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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2823_Библиотеки_им_академика_М_И_Перельмана
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is ready for indirect supervision, based on their experience in
various settings. Performing a quick check of the important
competency domains may confirm this, and the conclusion
may be drawn that the trainee meets Milestone level 3 of the
relevant competencies. Both procedural and nonprocedural
specialties have now reported success in organizing regular
assessments of postgraduate trainees (e.g., residents, fellows,
etc.) by scoring on an entrustment-supervision scale,
assuming alignment with Milestones scales.
73,153,154
EPAs – Competencies – Skills
While EPAs are units of work and competencies are
descriptors of personal qualities and abilities, in common
language educators tend to call “physical examination” a
competency. Strictly speaking, the competency is not the
physical examination itself; the ability to perform a physical
examination is the skill and is a feature of the learner or
professional. And it would be correct to say that physical
examination skill, on a more detailed level, requires manual
skills, visual skills, auditory skills, and even time
management and communication skills. If a learner possesses
these skills, or competencies, the learner may be granted the
trust to do the physical examination without supervision.
Simply put, health professionals require an integrated set of
abilities (i.e., competencies) to effectively execute the clinical
activity (i.e., EPA).
155
EPAs Across the Continuum and Nested
EPAs
Activities can be small or large. There is no easy answer to
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what is the “right” breadth of EPAs and consequently to the
right number of EPAs. If the question is “What is the scope of
responsibility that is covered when an EPA is entrusted to a
trainee for indirect supervision?” then clearly big differences
can arise depending on the stage of training of the trainee in
question. The first EPA that may be entrusted to a junior
medical student could be “Measuring blood pressure.” If we
consider this a unit of professional practice or activity that
one can trust a trainee to complete without being checked by
a supervisor, then it is a true EPA.
But clearly, at a later stage this responsibility is part of a full
standard physical examination that is a more logical activity
for entrustment for advanced medical students. The full
standard physical examination, in turn, can be included in a
broader EPA of a standard outpatient consultation that also
includes the history. In technical terminology, smaller EPAs
are nested within larger EPAs.
Among the Utrecht University undergraduate EPAs is the
clinical consultation, and it is to be entrusted to any medical
school graduate before graduation for indirect supervision.
This is a relatively broad EPA, as it requires neurological,
ENT, gynecological, psychiatric, and other history and
physical examination skills. In the Utrecht curriculum,
students are to be entrusted with a focused “neurological
clinical consultation” at an earlier stage, and likewise for
other specialities during a dedicated clerkship. Only in the
final year do all these smaller EPAs become nested within a
broader EPA, leading to full trust in the broad EPA of the
clinical consultation and signed off separately in a
subinternship for indirect supervision (Fig. 1.10).
156
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FIG. 1.10 Nested EPAs.
For EPA-based evaluation, it is therefore adequate to
design EPAs for a particular course within the educational
continuum (e.g., EPAs for undergraduate education, to be
mastered before entering residency),
157
EPAs for the end of
training in general surgery,
158
or EPAs for a fellowship.
159–161
This does not mean that the EPAs are only mastered at the
end of that training period. Indeed, key to competency-based
training is that EPAs may be mastered and awarded with a
decrease in supervision and increase in autonomy as soon as
the trainee demonstrates the required competence.
Entrustment Decision-Making as
an Assessment Approach
Evaluating trainees with a focus on EPAs has the potential
benefit that it aligns with the daily practice of clinician
thinking. Much of it naturally focuses on whether clinical
activities are carried out well, both their own activities in the
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care of patients and those care activities of others. Rewarding
success in (1) diagnostic reasoning and therapeutic actions
and (2) patient satisfaction is an important driver to monitor
competence and quality of care.
162,163
From this, a series of
recommendation can be derived. Consider first focusing on
EPA execution, then looking at competencies.
When using EPAs, the primary focus of the learner
assessment is whether a job is being done well enough
(competently per Dreyfus) that direct supervision is no
longer required. In many cases, there is little need to make
detailed evaluations of all the competencies involved, but
faculty using an EPA-based assessment must possess an upto-date, evidence-based mental model of the clinical task.
Failure to fully incorporate and understand all the key
competencies needed places both patient and learner at risk:
the patient may receive suboptimal care and the learner may
receive suboptimal feedback and coaching as well as
inappropriate supervision moving forward. For learners who
do not perform optimally, systematically breaking down the
deficiencies in specific competency domains can support a
more effective analysis (“diagnosis” of the learning
difficulties) and facilitate more effective remediation (see
Chapter 17). In addition, understanding which competencies
are most important for the EPA can support better feedback
and coaching by providing specific language about what was
done well and what areas for improvement might exist.
Simply telling the learner they “did well” on the EPA is not
helpful feedback (see Chapter 14). The EPAs-Competencies
Matrix and Milestone descriptions may help identify
weaknesses and coach learners to improve.
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Distinguish Three Benchmarks or
Frames of Reference for Assessment
Educators often struggle in assessing learners due to lack of
clear standards, benchmarks, or appropriate frames of
reference (see Chapters 3, 4, and 5). Often, educators struggle
using criterion-referenced judgments (e.g., appropriate and
effective care of the patient with multiple chronic conditions)
versus normative-referenced judgments (e.g., is Robert as
good as Jane at this stage of training?). Educators also often
struggle in determining whether a learner should score
higher because they made great progress after a previous
observation, because they exerted extraordinary effort, or
because they perform as well as the educator does (i.e.,
normative and self as frame of reference). This leads to three
types of benchmarks being used for assessment and feedback
provision: (1) comparison with evidence and standards of
professional practice (expected performance based on best
available evidence); (2) comparison with other trainees or self
(how well do others do at similar stages of training or
compared to the faculty’s own standard of practice); and (3)
comparison with past development (how much has the
trainee progressed since the last assessment). Naturally, in
competency-based training, evidence-based standards for
adequate practice must form the benchmark for certification,
which is a criterion-referenced measure. However, learners are
usually evaluated with a mix of benchmarks because
criterion referencing is not easy. In any case, assessors should
at least be clear and transparent in expressing how the
benchmarks are defined based on the context and purpose of
assessment, and those being assessed should be aware of
expectations for their performance.
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Frame the Assessment as a
Developmental Entrustment Decision
Trusting a learner to work unsupervised, if even occasionally,
requires a broader view than simply measuring a skill in an
examination. The question in the back of one’s head is:
Would I trust this trainee to execute this EPA tomorrow
morning with a critical patient (or maybe a relative of mine)
without a supervising professional present? This question
about trust includes other features of the trainee besides their
knowledge and skill, such as their discernment of their own
limitations, willing to ask for help if needed,
conscientiousness in carrying out clinical tasks, and
truthfulness in communications to staff. Milestones 2.0 now
includes a specific subcompetency of reflective practice.
66,123
While leniency bias is a known and common problem of
workplace-based assessments (WBAs),
164–166
cautious
entrustment decisions might lead to the opposite; that is, a
stringency bias (“I will never fully trust a learner as long as
they are in training”). But this clearly leads to graduates who
are ill prepared for autonomous practice.60 Recent studies in
surgery also show that an increase in close supervision and a
corresponding decrease in autonomy of trainees in the past
decades has not particularly increased patient safety.
166–168
On the contrary, entrustment with unsupervised practice
for an EPA—that is, with only distant supervision as long as
learners are in training—provides them with necessary
autonomy experience before they leave training. Fig. 1.11
shows how, when the threshold of trust has passed and a
summative decision of entrustment with unsupervised
practice has been made, a learner can rise to higher levels of
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proficiency. “Competent” characterizes this threshold.
FIG. 1.11 Entrustment thresholds and stages of professional
development.
Entrustment Decisions Require the
Acceptance of Risks
Core in the definition of trust is the “acceptance of risk and
vulnerability, based on a positive expectation of the
intentions and behavior of the other.”
169–172
Ten Cate and
colleagues further added that “trust involves the confident
expectation that a person (i.e., the trainee) can be relied on to
honor implied or established commitments to an individual
and to protect the individual’s (i.e., faculty and patient)
interest. It renders the individual (faculty and patient)
vulnerable to the extent (s)he cannot oversee or control the
actions of the other, on whose expertise or integrity (s)he may
depend.” Trust in clinical trainees is an area of investigation
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that is sure to get more attention in the coming years,
including the role of intuition, gut feelings, and heuristics in
making entrustment decisions.
170,171
As noted earlier, the
context needs to be considered when making entrustment
decision. Risks may vary and range from breaching
confidentiality and hurting and confusing the patient, to
neglecting critical information, overestimating ability,
inadequately testing diagnostics, and applying the wrong
therapies and recommendations. These must all be avoided,
but adverse events also depend on contextual variables and
can never be fully excluded, and trainees must learn how to
act when they arise.
Align Scales With Supervision
Recommendation
Alignment of the constructs of clinical practice and
assessment of learners is likely to lead to enhanced reliability.
For example, Weller et al. used scales using the descriptors of
“supervisor required in the theater suite – supervisor
required in hospital – supervisor not required” for the
evaluation of anesthesiology residents;
172
and George et al.
used a (Zwisch) scale for surgical residents with “show and
tell – active help – passive help – supervision only”
signifying the required role of the supervisor during
surgery.
173
Both authors report increased reliabilities when
using these scales compared to a traditional one. The scale in
Fig. 1.11 and Table 1.4 is a more general representation of this
idea, but more detail may be added, depending on the stage
of training or the setting or specialty (see Chapter 4).
Table 1.6
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Alignment of Various Models of Development
MileStone
Level
Dreyfus
Model
Stages
Learner
Behavior
RIME Stages Transition to
Practitioner
1 Novice Doing what is
told, rule
driven
Reporter Introduction
to clinical
practice
2 Advanced
beginner
Comprehension Reporter/interpreter Guided
clinical
practice
3 Competent Application to
common
practice
Interpreter/manager Early
independence
4 Proficient Application to
uncommon
practice
Manager/educator Full
unsupervised
practice
5 Expert Experienced
clinician
Educator Aspirational
growth after
graduation
RIME, Reporter-Interpreter-Manager-Educator.
Distinguish Ad Hoc Entrustment
Decisions From Summative Entrustment
Decisions
Entrustment decisions may be distinguished as ad hoc
entrustment decisions, which happen every day in the moment,
are usually taken by individual supervisors, and pertain to
immediate permission for the trainee to act; or summative
entrustment decisions, which are grounded in more systematic
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observation and lead to permission to act under a specified
level of supervision, comparable to the driver’s license that
formalizes permission to drive unsupervised from that point
onward, but may need to be reviewed at some later point in
time. Ad hoc entrustment decisions per se do not have longterm consequences but may stimulate development and
evaluation of trainee readiness for summative decisions.
Conversely, a summative entrustment decision is a general
statement that must be documented, awards a higher level of
responsibility for future actions, and should be recognizable
by third parties. Summative entrustment decisions should
involve systematic processes and practices (see Chapter 3
).
Both are important in EPA-based curricula. The ad hoc
decision experiences of a supervisor may be documented in
the trainee’s portfolio (Was this a justified decision? If not,
why not? Would the observer recommend a summative
entrustment decision soon?).
Summative decisions may be informed by multiple ad hoc
decisions supplemented with information gathered through
other channels (multisource feedback, knowledge
assessment, skills assessment). Summative entrustment
decisions should be multisource decisions based on the
summation of smaller elements of information. Summative
entrustment decisions for level 4 over supervision may look
like certifications, STARS, or digital badges that may be
accessible for collaborators such as ward nurses or the
outside world.
174
As these should signify current
competence, a summative entrustment decision for level 4 of
an EPA should potentially be retracted if the individual does
not maintain the practice of the EPA, either within the
training or after training. Renewed supervision should then
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