Understanding Entrustment Decision Making By Surgical Program Directors
*Samantha L. Ahle1, *Katherine Gielissen1, *Danya E. Keene2, *Justin D. Blasberg1
1Yale School of Medicine, New Haven, CT; 2Yale School of Public Health, New Haven, CT
Objective: Explore factors that mediate entrustment decision-making by surgical program directors (PDs.) Current dogma suggests clinical entrustment is derived from: 1) trainee attributes, 2) supervisor attributes, 3) supervisor-trainee relationship, 4) context, and 5) nature of the task. However, these characteristics do not fully encapsulate how entrustment decision-making occurs in patient-care settings. The goal of this study is to elucidate variables that inform ad hoc and summative entrustment decisions of surgical PDs, and develop a common framework for entrustment paradigms. Design: Interviews obtained by purposive and convenient sampling. Setting: Fifteen nationally representative ACGME-certified surgical programs. Participants: Surgical PDs. Interventions: In-depth, semi-structured interviews transcribed using Revİ and coded with Dedooseİ qualitative software. Thematic codes were extrapolated following data analysis in an iterative process. Main Outcome Measures: Personal, professional, and systemic variables that inform entrustment decision-making. Results: 1) Presumption of competency based on expected trajectory: Surgical residency represents a traditional apprenticeship model. PDs entrust based on experience level under the assumption that trainees follow an expected trajectory, despite acknowledging that heterogeneity of achieving milestones exists. 2) Transference of competence: PDs are unable to directly observe trainees in all domains. When residents demonstrate competence in one domain, they are entrusted in other domains. 3) Quantitative competency assessments do not facilitate entrustment: Milestones and other quantitative assessments are not surrogates to predict entrustment. Conclusions: This study expands on established educational principles and milestone metrics that define surgical education. PDs play a vital role in facilitating entrustment by critically sorting inputs from multiple sources. Inherent to this process is an assumption of competence based on training level and performance in multiple domains; this can lead to false assumptions about trainee ability.