Trust is like the air we breathe–
when it’s present, nobody really notices;
when it’s absent, everybody notices.
– Warren Buffet
The practice of medicine is predicated on the concept of trust. Our patients trust that we will do what is in their best interest. Medical learners trust the expertise and experience of their teachers. In return, clinical teachers trust the willingness and ability of learners as they work together to provide patient care.
However, placing your trust in someone is fraught with risk and, to a certain extent, makes us vulnerable.
As medical teachers, we accept risk as we try to balance appropriate supervision of trainees with the increasing autonomy necessary to facilitate their journey toward independent practice. Historically, apprenticeship models in medicine placed a high value on learner autonomy (and were accompanied by adages like “see one, do one, teach one”). More recently, there has been a swing away from implicitly trusting trainees with high stakes tasks and toward a heightened (and important) focus on patient safety. As a result, the balance has shifted and learners must first prove themselves trustworthy.
There are many factors that influence how we trust and who is trusted. Entrustment decisions in medical education may appear to happen intuitively, as they are a routine part of our daily work. But behind the scenes, there are many factors at play.
In recent years, much has been written about the concept of entrustment in medical education literature. To date there are five elements that are most often cited as influencing trust: learner factors; teacher factors; nature of the task (e.g., simple or complex); context (e.g., urgency or location); and teacher-learner relationship.
Learner factors can include everything from how students perform clinical skills to how they conduct themselves. Is the learner responsible, compassionate and self-aware? These are all important to consider as we need to trust our learners not only to do the right thing, but also to behave predictably and reliably and to seek help when needed.
However, teachers’ impressions of the same student may differ based on individual experiences and values. Whether or not a teacher trusts a learner with a specific task may depend on the teacher’s prior experience with the learner as well as on how much time is available or what else needs to be prioritized that day.
We also might consider a sixth factor: the relationship between a supervising physician and the patient. The trust that exists within the physician-patient relationship also may influence how involved the supervisor chooses to be or how much autonomy is granted to the learner.
When assessing trainees, clinician teachers typically have relied on Likert-scales that assign a rating on a continuum (e.g., from poor to excellent or from not yet competent to proficient). Such scales were useful for a time but were eventually criticized for being too generic and not capturing what learners could actually do.
Enter entrustment scales (ES). ES attempt to re-frame assessments from a judgement of competency or proficiency to a question of whether a learner can be entrusted to perform a specific task. They have been designed to allow raters to apply their “real world” judgments to trainee assessments in clinical environments. When completing them, we ask ourselves: “Was the learner ready to complete this task on her/his own? How much supervision did I need to provide?” We can think of ES as being reverse-engineered to fit what clinical supervisors already do: make judgments several times a day about whether or not to allow a learner to perform a clinical task and what level of support to provide.
While ES are quickly becoming the assessment tools of choice in competency-based medical education, it is becoming clear that we need to understand more about how teachers use them. Deceptive in their simplicity, ES are proving to be just as complex to interpret as past scales and it remains unclear if teachers use them to record past performance or to predict future functioning.
When we determine that residents are ready to graduate, we are essentially certifying that they can be trusted to perform as physicians in the communities they will serve. In Canada, once you are trusted to practice in one province, you may practice anywhere in the country. This presumed trust upon graduation allows newly minted graduates to work wherever they may choose.
However, the deep trust that forms between doctors and their patients over time (also known as grounded trust) cannot be measured while a doctor is still in training. The best we can do is provide an estimate or prediction based on what we have been able to observe. It is in the long-term relationships that we build with individuals that patients come to trust us as their physicians.