From Competency to Entrustment in Medical Education

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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.

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One Comment

  1. Juan Perez-Gonzalez, MD, PhD
    October 3, 2016 at 9:18 AM

    With all due respect for Dr. Sharma’s opinions, I believe that they result from the misinterpretation of the term “entrustment”. This is not only, and, in my opinion, not even mainly, related to competence. The latter refers to the skill and ability with which a professional carries out his activities, and is, of course, a fundamental component of professional accreditation. “Entrustment” refers to this and also to the judgement that a doctor applies to his professional activities. A doctor can be competent and not be “entrustable”. To use Dr. Sharma’s own example, a perfectly competent GI specialist would not be “entrustable” if he or she is willing to undertake a delicate procedure when experimenting a hangover, or when being very tired, conditions that increase the risk of procedural error. The GI specialist who finds a case difficult to treat and asks his colleagues assistance is more “entrustable” than the one who carries on by himself. Doctors who see patients in a hurry are less “entrustable” than those who give each patient the appropriate time. Entrustment is the elusive attribute that makes even doctors select between two equally competent colleagues the one to whom a close relative is to be referred.
    Recertification and revalidation are not about “entrustment”. They are about keeping up to date with the new concepts, techniques and procedures that continually come into use in our specialties. Self-directed learning competencies and the right attitude towards learning are the attributes required for successful recertification or revalidation. However, a doctor who uses those attributes successfully would, indeed, be more “entrustable” than one who doesn’t.
    The main contribution of the Competency approach to Medical Education has been to abandon the paradigm that knowledge and skill are the main ingredients of professional competence, and to bring to the attention of educators other attributes that are also contributory and are often underestimated during the undergraduate and postgraduate formative years. The concept of “entrustment” fits well with this more holistic conception of medical practice.