By: Neel Sharma, MBChB, MSc, National University Hospital Singapore and Harvard Macy Institute
Michael Whitcomb highlighted his concerns regarding an overemphasis on competency-based medical education in his commentary published earlier this year. We are now beginning to see a further shift in the paradigm of competency-based education to one of entrustment. Entrustment, or more precisely entrustable professional activities, highlights the importance of determining when a trainee can be entrusted to perform a particular task unsupervised.
As a trainee, I have two concerns with this notion. First, is it really something novel? During my training thus far, initially in internal medicine and now in gastroenterology, although my supervisors never explicitly use the word entrustment, they certainly have been signing off on my knowledge, skills, and attitudes on the basis of their confidence in my abilities. I don’t recall them using the exact term entrustment, but it has been implied by the very nature of the supervision process. For example, a trainee is deemed competent to complete an upper GI endoscopy after having adequately completed the various elements of the procedure (e.g., successful sedation, oesophageal intubation, and biopsy sampling) over a prolonged period of time.
The second concern I have is in regards to the post training phase. There are countless scenarios in which trained specialists face situations that are difficult to manage. Again using the example of an upper GI endoscopy, there are times when even specialists may find a case difficult to treat and must rely on their colleagues to assist them (e.g., with a concerning GI bleed). Are specialists then deemed incompetent? Do they face concerns regarding entrustment? Of course not. Maintenance of certification in the United States and revalidation in the United Kingdom are meant to ensure that specialists undergo regular reassessment. Interestingly, the concept of entrustment does not feature in these processes. Surely doctors of every level should be subjected to the same umbrella of regulations.
Innovation, or apparent innovation, in medical education is fast paced. While there was a time when the field changed very little, we now have seemingly constant change. However, such change is often limited to the education of trainees, when in fact, training never ends. Advancement in the field should apply even to specialists who must learn to adapt accordingly. Entrustment therefore requires clarity. If any doctors are assessed for entrustment then all doctors should be, even those in practice. Without this requirement, entrustment is simply a term used to potentially add value to the competency-based education system. Yet, in reality, it probably adds very little to a system that currently serves this purpose well.