A realist evaluation of prospective entrustment decisions in paediatric residency clinical competency committees

Making entrustment decisions (granting more responsibility, advancement and graduation) are important actions in medical training that pose risks to trainees and patients if not done well. A previous realist synthesis of the existing literature revealed that clinical competency committees (CCCs) do not typically make deliberate entrustment decisions, instead defaulting to the promotion and graduation of trainees in the absence of red flags. This study sought further understanding of these areas through empirical data.

The authors conducted a realist inquiry to better understand how CCC prospective entrustment decision-making is carried out in paediatric residency programs. They conducted four CCC meeting observations and 18 interviews with CCC members at eight sites in an effort to confirm, disconfirm, and elaborate an existing theory that was based on a literature synthesis.

The literature-based theory held up well against the empiric data collected in this study. Therefore, the authors did not modify that theory and instead developed three new demi-regularities (recurring patterns in data when conducting realist work) that add detail and nuance to their previous understanding of this model. These new demi-regularities focus on (i) expounding on how deliberate actions of CCCs focus more on resident development than on resident entrustment; (ii) elucidating that effortful work is not only about reconciling a paucity of data or incongruent data but also working hard to 'do the right thing' for residents; and (iii) describing how programs consider bias, equity and fairness, with a wide range of intentionality from being reactive to being proactive.

This study offers evidence of deliberate CCC efforts to support resident development. Moving forward, a similar focus should be more consistently placed on equitable entrustment and advancement decisions to balance both of these foundational goals.