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Entrustment Decision Making: Extending Miller's Pyramid.

Olle Ten Cate1, Carol Carraccio2, Arvin Damodaran3

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Miller's pyramid, a medical education assessment framework, needs an update. A new "trusted" level is proposed to encompass workplace readiness beyond observed skills, reflecting educator trust in learners.

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Area of Science:

  • Medical Education
  • Assessment in Healthcare Training

Background:

  • Miller's pyramid (1989) established four levels of medical education assessment: knows, knows how, shows how, and does.
  • The 'does' level, focusing on workplace assessment, remained underdeveloped for decades.
  • Competency-based medical education (CBME) has increased the need for workplace assessment methods.

Purpose of the Study:

  • To evaluate the limitations of existing assessment frameworks in medical education.
  • To propose an enhancement to Miller's pyramid to better reflect workplace readiness.
  • To introduce a new assessment level addressing learner trustworthiness in clinical settings.

Main Methods:

  • Analysis of Miller's pyramid and its application in medical education.
  • Review of developments in workplace-based assessment and CBME.
  • Conceptual analysis of entrustment and learner supervision in clinical practice.

Main Results:

  • Existing frameworks, including the 'does' level, do not fully capture the nuances of learner competence in the workplace.
  • Entrustable Professional Activities (EPAs) are a key innovation in CBME for the 'does' level.
  • Trust in a learner involves more than observed performance; it includes risk assessment and judgment of readiness for unsupervised practice.

Conclusions:

  • The current assessment levels in medical education are insufficient to evaluate a learner's true readiness for independent practice.
  • A fifth level, "trusted," is proposed for Miller's pyramid to signify a learner's demonstrated trustworthiness and readiness for unsupervised clinical responsibilities.
  • This enhanced framework better aligns with the principles of CBME and the complexities of modern healthcare.