they do not feel if he can trust me to perform on my own,
or try once, and you have to tell me what
confident, they generally receive you see.” He failed to do both. I had poor whether or not it is necessary to postpone
supervision, whether or not a faculty judgment; it was misplaced trust on my execution of activities for 15 minutes or
member trusts a resident to execute an side. That situation had its effect later on. so. If he is here already … it’s easier, he
activity. A week later, he again was my junior will be here whether it is really necessary
resident, and thinking back, I believe I did or not. (Resident, PGY4)
When a resident asks me to assist him, I not let him do as much as I would
will, even if I do not think it is really normally have allowed him to do. Residents also stated that the time of day
necessary. (Faculty, senior level) (Resident, PGY5) and mere convenience can each be a
1414 Academic Medicine, Vol. 85, No. 9 / September 2010Patient Safety
factor in the amount of trust that an than attendings consider justified. trainee. In fact, supervisors must judge
attending places in them. Interestingly, PGY1 residents reported the interplay of factors related to the (1)
that, in the last three months, they had resident, (2) the EPA, and (3) the clinical
This may sound strange, but also the time
been assigned responsibilities beyond the circumstances, including the facilities and
of day…. It can make a difference when
you call your supervisor at 11 PM, when level that attendings on average indicate the available clinical support of the
he is still awake and alert, or in the middle as justified for this stage. The residents microsystem.19,20 Table 2 may therefore
of the night. When you wake him, I think themselves see few problems with this serve as a first step in developing an
sometimes he might be less eager to situation, as they also perceive their entrustment decision support model and
come. (Resident, PGY4) abilities to usually meet or exceed those checklist. Sufficient acquaintance with
It’s contradictory sometimes. For
necessary to perform these assignments. the resident, the resident’s stage of
example, during the day, you receive full To determine whether residents training, the availability of other
supervision on a spinal needle placement overestimate their abilities or not is personnel, the difficulty of the task, the
on an ASA 2 patient who comes in for an difficult. Successfully and independently risk of complications, and the condition
ACL reconstruction, and in the middle of executing a critical activity that exceeds of the patient all seem important. These
the night I find myself managing an ASA one’s expected ability, if no factors may appear self-evident; however,
3 patient without supervision. (Resident,
complications occur, may boost they presently create much ambivalence
PGY4)
residents’ self-efficacy.18 Self-confidence and anxiety among faculty, and not
D. Type of activity. Both faculty and is needed to stimulate further understanding these factors and their
residents stated that the condition of the development, and it may be natural, even interplay could potentially lead to much
patient, the team, and discrete steps of educationally necessary, for trainees to ambiguity and patient harm. For
the EPA are important in entrusting overestimate their ability somewhat. example, the finding that the quality of
decisions. However, the supervisor’s judgment to patient care is inadvertently
limit independent execution of EPAs is compromised during the time of the year
For such a complicated case I will just critical if a trainee’s overconfidence may when more inexperienced residents are
come, the risks are too high. (Faculty,
intermediate level)
compromise patient safety (e.g., when employed in hospitals allows hospital
airway intubations take longer than they leaders to act on that information.21
I think the most important [thing] for my should, thoracic epidurals overshoot the
boss is the case, how the patient is doing. epidural space, or central lines require We suggest that these factors may be
(Resident, PGY4) several needle punctures). operationalized in a robust manner and
give faculty the tools to make better
Discussion We found substantial differences among decisions when faced with deciding
surveyed attendings’ views of which whether to entrust residents with
We explored when and why attending activities residents should be able to clinical activities.
anesthesia specialists decide to trust handle across varying stages of training.
residents to execute critical patient-care Factors related to individual residents, We recognize several limitations to the
tasks. Residents’ and attendings’ the clinical circumstances, or the nature study. We confined our study to a single
expectations differ with regard to what is of the EPA affect differences across EPAs, Dutch anesthesia training program, and
expected from residents, what residents but factors related to the supervisor seem thus our findings need to be replicated in
actually do, and what residents think they especially important for individual EPAs other clinical settings to determine
can do safely. (Figure 2). This greater importance could external generalizability. Further,
Attendings generally agree more on the reflect the supervisor’s estimation of the qualitative studies involving interviews
levels of responsibility residents should difficulty or complexity of the EPAs and his bear an inherent risk of subjectivity
have at the beginning and end of training or her estimation of the risk to patients. because the interviewer can influence the
than in their views about how much nature of the interview, and other
responsibility residents should have in Through the interviews, we identified 30 researchers may find different themes. To
the intervening years (PGY2–4). One factors that influence entrustment minimize these risks, we structured our
surveyed faculty member would not fully decisions. All of these factors fit within interviews with a carefully scripted
entrust any resident with any EPA at any the four categories we defined in an interview guide, and we identified
stage. It is tempting to speculate on the earlier study13: factors related to the relevant factors using factor analysis and
reasons for these differences among resident, supervisor, clinical theme saturation. We assessed only six
faculty, but any suggestions would need circumstances, and patient-care task. EPAs, and assessing other clinical
further analysis. Our impression is that Given the expected levels of proficiency domains might yield additional factors,
overbearing attendings may lead residents to at different stages of training, the but these would most likely overlap with
be more hesitant, resulting in attendings multitude of factors involved helps the factors we identified above.
trusting residents less, whereas open and explain the differences among the
engaging attendings likely give the resident attendings’ entrustment decisions. To our knowledge, this is the first time
space to grow and think, resulting in greater a study has assessed the opinions of
trust. More in-depth studies are needed to The appropriate amount of trust individual faculty and trainees on
substantiate this speculation. attendings should place in a resident in a entrustment decisions. Dijksterhuis and
particular year of training cannot be colleagues14 conducted a related, focus-
Residents, especially trainees in PGY1, 2, determined in a generalized sense but group study among obstetrics–gynecology
and 3, estimate their own abilities higher must be individually customized to the faculty and trainees, but our study yields
Academic Medicine, Vol. 85, No. 9 / September 2010 1415Patient Safety
factors on a more detailed, generalizable, determine supervisors’ decisions to 3 Konrad C, Schüpfer G, Wietlisbach M,
and actionable level. Dijksterhuis and entrust residents with patient-care tasks. Gerber H. Learning manual skills in
anesthesiology: Is there a recommended
colleagues make a conceptual distinction These studies might aim to validly number of cases for anesthetic procedures?
between levels of competence and degrees measure these decisions or to understand Anesth Analg. 1998;86:635–639.
of independence, whereas we consider the whether and how entrustment decisions 4 de Oliveira Filho GR. The construction of
level of competence a measure of the can play an important part in assessing learning curves for basic skills in anesthetic
procedures: An application for the
trainee. In another study of internists and trainees. If entrustment decisions can be cumulative sum method. Anesth Analg. 2002;
emergency medicine physicians, Kennedy better validated, they may lead to more 95:411–416.
and colleagues15 used a similar formalized statements of awarded 5 Sites BD, Gallagher JD, Cravero J, Lundberg
methodology but from a different angle. responsibility that could be included as J, Blike G. The learning curve associated with
a simulated ultrasound-guided interventional
Their questions was not, “When do milestones in a trainee’s competency task by inexperienced anesthesia residents.
supervisors entrust responsibility?” but, portfolio.13,26 Such an advance could Reg Anesth Pain Med. 2004;29:544 –548.
rather, “When do trainees ask for help?” accelerate the development of a 6 Ten Cate O. Trust, competence and the
They found that factors in the resident, competency-based training program. supervisor’s role in postgraduate training.
BMJ. 2006;333:748 –751.
factors in the supervisor, and the nature of These programs support patient and 7 Vygotsky LS. Chapter 6: Interaction between
the clinical question (i.e., those related to provider educational outcomes, and they learning and development. In: Cole M, John-
the EPA) determine the requests. are more influenced by the quality of care Steiner V, Scribner S, Souberman E, eds.
Requesting help from an attending and and the providers’ actions than the mere Mind in Society: The Development of Higher
Psychological Processes. Cambridge, Mass:
deciding to trust a resident are intimately educational content or duration of the Harvard University Press; 1978:79 –91.
related, and we feel the Kennedy and training program. 8 Cantillon P, Macdermott M. Does
colleagues’ study supports our findings. In responsibility drive learning? Lessons from
Dr. Sterkenburg was, at the time of this study,
another recent qualitative study, Ginsburg research associate, Center for Research and
intern rotations in general practice. Med
Development of Education, University Medical
Teach. 2008;30:254 –259.
and colleagues22 interviewed 19 9 Kennedy TJ, Regehr G, Baker GR, Lingard
Center Utrecht, Utrecht, the Netherlands.
experienced internal medicine attendings LA. Progressive independence in clinical
on qualities of outstanding, average, and Dr. Barach was, at the time of this study, training: A tradition worth defending? Acad
problematic residents. They came up with anesthetist, Department of Anesthesiology; he Med. 2005;80(10 suppl):S106 –S111.
currently is visiting researcher, Patient Safety Center, 10 Vermunt JD, Verloop N. Congruence and
eight clusters of factors, based on a University Medical Center Utrecht, Utrecht, the friction between learning and teaching. Learn
grounded theory approach, that are similar Netherlands. Instr. 1999;9:257–280.
to our findings (Table 2, “Factors in the 11 Ten Cate O, Snell L, Mann K, Vermunt J.
Dr. Kalkman is professor of anesthesiology,
trainee”), but they also uncovered Orienting teaching toward the learning
Department of Anesthesiology, and director, Patient
process. Acad Med. 2004;79:219 –228.
additional resident qualities, such as work Safety Center, University Medical Center Utrecht,
12 Ten Cate O. Entrustability of professional
Utrecht, the Netherlands.
ethic, leadership skills, and impact on staff. activities and competency-based training.
These factors do not overlap with ours but, Dr. Gielen is senior anesthetist, University Medical Med Educ. 2005;39:1176 –1177.
Center St. Radboud, Nijmegen, the Netherlands. 13 Ten Cate O, Scheele F. Competency-based
rather, seem to supplement them. This
postgraduate training: Can we bridge the gap
indicates that further studies will be helpful Dr. ten Cate is professor of medical education and between theory and clinical practice? Acad
to complete the picture of factors that affect director, Center for Research and Development of Med. 2007;82:542–547.
Education, University Medical Center Utrecht, 14 Dijksterhuis MG, Voorhuis M, Teunissen
decisions to entrust critical care to trainees.
Utrecht, the Netherlands. PW, et al. The assessment of competence and
progressive independence in postgraduate
Finally, we hope this study will help to Funding/Support: None. clinical training. Med Educ. 2009;43:1156 –
improve postgraduate training. The 1165.
study’s findings fit into the competency- Ethical approval: This study was exempt from 15 Kennedy T, Regehr G, Baker GR, Lingard L.
ethical approval by the ethical review board of Preserving professional credibility: Grounded
based postgraduate training models that the University Medical Center Utrecht, Utrecht, theory study of medical trainees’ requests for
have emerged in recent years.2,13,20,23–25 the Netherlands (See also “Method / Ethical clinical support. BMJ. 2009;338:b128.
Construct assessments that address both considerations,” above). 16 Scheele F, Teunissen P, Van Luijk S, et al.
trainee competence and patient safety are Introducing competency-based postgraduate
Conflicts of interest: None. medical education in the Netherlands. Med
necessary. Current methods of assessing
Teach. 2008;30:248 –253.
clinical competence, which use duration Previous presentations: Some of the results of this 17 The American Board of Anesthesiology.
of training as a major criterion, may not study were orally presented at the 2009 meeting Examinations and certifications. Available at:
be sufficient. Assessments should include of the Association for Medical Education in http://www.theaba.org/Home/examinations_
certifications. Accessed June 1, 2010.
both measuring the amount of trust Europe (Malaga, Spain) and the 2009 Annual
18 Bandura A. Social Foundations of Thought
attendings place in residents and Meeting of the American Society of
and Action: A Social Cognitive Theory.
Anesthesiologists (New Orleans, Louisiana).
understanding why they do so. Englewood Cliffs, NJ: Prentice-Hall; 1986.
Understanding entrustment decisions 19 Mohr J, Batalden P, Barach P. Integrating
patient safety into the clinical microsystem.
and including them in assessing and Qual Saf Health Care. 2004;13(suppl 2):ii34 –
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