So I think the discussion forum has been quite interesting. You all have been talking about what does entrustment and autonomy look like in your environment? And what might affect the amount of autonomy you give to your learners? This next segment is going to look at the literature of surrounding factors affecting autonomy, but first we're going to take a little bit of a detour and we're going to talk about, competencies and EPAs. And so, a competency is the performance of the trainee, and EPA is the work pa, place activity that happens. So, EPA is an entrustable professional activity. This word was really kind of initiated by Olle Ten Cate about ten years ago at this point. And some of the medical education systems are moving towards EPAs rather than competencies, or in addition to competencies. And so, so just to clarify that a competency is a quality of a trainee. It's really a quality of a trainee's performance that we see develop over time and that should reach a certain measurement or metric that then determines that the trainee is competent. Entrustable professional activities are more, centered around the work place tasks, that trainees are doing, and related the autonomy, or responsibility, or supervision that we're giving to those tasks. So a number of the, medical education settings are using competency, so the ACGME which is in the United States. The General Medical Council in the UK. There's the CANMEDS system, so these are good as their current kind of competency frameworks. When we think about competency, we think about, really kind of performance of trainees in a number of these different areas. So it can be teamwork or communication, it can be, their learning, or medical knowledge To compliment that, Dr. Ten Cate proposed Entrustable Professional Activities. With these activities, there's the sense of how much autonomy, responsibility and supervision that we will give a trainee. And there's several different levels. And it, it depends on which system that you're looking at as to what the levels are. But, you know, a trainee that does not have a lot of knowledge. We may have very close and direct supervision. As they get more independent and more proficient they may act under close supervision, where act under supervision's needed. And then ultimately they're going to act independently and supervise others. Within more of the US centric system, we talk about direct supervision which is, that the physician is physically present. And we talk about indirect supervision, which is first that the supervisor is available, perhaps outside the room or in another room or close by, or whether or not, they are available, but not immediately available. Perhaps available by phone or available in other ways. Each of these things is arguing to how much supervision that we are giving in the workplace setting. And so, what's helpful, is to think about the intersection of EPA. So entrustable professional activities, and competencies. So the ACGME's competencies include things such as, patient care, medical knowledge, communication, and professionalism. And that, the feature of the train here. The performance of the trainee determines whether or not the trainee is competent in, taking a history or doing a physical exam. Do they have the medical knowledge around something such as hypotension or sepsis? Are they able to communicate effectively with patients and families? Each of those would be competencies within a competency-based framework. What an EPA does is, it looks at the features of work. So, in this case, we're talking about the care of a critical patient. The care of a critical patient, requires multiple competencies to be, performed in the workplace setting, so that as their training is taking care of a critical patient, we expect them to be able to provide appropriate patient care through a history and physical. We expect them to be able to know the differential of hypotension and that this might be sepsis, and what antibiotics to give. We expect them to be able to communicate effectively with the patients and family, it's going to work well in a team. In addition, we want them to understand the ethics of goals of care and treat others with respect. Each of those are competencies but they are, taking place within the the workplace environment, and as such the entire, performance because it becomes an entrustable professional activity. And as a supervisor I decide how much entrustment I'm going to give for them. For each of these pieces of the, of care of a critical patient. And so likely if they're a senior resident I'm going to expect them to be able to do most of the patient care. I may double check a couple of things. I going to expect to have good medical knowledge. Because I, I expect at that point as a senior resident that they know, about things such as hypotension and antibiotics in sepsis. In addition, they, I expect them to be able to communicate with patients and families. And I essentially, at that time, entrust them with these activities. And I have probably, indirect but closely available supervision, for the trainee during these times. If I'm concerned about trainee or a trainee is not as far advanced, then I may have less autonomy, I may supervise more closely. So I may be actually in the room at the time that they talk to the family about [INAUDIBLE] of care and so, I might hit direct supervision with that time, with that, at that time. And so, as you can see, there is kind of an intersection of what the competencies are, meaning the performance of the trainee, and what the entrustful professional activity is, which is where you see the trainee in the workplace environment. So, that's where, we, this is that, that's the way that we think about competency, and entrustable professional activities. So now we're going to talk more about entrustment. Olle Ten Cate one of his colleagues wrote a paper a couple of years ago about entrustment, and the factors affecting entrustment. I read this paper and was just fascinated by it, and decided that I wanted to kind of look at it in my own environment, which is emergency medicine. And so, a number of us got together, faculty and residents and did some focus groups looking at what are the factors affecting, entrustment autonomy. And then also, how do faculty entrust residents with the appropriate autonomy? And we looked at it both, from the faculty point of view, as well as it, from the resident point of view. And these are some of the things that came out of it. So this work is a mixture of, of our own work, as well as the paper by Olle Ten Cate. So, specifically what we talk about, and maybe this is a phrase in the US that you don't use. But what we talk about is, how much rope did I give them? Which is to say, how much autonomy, or how much responsibility, or how much leeway do I give a trainee so that they don't hang themselves. So do I keep them really close so that the rope is not long, or do I let them out pretty far. We also talk about this in terms of, kind of a leash of how much space do they have, with the important thing that this needs to be safe. And that I need to give the appropriate amount of autonomy and entrustment, but not to the point that it is unsafe for the patient. And so, there's a couple of factors that are effected, that affect the amount of autonomy. So the first one is faculty. The next one is really the trainees, so the characteristics of the trainee themselves. The third one is the patient, or it might be the family. And then the fourth one is the environment or system. And we're going to go through these now. Okay. Let's talk a minute about the way that we view our patients. This is a line, as you can see. And what I want you to do is think about a patient you saw in the past kind of week or two. That you may have seen within advanced training. And I want you to think about how you thought about the care of that patient. Did you think about it as my patient? Did you think about it as our patient, or did you think about it as the trainee's patient? And I want you to take a minute and think about where that X would be on that line. Okay, and so if you're thinking about it being my patient then, I'm thinking that you're not very good at necessarily entrusting, someone with autonomy. Because if you really kind of hold on to it as being your patient, then you're not willing to give the trainee the responsibility to be able to step up into the work that needs to be done. Now, when I'm working with a student it probably is my patient, but I try to tell the student it's their patient but in reality I'm really carefully supervising and I'm talking to the patient and the family, and so then it really is my patient. But I would hope that as we see our kind of senior residents or as their you know, ready for graduation, as their almost done. That we think about the patients as being the trainee's patients, and in reality I am never going to give up my own responsibility for them, but that the, the process is more thinking about it as being a residence patient, or the trainee's patient. If you find yourself fon this side of the line, then chances are then you are probably a bit more entrusting than some of your colleagues are who are on the other end of the line. I find this to be really helpful because I think, I think it, I think it's important to think about where we are on this line. And to see if we can move ourselves in an appropriate place, according to both the patient and the trainee. So we've talked about, how long is the leash? And so, it's a sense of how much responsibility you're going to give them so that they don't get into trouble, but that they still have some degree of autonomy for that. And so as we've talked about the study of my colleagues and we were researching, we really kind of talked about the leash. How long is the leash or how long is the rope with a sense of what does that look like? So let's talk some more about some of the faculty factors, so one of the big ones is that some faculty are what we would call, micromanagers, and perhaps that's a strong word that nobody wants to really adopt. Perhaps I use that intentionally because I don't want people to be thinking that that's a good thing to do. But it's the faculty member who really feels that they have to pay attention to every single detail, and can't let go of the things that, the small details along the way. And so that's, if one's personality tends to micro-management, then probably the entrustments that you will give will be less than some of your other colleagues. Another thing that can effect it is the confidence, of the faculty member. If somebody is highly confident, I think that they feel more comfortable giving the trainee more autonomy and more leeway to do what, to do what they want to do. Because they understand that if, the trainee gets in trouble, they can always kind of catch them and pick up on whatever, whatever the problem is that happens. There are also faculty who are less comfortable with the lack of control, and so it's kind of a, a comfort with less control, so that if they feel like, in order to feel like they have control of what's going on, they're going to hold onto the details, or ask the resident about every little piece. So those are, those are faculty who will tend to entrust less, rather than entrusting more. There's a number of people who are afraid of making mistakes. Now, I think to some extent we all are afraid of making mistakes, but sometimes this can really cause the faculty member to be very not entrusting meaning that they'll insist on getting tests that are extremely conservative. So in emergency medicine, our really our litmus test is, who do you get a CAT scan on for a pulmonary embolism. You know, anybody who walks in with chest pain, or do you actually discriminate about what that, what that actually might be and decide what it is. What we find is that, there's a certain, there's certainly faculty who are concerned very much about making mistakes. Either about getting sued or getting some sort of a peer-review letter. And so they tend to be, less entrusting. It can also be that that the past couple of shifts honestly the past couple of shifts I've seen a pulmonary embolism almost every shift. And so I know that I'm afraid of missing a pulmonary embolism and I might be a little bit more aggressive about ordering a CT scan and in those cases, I'm going to be less willing to offer the resident the opportunity to not do that, if they think that they don't need a CAT scan. And I may feel like I need to step in and limit their autonomy in that way by ordering CT scans which the resident might not choose to do. Another thing can be kind of prior experiences. So, it comes back to what I just talked about. If I had seen a PE recently I may be more likely to do a pulmonary embolism. It may be that my experience or comfort with a certain kind of case. So, you know, if I don't see a lot of pediatrics and a child comes into the pedi, into the adult CT, then I may be more or less entrusting based on the prior experiences that I have and my own kind of ability for that. The next thing is really educational responsibility. As my colleagues and the residents looked at the faculty factors. A number of the residents and the faculty will talk about their responsibilty to train residents, and that they, they do that sometimes they might prefer to practice in a certain way and order a certain test but they knew that it was important to allow the residents the autonomy and responsibility to grow and to learn and that if I completely control everything that a resident does, then in the end I have not benefited either them or their future patients, because they have practiced according to what I wanted and not been allowed to make their own decisions. And so we found that there were some faculty who were just really good about that giving responsibility to the residents. Because they felt that was their kind of true, purpose in this, is to, to make the residents about as good as they could by giving them responsibility that they needed. I think we talked a little bit about this before, but there's some faculty who are just risk-averse. Right, is that, missing any pulmonary embolism, or any fracture, or any possible heart attack, is unacceptable. And so that they tend to be very conservative. And tend not to allow a lot, a lot of autonomy. And it also comes back to their experience. We were curious in the beginning about whether or not the new faculty would be more or less interesting, and we actually found that in the very beginning, brand new faculty were uncomfortable with allowing autonomy, and as they gained more experience and gained more comfort with, you know, what could go wrong and how to prevent what goes wrong, and how to entrust a little bit better through some kind of subtle ways, we found that, that many of the faculty became more entrusting as they gained more experience. And so clearly the, the level of training of the physician and the attending does as well. And then finally this sense of faculty personality, you know, there's some who will just always, maintain kind of patient, the patient on my, as my patient. And there are others who feel much more comfortable with letting it go and, understand that the resident, that the resident can do a good job as well. So here's a comment from our faculty based on our study that we did, and it's about the committment to education and responsibility that we talked about earlier, but I think the individuals where it matters, who's going to benefit more from me entrusting them more. Who is is going to make less of a difference for, the R2 is the one. I go out of my way, against my better judgement to try to give more latitude because I think it is one of the things that will make her better. I think it is one of the things she really needs to learn. So this is specifically about a problem resident, that we have been working with to try to get better. And normally because because as a faculty member I recognize that her clinical judgement is not great. I tend to want to tell her what to do, rather than allowing her to chose what to do. But remember that every time I tell her what to do. She's missing the opportunity to have learned how she might have made that decision and might have made that decision incorrectly. And so this faculty member was, was very insightful to say, it is particularly with the problem resident is when I really need to let them try to make their own decisions. It doesn't mean that you have to let them do it. right, so it's mostly that you're letting them, attempt to make their decisions and decide what the plan is. And then you can correct and adjust that plan based on, what you think is safe for the patient. But we need to allow them to do it as opposed to simply saying, just do this. I found that one to be a really interesting comment. Another comment, and this was from a resident. One physician in particular that we, I think doesn't have much trust in his own capabilities and so he kind of casts a wide net, wants a lot of consults brought in, wants every test to be done just because he isn't confident in himself. It's kind of interesting, it's a resident kind of picking up on the faculty discomfort with this. And so hopefully as the faculty member becomes more comfortable with her practice. They will be, less likely to feel like they need to be really conservative in their practice and ordering a bunch of tests. So that's from the residents perspective.
