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How Entrustment Is Informed by Holistic Judgments Across Time in a Family Medicine Residency Program: An Ethnographic
Margaretha H Sagasser1, Cornelia R M G Fluit, Chris van Weel
1M.H. Sagasser was educationalist and researcher, Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands, at the time of the study. The author is now educationalist and researcher, Huisartsopleiding Nederland, Utrecht, the Netherlands. C.R.M.G. Fluit is head, Center on Research in Learning and Education, Radboud University Medical Center Health Academy, Nijmegen, the Netherlands. C. van Weel is professor emeritus of general practice, Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands, and honorary professor of primary health care research, Department of Health Services Research and Policy, Australian National University, Canberra, ACT, Australia. C.P.M. van der Vleuten is professor of education and director, School of Health Professions Education, Faculty of Health, Medicine, and Life Sciences, Maastricht University, the Netherlands. A.W.M. Kramer is general practitioner, professor of general practice, and head, Family Medicine Residency Program, Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands.
Purpose:
Entrustment has mainly been conceptualized as delegating discrete professional tasks. Because residents provide most of their patient care independently, not all resident performance is visible to supervisors; the entrustment process involves more than granting discrete tasks. This study explored how supervisors made entrustment decisions based on residents' performance in a long-term family medicine training program.
Method:
A qualitative nonparticipant observational study was conducted in 2014-2015 at competency-based family medicine residency programs in the Netherlands. Seven supervisor-resident pairs participated. During two days, one researcher observed first-year residents' patient encounters, debriefing sessions, and supervisor-resident educational meetings and interviewed them separately afterwards. Data were collected and analyzed using iterative, phenomenological inductive research methodology.
Results:
The entrustment process developed over three phases. Supervisors based their initial entrustment on prior knowledge about the resident. In the ensuing two weeks, entrustment decisions regarding independent patient care were derived from residents' observed general competencies necessary for a range of health problems (clinical reasoning, decision making, relating to patients); medical knowledge and skills; and supervisors' intuition. Supervisors provided supervision during and after encounters. Once residents performed independently, supervisors kept reevaluating their decisions, informed by residents' overall growth in competencies rather than by adhering to a predefined set of tasks.
Conclusions:
Supervisors in family medicine residency training took a holistic approach to trust, based on general competencies, knowledge, skills, and intuition. Entrustment started before training and developed over time. Building trust is a mutual process between supervisor and resident, requiring a good working relationship.
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