How Residents Develop Trust in Interns: A Multi-Institutional Mixed-Methods Study

Trainee Autonomy and Supervision in the Inpatient Clinical Learning Environment

BACKGROUND

Balancing autonomy and supervision during medical residency is important for trainee development while ensuring patient safety. In the increasingly complex inpatient clinical learning environment, tension exists when this balance is skewed. In this study, we aimed to understand current and ideal states of autonomy and supervision and then describe factors that contribute to imbalance from both trainee and attending perspectives.

METHODS

A sequential mixed-methods design included surveys and focus groups of trainees and attendings at three institutionally affiliated hospitals between May 2019 and June 2020. Survey responses were compared using t-tests, chi-square tests or Fisher's exact tests. Open-ended survey and focus group data were analysed using thematic analysis.

FINDINGS

Survey response rate was 42% (76/182) for trainees and 49% (101/208) for attendings. Fourteen trainees and 32 attendings participated in 14 focus groups. Trainees perceived current culture to be significantly more autonomous than attendings; both groups described 'ideal' culture as more autonomous than current state. Focus group analysis revealed five core contributors to the balance of autonomy and supervision: attending, trainee, patient, interpersonal and institutional. These factors were found to be complex and interactive and require frequent adjustment to avoid tension.

CONCLUSIONS

Trainees and attendings agree that resident autonomy should be prioritized more than it currently is. Attendings, trainees and patients contribute to a complex dynamic between autonomy and supervision, further impacted by both interpersonal and institutional factors, in the inpatient clinical learning environment. Capturing complex interactions between individual factors that impact this dynamic is critical to understanding and optimization by both trainees and attending.

Assessing supervisor versus trainee viewpoints of entrustment through cognitive and affective lenses: an artificial intelligence investigation of bias in feedback

The entrustment framework redirects assessment from considering only trainees' competence to decision-making about their readiness to perform clinical tasks independently. Since trainees and supervisors both contribute to entrustment decisions, we examined the cognitive and affective factors that underly their negotiation of trust, and whether trainee demographic characteristics may bias them. Using a document analysis approach, we adapted large language models (LLMs) to examine feedback dialogs (N = 24,187, each with an associated entrustment rating) between medical student trainees and their clinical supervisors. We compared how trainees and supervisors differentially documented feedback dialogs about similar tasks by identifying qualitative themes and quantitatively assessing their correlation with entrustment ratings. Supervisors' themes predominantly reflected skills related to patient presentations, while trainees' themes were broader-including clinical performance and personal qualities. To examine affect, we trained an LLM to measure feedback sentiment. On average, trainees used more negative language (5.3% lower probability of positive sentiment, p < 0.05) compared to supervisors, while documenting higher entrustment ratings (+ 0.08 on a 1-4 scale, p < 0.05). We also found biases tied to demographic characteristics: trainees' documentation reflected more positive sentiment in the case of male trainees (+ 1.3%, p < 0.05) and of trainees underrepresented in medicine (UIM) (+ 1.3%, p < 0.05). Entrustment ratings did not appear to reflect these biases, neither when documented by trainee nor supervisor. As such, bias appeared to influence the emotive language trainees used to document entrustment more than the degree of entrustment they experienced. Mitigating these biases is nonetheless important because they may affect trainees' assimilation into their roles and formation of trusting relationships.

Definition, Measurement, Precursors, and Outcomes of Trust Within Health Care Teams: A Scoping Review

PURPOSE

This scoping review aims to map the breadth of the literature examining how trust is defined in health care teams, describe what measurements of trust are used, and investigate the precursors and outcomes of trust.

METHOD

Five electronic databases (Ovid MEDLINE, CINAHL, PsycInfo, Embase, and ASSIA [Applied Social Sciences Index and Abstracts]) were searched alongside sources of gray literature in February 2021. To be included, studies needed to discuss a health care team directly involved in managing patient care and one aspect of trust as a relational concept. A content count of the definitions of trust and tools used to measure trust and a deductive thematic analysis of the precursors and outcomes of trust in health care teams were conducted.

RESULTS

Ultimately, 157 studies were included after full-text review. Trust was the main focus of 18 (11%) studies and was not routinely defined (38, 24%). Ability appeared to be key to the definition. Trust was measured in 34 (22%) studies, often using a bespoke measure (8/34, 24%). The precursors of trust within health care teams occur at the individual, team, and organizational levels. The outcomes of trust occur at the individual, team, and patient levels. Communication was a broad overarching theme that was present at all levels, both as a precursor and outcome of trust. Respect, as a precursor, influenced trust at the individual, team, and organizational levels, while trust influenced learning, an outcome, across the patient, individual, and team levels.

CONCLUSIONS

Trust is a complex, multilevel construct. This scoping review has highlighted gaps in the literature, including exploration of the swift trust model, which may be applicable to health care teams. Furthermore, knowledge from this review may be integrated into future training and health care practices to optimize team processes and teamworking.

The Senior Resident-Fellow Dynamic on Pediatric Hospital Medicine Teams: A Qualitative Study

BACKGROUND AND OBJECTIVES

With the Accreditation Council for Graduate Medical Education accreditation in place for pediatric hospital medicine (PHM) fellowships, fellows are playing a larger role in resident education. However, the impact of PHM fellows on pediatric residency training is not well described. We aimed to identify the factors that affect the dynamic between senior residents and fellows working together on PHM teams.

METHODS

In this qualitative study, we used purposive sampling and interviewed 15 senior residents and 8 PHM fellows between April and September 2020. We created a conceptual framework for the senior resident-fellow dynamic to develop the interview guide. Using verbatim transcripts uploaded into Dedoose software, 2 authors coded responses and identified themes using directed content analysis.

RESULTS

Twelve themes emerged as factors that impact the senior resident-fellow dynamic and fell into 6 categories: Team organization, role clarity, teaching, fellow approachability, decision-making, and attending involvement. Both senior residents and PHM fellows described an optimal dynamic in which a hierarchal approach to team structure, teaching, and decision-making is counterbalanced by fellow approachability. Role uncertainty, especially with increased attending involvement, led to conflict between residents and fellows.

CONCLUSIONS

This study demonstrated that a structured hierarchy surrounding supervision, decision-making, and teaching promoted level-appropriate autonomy for both senior residents and fellows. These findings can be used to design an intervention, such as a leadership curriculum for fellows and senior residents, to target behaviors that facilitate a stepwise approach to supervision and patient care.

Residents as supervisors: How senior residents make ad hoc entrustment decisions

BACKGROUND

As residency programmes transition to competency-based medical education, there has been substantial inquiry into understanding how ad hoc entrustment decisions are made by attending supervisors in the clinical context. However, although attendings are ultimately responsible for the decisions and actions of resident trainees, senior residents are often the ones directly supervising junior residents enrolled in competency-based training programmes. This clinical dynamic has been largely overlooked in the ad hoc entrustment literature. The purpose of this study was to explore the considerations senior residents entertain when making ad hoc entrustment decisions for their junior resident colleagues.

METHODS

In semi-structured interviews, 11 senior resident supervisors (third, fourth and fifth year) in obstetrics and gynaecology described how they entrust junior residents with clinical activities in the moment. Following constructivist grounded theory methodology, data were iteratively collected and coded with constant comparison until theoretical sufficiency was determined.

RESULTS

Senior residents described many similar considerations as attendings regarding ad hoc entrustment of junior residents, including patient safety, desire to optimise the learning environment, junior resident qualities (such as discernment and communication skills), learner handover from colleagues, and situational factors. Uniquely, senior residents discussed how their role as a middle manager and their desire to protect the junior resident (from burnout, becoming a second victim and from attendings) impacts their decisions.

CONCLUSIONS

Although senior residents make ad hoc entrustment decisions with some similar considerations to attendings, they also seem to think about additional factors. It may be that these different considerations need to be accommodated in documentation of ad hoc entrustment decisions if these documents are to be used for high-stakes summative entrustment decisions made by competency committees.

Trainee Autonomy and Supervision in the Modern Clinical Learning Environment: A Mixed-Methods Study of Faculty and Trainee Perspectives

Background

Balancing autonomy and supervision during medical residency is important for trainee development while ensuring patient safety. In the modern clinical learning environment, tension exists when this balance is skewed. This study aimed to understand the current and ideal states of autonomy and supervision, then describe the factors that contribute to imbalance from both trainee and attending perspectives.

Methods

A mixed-methods design included surveys and focus groups of trainees and attendings at three institutionally affiliated hospitals between May 2019-June 2020. Survey responses were compared using chi-square tests or Fisher's exact tests. Open-ended survey and focus group questions were analyzed using thematic analysis.

Results

Surveys were sent to 182 trainees and 208 attendings; 76 trainees (42%) and 101 attendings (49%) completed the survey. Fourteen trainees (8%) and 32 attendings (32%) participated in focus groups. Trainees perceived the current culture to be significantly more autonomous than attendings; both groups described an "ideal" culture as more autonomous than the current state. Focus group analysis revealed five core contributors to the balance of autonomy and supervision: attending-, trainee-, patient-, interpersonal-, and institutional-related factors. These factors were found to be dynamic and interactive with each other. Additionally, we identified a cultural shift in how the modern inpatient environment is impacted by increased hospitalist attending supervision and emphasis on patient safety and health system improvement initiatives.

Conclusions

Trainees and attendings agree that the clinical learning environment should favor resident autonomy and that the current environment does not achieve the ideal balance. There are several factors contributing to autonomy and supervision, including attending-, resident-, patient-, interpersonal-, and institutional-related. These factors are complex, multifaceted, and dynamic. Cultural shifts towards supervision by primarily hospitalist attendings and increased attending accountability for patient safety and systems improvement outcomes further impacts trainee autonomy.

Exploring how feedback reflects entrustment decisions using artificial intelligence

CONTEXT

Clinical supervisors make judgements about how much to trust learners with critical activities in patient care. Such decisions mediate trainees' opportunities for learning and competency development and thus are a critical component of education. As educators apply entrustment frameworks to assessment, it is important to determine how narrative feedback reflecting entrustment may also address learners' educational needs.

METHODS

In this study, we used artificial intelligence (AI) and natural language processing (NLP) to identify characteristics of feedback tied to supervisors' entrustment decisions during direct observation encounters of clerkship medical students (3328 unique observations). Supervisors conducted observations of students and collaborated with them to complete an entrustment-based assessment in which they documented narrative feedback and assigned an entrustment rating. We trained a deep neural network (DNN) to predict entrustment levels from the narrative data and developed an explainable AI protocol to uncover the latent thematic features the DNN used to make its prediction.

RESULTS

We found that entrustment levels were associated with level of detail (specific steps for performing clinical tasks), feedback type (constructive versus reinforcing) and task type (procedural versus cognitive). In justifying both high and low levels of entrustment, supervisors detailed concrete steps that trainees performed (or did not yet perform) competently.

CONCLUSIONS

Framing our results in the factors previously identified as influencing entrustment, we find a focus on performance details related to trainees' clinical competency as opposed to nonspecific feedback on trainee qualities. The entrustment framework reflected in feedback appeared to guide specific goal-setting, combined with details necessary to reach those goals. Our NLP methodology can also serve as a starting point for future work on entrustment and feedback as similar assessment datasets accumulate.

How preceptors develop trust in continuity clinic residents and how trust influences supervision: A qualitative study

INTRODUCTION

To advance in their clinical roles, residents must earn supervisors' trust. Research on supervisor trust in the inpatient setting has identified learner, supervisor, relationship, context, and task factors that influence trust. However, trust in the continuity clinic setting, where resident roles, relationships, and context differ, is not well understood. We aimed to explore how preceptors in the continuity clinic setting develop trust in internal medicine residents and how trust influences supervision.

METHODS

In this qualitative study, we conducted semi-structured interviews with faculty preceptors from two continuity clinic sites in an internal medicine residency program at an urban academic medical center in the United States from August 2018-June 2020. We analyzed transcripts using thematic analysis with sensitizing concepts related to the theoretical framework of the five factors of trust.

RESULTS

Sixteen preceptors participated. We identified four key drivers of trust and supervision in the continuity clinic setting: 1) longitudinal resident-preceptor-patient relationships, 2) direct observations of continuity clinic skills, 3) resident attitude towards their primary care physician role, and 4) challenging context and task factors influencing supervision. Preceptors shared challenges to determining trust stemming from incomplete knowledge about patients and limited opportunities to directly observe and supervise between-visit care.

DISCUSSION

The continuity clinic setting offers unique supports and challenges to trust development and trust-supervision alignment. Maximizing resident-preceptor-patient continuity, promoting direct observation, and improving preceptor supervision of residents' provision of between-visit care may improve resident continuity clinic learning and patient care.

How supervisor trust affects early residents' learning and patient care: A qualitative study

INTRODUCTION

Trust between supervisors and trainees mediates trainee participation and learning. A resident (postgraduate) trainee's understanding of their supervisor's trust can affect their perceptions of their patient care responsibilities, opportunities for learning, and overall growth as physicians. While the supervisor perspective of trust has been well studied, less is known about how resident trainees recognize supervisor trust and how it affects them.

METHODS

In this qualitative study, 21 pediatric residents were interviewed at a single institution. Questions addressed their experiences during their first post-graduate year (PGY-1) on inpatient wards. Each interviewee was asked to describe three different patient care scenarios in which they perceived optimal, under-, and over-trust from their resident supervisor. Data were analyzed using thematic analysis.

RESULTS

Residents recognized and interpreted their supervisor's trust through four factors: supervisor, task, relationship, and context. Optimal trust was associated with supervision balancing supervisor availability and resident independence, tasks affording participation in decision-making, trusting relationships with supervisors, and a workplace fostering appropriate autonomy and team inclusivity. The effects of supervisor trust on residents fell into three themes: learning experiences, attitudes and self-confidence, and identities and roles. Optimal trust supported learning via tailored guidance, confidence and lessened vulnerability, and a sense of patient ownership and team belonging.

DISCUSSION

Understanding how trainees recognize supervisor trust can enhance interventions for improving the dialogue of trust between supervisors and trainees. It is important for supervisors to be cognizant of their trainees' interpretations of trust because it affects how trainees understand their patient care roles, perceive autonomy, and approach learning.

Medical Students' Perspectives on Entrustment Decision Making in an Entrustable Professional Activity Assessment Framework: A Secondary Data Analysis

PURPOSE

Research on how entrustment decisions are made identifies 5 influential factors (supervisor, trainee, supervisor-trainee relationship, context, task). However, this literature primarily represents the perspective of supervisors in graduate medical education and is conducted outside of an assessment framework where entrustment decisions have consequences for trainees and for patients. To complement the literature, the authors explored how medical students in a pilot program that used an entrustable professional activity (EPA) assessment framework perceived factors influencing entrustment decisions.

METHOD

The authors conducted a secondary analysis of qualitative data from program evaluation of a pilot project using an EPA assessment framework to advance students through their curriculum and into residency. Data were derived from 8 focus groups conducted over 4 years (2015-2018) with 27 students who shared their experience of learning and supervision in the project. Sensitized by the entrustment literature, the authors coded and analyzed focus group transcripts according to principles of thematic analysis.

RESULTS

Components of the trainee and supervisor-trainee relationship factors predominated students' perceptions of entrustment decisions. Students directed their own learning by asking for feedback, seeking opportunities to engage in learning, sharing limitations of their knowledge with supervisors, and pushing supervisors to recalibrate assessments when appropriate. Students' agentic actions were facilitated by longitudinal supervisor-trainee relationships wherein they felt comfortable asking for help and built confidence in patient care. Students mentioned components of other factors that influenced entrustment decisions (supervisor, clinical task, clinical context), but did so less frequently and from a nonagentic vantage point.

CONCLUSIONS

Students' perspectives on entrustment decisions can be derived from their views on learning and supervision in an EPA assessment framework. Their perspectives complement the literature by highlighting students' agentic actions to influence entrustment decisions and promotion of agentic action through practices incorporating longitudinal supervisor-trainee relationships.

Entrustment decisions and the clinical team: A case study of early clinical students

PURPOSE

Clinical learning contexts influence how medical students engage with entrustment decisions. However, it is unclear how students and health care team members perceive the entrustment decision process. This study explored which factors students and team members consider relevant to entrustment decisions in early clinical rotations.

METHODS

The authors conducted a case study at an academic teaching hospital, interviewing 28 medical students and four health care team members during the clerkship year. Within a social constructivist epistemology, we explored students' and health care team members' perceptions of ad hoc entrustment decisions using semi-structured interviews. Transcripts from the interviews and notes from feedback rounds with students were used for analysis.

RESULTS

Medical students in their core clerkship year perceived clinical residents as critical educational gatekeepers and key facilitators of entrustment decisions. Another important theme emerged around students' motivation, initiative and willingness to engage with the health care team and patients. Students actively engaged in trust formation processes with different health care team members. The entrustment decision process was perceived as multilateral and dynamic, involving all health care team members and patients. Multiple entrusting supervisors for clerkship students, including nurses and psychologists, emerged from our interview data. They assumed an active role in negotiating entrustment decisions both with and for clerkship students, either facilitating or hindering opportunities. The entrustment decisions emerged as a result of a multifaceted supervisor network interaction.

CONCLUSIONS

Supervising residents' ability to integrate students into clinical teams seems to be a critical factor in facilitating entrustment opportunities for clinical activities. Students' active management of informal supervisor networks of health care team members and these team members' willingness to assume responsibility for the students' education emerged as relevant aspects for ad hoc entrustment. Our data suggest that supervision from different health professionals is beneficial for clinical education of medical students and merits further exploration.

The ingredients of a rich entrustment decision

Entrustment decision-making has become a topic of interest in workplace-based assessment in the health professions and is germane to the use of entrustable professional activities. Entrustment decisions stem from judgments of a trainee's competence and include the permission to act with a higher level of responsibility or autonomy and a lower level of supervision. Making entrustment decisions differs from regular assessment of trainees, which usually has no consequences beyond marking trainee progress. Studies show that clinicians generally weigh more factors in making an entrustment decision than when merely assessing trainee competence or performance without direct consequences for patient care. To synthesize the varying factors reported in literature, the authors performed a thematic analysis of key qualitative studies that investigated trainee features clinical supervisors find important when making entrustment decisions. Five themes emerged from the 13 publications: Capability (specific knowledge, skills, experience, situational awareness), Integrity (truthful, benevolent, patient-centered), Reliability (conscientious, predictable, accountable, responsible), Humility (recognizes limits, asks for help, receptive to feedback), Agency (proactive toward work, team, safety, personal development). Thoughtful entrustment decisions, made either by individual clinical supervisors or by clinical competency committees, may be enriched by taking into account these five features.

It's a matter of trust: exploring the basis of program directors' decisions about whether to trust a resident to care for a loved one

There has been increased attention to and emphasis on competency-based medical education and the transformation from highly supervised medical students towards independent, entrustable physicians. We explored how program directors (PDs) justify decisions about whether they would trust finishing Post Graduate Year 1 (PGY1) residents to care for the PD or a loved one. Using an end of year survey with validity evidence, we assessed PDs' responses (Yes, No, Not Sure) and written comments about this entrustment decision for USUHS medical students from graduating classes of 2013-2015 (PGY1). We performed a qualitative inductive content analysis to identify themes in how PDs justified their decisions as well as descriptive statistics and a contingency table analysis to examine associations between trust decisions and election to membership in Alpha Omega Alpha (AOA), or conversely, referral to the Student Promotions Committee (SPC) for remediation. Qualitative analyses revealed five themes related to this trust decision about medical residents: personal, interpersonal, knowledge, competence, and developmental. Neither AOA status, nor SPC referral status was significantly associated with the trust measure, overall, but positive trust decisions were significantly higher among those elected to AOA than in those who were not. Positive trust decisions were significantly associated with AOA status but negative trust decisions were not significantly associated with referral to the SPC. This study offers insights into what attributes may underpin trust decisions by PDs. Our findings suggest that PDs' frequent use of personal and interpersonal characteristics to justify trust decisions contrasts with the use of clinical and knowledge based assessments during undergraduate medical education (UME), and emphasize the importance of critical intrinsic abilities.

Fostering a Feedback Mindset: A Qualitative Exploration of Medical Students' Feedback Experiences With Longitudinal Coaches

PURPOSE

Feedback is important for medical students' development. Recent conceptualizations of feedback as a dialogue between feedback provider and recipient point to longitudinal relationships as a facilitator of effective feedback discussions. This study illuminates how medical students experience feedback within a longitudinal relationship with a physician coach.

METHOD

In this qualitative study, second-year medical students from the University of California, San Francisco, School of Medicine participated in semistructured interviews that explored their experiences discussing feedback within longitudinal, nonevaluative coaching relationships. Interviews occurred between May and October 2018. Interview questions addressed students' experiences receiving feedback from their coach, how and when they used this feedback, and how their relationship with their coach influenced engagement in feedback discussions. Interviews were analyzed using constructivist grounded theory.

RESULTS

Seventeen students participated. The authors identified 3 major themes. First, students' development of a feedback mindset: Over time, students came to view feedback as an invaluable component of their training. Second, setting the stage for feedback: Establishing feedback routines and a low-stakes environment for developing clinical skills were important facilitators of effective feedback discussions. Third, interpreting and acting upon feedback: Students described identifying, receiving, and implementing tailored and individualized feedback in an iterative fashion. As students gained comfort and trust in their coaches' feedback, they reported increasingly engaging in feedback conversations for learning.

CONCLUSIONS

Through recurring feedback opportunities and iterative feedback discussions with coaches, students came to view feedback as essential for growth and learning. Longitudinal coaching relationships can positively influence how students conceptualize and engage in feedback discussions.

Trusted to Learn: a Qualitative Study of Clerkship Students' Perspectives on Trust in the Clinical Learning Environment

BACKGROUND

Trust informs supervision decisions in medical training. Factors that influence trust differ depending on learners' and supervisors' level. Research has focused on resident trainees; questions exist about how medical students experience entrustment.

OBJECTIVE

This study examines how clerkship students perceive supervisors' trust in them and its impact on their learning.

DESIGN

Qualitative study using individual semi-structured interviews.

PARTICIPANTS

Clerkship medical students at the University of California, San Francisco.

APPROACH

We invited 30 core clerkship students to participate in interviews (October 2017 to February 2018) eliciting examples of appropriate, over-, and under-trust. We coded and analyzed transcripts using thematic analysis.

KEY RESULTS

Sixteen (53%) students participated. Three major themes arose: trust as scaffolding for learning, effects of trust on the learning environment, and consequences of trust for patients. Appropriate trust usually involved coaching and close guidance, often with more junior supervisors (interns or residents). These situations fostered students' motivation to learn, sense of value on the team, and perceived benefits to patients. Over-trust was characterized by task assignment without clear instruction, supervision, or feedback. Over-trust prompted student anxiety and stress, and concerns for potential patient harm. Under-trust was characterized by lack of clarity about the student role, leading to frustration and discontent, with unclear impact on patients. Students attributed inappropriate trust to contextual and supervisor factors and did not feel empowered to intervene due to concerns about performance evaluations and hierarchy.

CONCLUSIONS

As early learners in the clinical workplace, students frame trust as entailing high levels of support. It is important for medical educators to consider ways to train resident and faculty supervisors to enact trust and supervision for students differently than for residents. Structures that encourage students and supervisors to discuss trust and supervision in a transparent way can enhance learning.

Relationships Matter: Enhancing Trainee Development with a (Simple) Clerkship Curriculum Reform

PROBLEM

The traditional clerkship model of brief encounters between faculty and students results in reduced meaningful learning opportunities due to the lack of a relationship that enables repeated observation, supervisor feedback, trust formation, and growth.

INTERVENTION

Clinical clerkships at our institution were restructured to decrease fragmentation of supervision and foster an educational alliance between faculty and student. A mixed-methods approach was used to study the impact of this curriculum reform on the student experience in the obstetrics and gynecology clerkship. Student participation in patient care was assessed by comparing the number of common obstetric procedures performed before and after clerkship reform. Separate qualitative analyses of comments from student surveys and a faculty focus group revealed themes impacting student involvement. The supervisor-trainee relationship was further investigated by analysis of "rich picture" discussions with students and faculty.

CONTEXT

Clerkships in the 3rd year of our 4-year undergraduate medical curriculum were converted from an experience fragmented by both didactic activities and multiple faculty supervisors to one with a single supervisor and the elimination of competing activities.

OUTCOMES

Students in the revised clerkship performed twice the number of obstetric procedures. Objective measures (United States Medical Licensing Examination Step 1 scores, receiving clerkship honors, self-reported interest in obstetrics, and gender) did not correlate with the number of procedures performed by students. Qualitative analysis of student survey comments revealed that procedure numbers were influenced by being proactive, having a supervisor with a propensity to teach (trust), and contextual factors (busy service or competition with other learners). Themes identified by faculty that influenced student participation included relationship continuity; growth of patient care skills; and observed student engagement, interest, and confidence. The quality of the relationship was cited by both students and faculty as a factor influencing meaningful clinical participation. Discussions of "rich pictures" drawn by students and faculty revealed that relationships are influenced by continuity, early alignment of goals, and the engagement and attitude of both student and faculty.

LESSONS LEARNED

Clinical curricular reforms that strengthen the continuity of the supervisor-trainee relationship promote mutual trust and can result in a more meaningful training experience in less time. Reciprocal engagement and early alignment of goals between supervisor and trainee are critical for creating a positive relationship.

Time-Variable Training in Medicine: Theoretical Considerations

The introduction of competency-based medical education has shifted thinking from a fixed-time model to one stressing attained competencies, independent of the time needed to arrive at those competencies. In this article, the authors explore theoretical and conceptual issues related to time variability in medical training, starting with the Carroll model from the 1960s that put time in the equation of learning. They discuss mastery learning, deliberate practice, and learning curves.While such behaviorist theories apply well to structured courses and highly structured training settings, learning in the clinical workplace is not well captured in such theories or in the model that Carroll proposed. Important in clinical training are self-regulation and motivation; neurocognitive perspectives of time and learning; professional identity formation; and entrustment as an objective of training-all of which may be viewed from the perspective of the time needed to complete training. The authors conclude that, in approaching time variability, the Carroll equation is too simplistic in its application to the breadth of medical training. The equation may be expanded to include variables that determine effective workplace learning, but future work will need to examine the validity of these additional factors.

Attending Physician Remote Access of the Electronic Health Record and Implications for Resident Supervision: A Mixed Methods Study

BACKGROUND

Advances in information technology have increased remote access to the electronic health record (EHR). Concurrently, standards defining appropriate resident supervision have evolved. How often and under what circumstances inpatient attending physicians remotely access the EHR for resident supervision is unknown.

OBJECTIVE

We described a model of attending remote EHR use for resident supervision, and quantified the frequency and magnitude of use.

METHODS

Using a mixed methods approach, general medicine inpatient attendings were surveyed and interviewed about their remote EHR use. Frequency of use and supervisory actions were quantitatively examined via survey. Transcripts from semistructured interviews were analyzed using grounded theory to identify codes and themes.

RESULTS

A total of 83% (59 of 71) of attendings participated. Fifty-seven (97%) reported using the EHR remotely, with 54 (92%) reporting they discovered new clinical information not relayed by residents via remote EHR use. A majority (93%, 55 of 59) reported that this resulted in management changes, and 54% (32 of 59) reported making immediate changes by contacting cross-covering teams. Six major factors around remote EHR use emerged: resident, clinical, educational, personal, technical, and administrative. Attendings described resident and clinical factors as facilitating "backstage" supervision via remote EHR use.

CONCLUSIONS

In our study to assess attending remote EHR use for resident supervision, attendings reported frequent remote use with resulting supervisory actions, describing a previously uncharacterized form of "backstage" oversight supervision. Future work should explore best practices in remote EHR use to provide effective supervision and ultimately improve patient safety.

How Supervisor Experience Influences Trust, Supervision, and Trainee Learning: A Qualitative Study

PURPOSE

Appropriate trust and supervision facilitate trainees' growth toward unsupervised practice. The authors investigated how supervisor experience influences trust, supervision, and subsequently trainee learning.

METHOD

In a two-phase qualitative inductive content analysis, phase one entailed reviewing 44 internal medicine resident and attending supervisor interviews from two institutions (July 2013 to September 2014) for themes on how supervisor experience influences trust and supervision. Three supervisor exemplars (early, developing, experienced) were developed and shared in phase two focus groups at a single institution, wherein 23 trainees validated the exemplars and discussed how each impacted learning (November 2015).

RESULTS

Phase one: Four domains of trust and supervision varying with experience emerged: data, approach, perspective, clinical. Early supervisors were detail oriented and determined trust depending on task completion (data), were rule based (approach), drew on their experiences as trainees to guide supervision (perspective), and felt less confident clinically compared with more experienced supervisors (clinical). Experienced supervisors determined trust holistically (data), checked key aspects of patient care selectively and covertly (approach), reflected on individual experiences supervising (perspective), and felt comfortable managing clinical problems and gauging trainee abilities (clinical). Phase two: Trainees felt the exemplars reflected their experiences, described their preferences and learning needs shifting over time, and emphasized the importance of supervisor flexibility to match their learning needs.

CONCLUSIONS

With experience, supervisors differ in their approach to trust and supervision. Supervisors need to trust themselves before being able to trust others. Trainees perceive these differences and seek supervision approaches that align with their learning needs.

Twelve tips for the implementation of EPAs for assessment and entrustment decisions

The concept of entrustable professional activities (EPAs) reframes the approach to assessment in competency-based medical education. Key to this concept is the linking of assessment to decision making about entrusting learners with clinical responsibilities. Based on recent literature and the authors' experiences with implementing EPAs, this article provides practical recommendations for how to implement EPAs for assessment and entrustment decisions in the workplace. Tips for supervising clinicians include talking to learners about trust, using EPA descriptions to guide learning and teaching, providing learners with greater ad hoc responsibilities, using EPAs to identify/create opportunities for assessment and feedback, including case-based discussions and acknowledging gut feelings about learner readiness for more autonomy. Tips for curriculum leaders entail enabling the trust development, applying trust decisions at all levels of the supervision scale, employing all available information sources for entrustment, empowering learner ownership of the assessment process and using technology for learner tracking and program evaluation.

Entrustment Decisions: Bringing the Patient Into the Assessment Equation

With the increased interest in the use of entrustable professional activities (EPAs) in undergraduate medical education (UME) and graduate medical education (GME) come questions about the implications for assessment. Entrustment assessment combines the evaluation of learners' knowledge, skills, and behaviors with the evaluation of their readiness to be entrusted to perform critical patient care responsibilities. Patient safety, then, should be an explicit component of educational assessments. The validity of these assessments in the clinical workplace becomes the validity of the entrustment decisions.Modern definitions of the validity of educational assessments stress the importance of the purpose of the test and the consequences of the learner's score. Thus, if the learner is a trainee in a clinical workplace and entrusting her or him to perform an EPA is the focus of the assessment, the validity argument for that assessment should include a patient safety component.While the decision to allow a learner to practice unsupervised is typically geared toward GME, similar decisions are made in UME regarding learners' readiness to perform EPAs with indirect supervision (i.e., without a supervisor present in the room). Three articles in this issue address implementing EPAs in UME.The author of this Commentary discusses the possibility of implementing true entrustment decisions in UME. He argues that bringing the patient into the educational assessment equation is marrying educational and health care responsibilities. Building trust in learners from early on, gradually throughout the continuum of medical education, may reframe our vision on assessment in the workplace.