Basics of Competency-Based Medical Education

What Is Entrustment?

Entrustment is a key decision-making component of competency-based medical education (CBME), addressing the transition from a novice needing extensive direct supervision to an independent physician capable of providing care without supervision. Entrustment decisions seek to do more than assess knowledge or skills in isolation; it is intended to be an informed judgement by faculty about whether a resident can carry out their professional responsibilities as a physician independently.

What Are Key Elements of Entrustment?

• Decision-oriented: Entrustment is a discrete decision. A resident is either entrusted with the activity under consideration, such that they can perform it in the appropriate context at the designated level of independence or they cannot.1 As resident become more proficient, they may move through levels of independence, but an informed decision based on robust assessment data should be made at each level.
• Linked to specific outcomes: Entrustment is associated with an explicit outcome. Typically, these outcomes encompass observable, workplace-based skills, knowledge, and attitudes.
• Progressive responsibility: Entrustment occurs along a continuum. Residents will progress from needing direct supervision to indirect supervision to independent practice. The level of independence aligns with development of clinical competency.
• Trust as a core element: Entrustment is more than just an assessment of a clinical skill. It encompasses an informed judgement that a resident can perform a task with discernment, managing potential complications, and recognition of their own limitations. In other words, the resident can be trusted as reliable in performing the task.
• Context-dependent: Entrustment decisions are based on a resident’s competency and influenced by external factors such as clinical setting and patient complexity. The question becomes not just can a resident perform this task, but can this resident perform this task within a specific clinical context, with the ability to recognize likely complications, manage those complications and ask for help when needed?
• Dynamic and ongoing: Although entrustment decisions are discrete, the continuum of entrustment relies on ongoing, longitudinal assessment of learners. Resident readiness for entrustment for independent practice evolves as they gain experience, confidence, and opportunity for growth.

How Would I Use Entrustment Assessments and Decisions?

• Assessment of competence: Entrustment complements milestone-based assessments and evaluates residents’ readiness for independent practice
• Guiding supervision levels: Entrustment can inform decisions on transition from direct supervision to indirect supervision. Entrustment decisions are based on agreed upon outcomes or benchmarks. As learners demonstrate the required knowledge, skills, and attitudes of a particular benchmark, they can be entrusted to decreased supervision and eventually independent practice.
• Summative decision-making: Entrustment is used by CCCs and other decision-making bodies to determine readiness for advancement and promotion, including transition to unsupervised practice.
• Ensuring patient safety: Entrustment helps to balance resident autonomy with patient safety by ensuring that only those who are adequately prepared perform critical tasks independently.

Definitions

• Competence: mastery in multiple areas of clinical skills, within the context of and specific to stage of medical education or practice, this considers the transition to independent practice (Consider the Core Outcomes of Family Medicine).
• Competencies: specific observable clinical skills and attitudes of the physician in the domains of competence that can be measured and assessed. Competencies incorporate the specific components that illustrate a learner’s progression towards competence. (Consider the ACGME Competencies, Subcompetencies, and Milestones).
• Entrustment: a judgement on the level of responsibility/supervision needed for specific skills

Five Core Components of CBME

• An outcomes-based competency framework
• Progressive sequencing of competencies
• Learning experiences tailored to the competencies in CBME (time/number not the driver; tied to ability and entrustment; and flexibility for individual progression)
• Teaching tailored to competencies (responsive to individual needs; learners actively engaged; and coaching model used)
• System of assessment in place (multi-source and multi-assessor, rooted in direct observation; attention to bias; and system for decision-making with progression based on entrustment)

Important Elements of Competency-Based Medical Education

• Multi-source and multi-assessor assessment with direct observation
• Coaching and reflection
• Goal-setting and deliberate practice
• Flexible and adaptable learning experiences
• Self-regulated and self-directed learning
• Time as a resource for instruction and skill development