Mo1989 CONCEPTUALIZING ENTRUSTMENT IN ENDOSCOPIC TRAINING

Abstract

Competency-based medical education (CBME) is a novel educational paradigm being instituted around the world. CBME places emphasis on the development of measurable skills during training rather than time spent in training. A common element of CBME systems is entrustment – the process whereby supervisors come to trust trainees to perform specific tasks without supervision. How entrustment decisions are made with respect to endoscopic training has not been elucidated. We aimed to: (1) identify the factors trainers consider in making endoscopic entrustment decisions and (2) characterize this entrustment decision-making process. A qualitative, interview-based study was conducted using a constructivist grounded theory approach. A purposive sample of endoscopic trainers from across North America were recruited with representation from pediatric and adult gastroenterology, general surgery, and family medicine. Consenting endoscopic trainers undertook audio-recorded, semi-structured interviews designed to elicit how they make endoscopic entrustment decisions and the factors they consider in making these decisions. Interview transcripts were analyzed using constant comparison and themes were identified iteratively, working toward an explanatory framework that highlighted relationships among themes. Recruitment continued alongside analysis until theoretical saturation, determined as the point at which no new insights arose from the data. Twenty-nine trainer interviews were conducted, comprising 9 (31.0%) with pediatric gastroenterologists, 10 (34.5%) with adult gastroenterologists, 7 (24.1%) with general surgeons, and 3 (10.3%) with family physicians. Of those interviewed, 18 (62.1%) practiced in the United States and 11 (37.9%) practiced in Canada. Trainer supervisory experience ranged from <1 to 36 years. Interviewees conceptualized entrustment as a continuum rather than a binary (yes/no) decision. Entrustment was found to be a complex process, involving factors related to the: (1) trainee (insight into own abilities, technical skills, nontechnical skills); (2) trainer (perceived self-competence, disposition, prioritization of trainee learning relative to competing demands); (3) trainer-trainee relationship (familiarity); (4) patient (acuity, comorbidity, comfort); (5) procedure (complexity); and (6) environment (time constraints, equipment, presence of anesthesiologist). These factors directly and indirectly contributed to trainee readiness, trainer comfort, and patient safety; themes which were identified as central to supervisors’ endoscopic entrustment decisions. Entrustment in endoscopic training is a complex process incorporating multiple factors. Clarification of this process and identification of predictive factors informs the development of endoscopic assessment tools and curricula uniquely suited to CBME.