The Greater Good: How Supervising Physicians Make Entrustment Decisions in the Pediatric Emergency Department



      Graduate medical education is transitioning to the use of entrustable professional activities to contextualize educational competencies. Factors influencing entrustment decisions have been reported in adult medicine. Knowing how such decisions are made in pediatrics is critical to this transition.


      To understand how supervisors determine the level of procedural supervision to provide a resident, taking into consideration simulation performance; to understand factors that affect supervisors' transparency to parents about residents' procedural experience.


      We conducted 18 one-on-one interviews with supervisors in a tertiary care pediatric emergency department, iteratively revising interview questions as patterns in the data were elucidated. Two researchers independently coded transcripts and then met with the investigative team to refine codes and create themes.


      Five factors influenced supervisors' entrustment decisions: 1) resident characteristics that include self-reported confidence, seniority, and prior interactions with the resident; 2) supervisor style; 3) nature of the procedure/characteristics of the patient; 4) environmental factors; and 5) parental preferences. Supervisors thought that task-based simulators provided practice opportunities but that simulated performance did not provide evidence for entrustment. Supervisors reported selectively omitting details about a resident's experience level to families to optimize experiential learning for residents they entrusted to perform a procedure.


      In pediatrics, supervisors consider various factors when making decisions regarding resident procedural readiness, including parental preferences. An educational system using entrustable professional activities may facilitate holistic assessment and foster expertise-informed decisions about residents' progression toward entrustment; such a system may also lessen supervisors' need to omit information to parents about residents' procedural readiness.


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        • Ten Cate O.
        Entrustability of professional activities and competency-based training.
        Med Educ. 2005; 39: 1176-1177
        • Van der Vleuten C.P.
        • Schuwirth L.W.
        Assessing professional competence: from methods to programmes.
        Med Educ. 2005; 39: 309-317
        • Balmer D.F.
        • Master C.L.
        • Richards B.
        • Giardino A.P.
        Implicit versus explicit curricular in general pediatrics education: is there a convergence?.
        Pediatrics. 2009; 124: e347-e354
        • Zibrowski E.M.
        • Singh S.I.
        • Goldszmidt M.A.
        • et al.
        The sum of the parts detracts from the intended whole: competencies and in-training assessments.
        Med Educ. 2009; 43: 741-748
        • Ten Cate O.
        Nuts and bolts of entrustable professional activities.
        J Grad Med Educ. 2013; 5: 157-158
        • Ten Cate O.
        • Scheele F.
        Competency-based postgraduate training: can we bridge the gap between theory and clinical practice?.
        Acad Med. 2007; 82: 542-547
      1. Hauer KE, ten Cate O, Boscardin C, et al. Understanding trust as an essential element of trainee supervision and learning in the workplace. Adv Health Sci Educ Theory Pract. 2014;19:435-456.

        • Jones Jr., M.D.
        • Rosenberg A.A.
        • Gilhooly J.T.
        • Carraccio C.L.
        Competencies, outcomes, and controversy—linking professional activities to competencies to improve resident education and practice.
        Acad Med. 2011; 86 ([perspective]): 161-165
        • Sterkenburg A.
        • Barach P.
        • Kalkman C.
        • et al.
        When do supervising physicians decide to entrust residents with unsupervised tasks?.
        Acad Med. 2010; 85: 1408-1417
        • Dijksterhuis M.G.
        • Voorhuis M.
        • Teunissen P.W.
        • et al.
        Assessment of competence and progressive independence in post graduate clinical training.
        Med Educ. 2009; 43: 1156-1165
        • Aldeen A.Z.
        • Gisondi M.A.
        Bedside teaching in the emergency department.
        Acad Emerg Med. 2006; 13: 860-866
        • Kozer E.
        • Scolnik D.
        • Macpherson A.
        • et al.
        Variables associated with medication errors in pediatric emergency medicine.
        Pediatrics. 2002; 110: 737-742
        • Bandiera G.
        • Lee S.
        • Tiberius R.
        Creating effective learning in today's emergency departments: how accomplished teachers get it done.
        Ann Emerg Med. 2005; 45: 253-261
        • Mittiga M.R.
        • Geis G.L.
        • Kerrey B.T.
        • Reinderknecht A.S.
        The spectrum and frequency of critical procedures performed in a pediatric emergency department: implications of a provider-level view.
        Ann Emerg Med. 2013; 61: 263-270
        • Mittiga M.R.
        • Schwartz H.P.
        • Iyer S.B.
        • Gonzalez Del Rey J.A.
        Pediatric emergency medicine experience: requirements versus reality.
        J Grad Med Educ. 2010; 2: 571-576
        • Del Beccaro M.A.
        • Shugerman R.P.
        Pediatric residents in the emergency department: what is their experience?.
        Ann Emerg Med. 1998; 31: 49-53
        • Auerbach M.
        • Chang T.P.
        • Reid J.
        • et al.
        Are pediatric interns prepared to perform infant lumbar punctures? A multi-institutional descriptive study.
        Pediatr Emerg Care. 2013; 29: 453-457
        • Kessler D.O.
        • Arteaga G.
        • Ching K.
        • et al.
        Interns' success with clinical procedures in infants after simulation training.
        Pediatrics. 2013; 131: e811-e820
        • Carraccio C.L.
        • Englander R.
        From Flexner to competencies: reflections on a decade and the journey ahead.
        Acad Med. 2013; 88: 1067-1073
        • Carraccio C.
        • Burke A.E.
        Beyond competencies and milestones: adding meaning through context.
        J Grad Med Educ. 2010; 2: 419-422
        • Miller W.
        • Crabtree B.
        Depth interviewing.
        in: Crabtree B. Miller W. Doing Qualitative Research. 2nd ed. Sage, Thousand Oaks, Calif1999: 89-107
        • Hanson J.L.
        • Balmer D.F.
        • Giardino A.P.
        Qualitative research methods for medical educators.
        Acad Pediatr. 2011; 11: 375-386
        • Charmaz K.
        Constructing Grounded Theory: A Practical Guide Through Qualitative Analysis.
        Sage Publications, Newbury Park, Calif2006
        • Strauss A.L.
        • Corbin J.M.
        Basics of Qualitative Research: Grounded Theory Procedures and Techniques.
        Sage Publications, Newbury Park, Calif1990
        • Miles M.
        • Huberman A.M.
        Qualitative Data Analysis: An Expanded Sourcebook.
        Sage Publications, Thousand Oaks, Calif1994
        • Kennedy T.J.
        • Regehr G.
        • Baker G.R.
        • Lingard L.
        Point-of-care assessment of medical trainee competence for independent clinical work.
        Acad Med. 2008; 83: S89-S92
      2. Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in pediatrics. Approved September 30, 2012.

        • Davis D.A.
        • Mazmanian P.E.
        • Fordis M.
        • et al.
        Accuracy of physician self-assessment compared with observed measures of competence: a systematic review.
        JAMA. 2006; 296: 1094-1102
        • Barnsley L.
        • Lyon P.M.
        • Ralston S.J.
        • et al.
        Clinical skills in junior medical officers: a comparison of self-reported confidence and observed competence.
        Med Educ. 2004; 38: 358-367
        • Leopold S.S.
        • Morgan H.D.
        • Kadel N.J.
        • et al.
        Impact of educational intervention on confidence and competence in the performance of a simple surgical task.
        J Bone Joint Surg Am. 2005; 87: 1031-1037
        • Fox R.A.
        • Ingham Clark C.L.
        • Scotland A.D.
        • Dacre J.E.
        A study of pre-registration house officers' clinical skills.
        Med Educ. 2000; 34: 1007-1012
        • Eva K.W.
        • Regehr G.
        Exploring the divergence between self-assessment and self-monitoring.
        Adv Health Sci Educ Theory Pract. 2011; 16: 311-329
        • Regehr G.
        • Eva K.
        Self-assessment, self-direction, and the self-regulating professional.
        Clin Orthop Relat Res. 2006; 449: 34-38
        • Sanders Jr., R.C.
        • Giuliano Jr., J.S.
        • Sullivan J.E.
        • et al.
        Level of trainee and tracheal intubation outcomes.
        Pediatrics. 2013; 131: e821-e828
        • Haubner L.Y.
        • Barry J.S.
        • Johnston L.C.
        • et al.
        Neonatal intubation performance: room for improvement in tertiary neonatal intensive care units.
        Resuscitation. 2013; 84: 1359-1364
        • Baxter A.L.
        • Fisher R.G.
        • Burke B.L.
        • et al.
        Local anesthetic and stylet styles: factors associated with resident lumbar puncture success.
        Pediatrics. 2006; 117: 876-881