Use of graded responsibility and common entrustment considerations among United States emergency medicine residency programs.

Jason Lai,Mary Westergaard,Jamie Hess,Benjamin Holden Schnapp,Aaron Kraut,David Simon Tillman

doi:10.3352/jeehp.2020.17.11

Abstract

PurposeThe Accreditation Council for Graduate Medical Education (ACGME) requires all residency programs to provide increasing autonomy as residents progress through training, known as graded responsibility. However, there is little guidance on how to implement graded responsibility in practice and a paucity of literature on how it is currently implemented in emergency medicine (EM). We sought to determine how EM residency programs apply graded responsibility across a variety of activities and to identify which considerations are important in affording additional responsibilities to trainees.MethodsWe conducted a cross-sectional study of EM residency programs using a 23-question survey that was distributed by email to 162 ACGME-accredited EM program directors. Seven different domains of practice were queried.ResultsWe received 91 responses (56.2% response rate) to the survey. Among all domains of practice except for managing critically ill medical patients, the use of graded responsibility exceeded 50% of surveyed programs. When graded responsibility was applied, post-graduate year (PGY) level was ranked an “extremely important” or “very important” consideration between 80.9% and 100.0% of the time.ConclusionThe majority of EM residency programs are implementing graded responsibility within most domains of practice. When decisions are made surrounding graded responsibility, programs still rely heavily on the time-based model of PGY level to determine advancement.

Highlights

Background/rationale It is relatively intuitive that a resident physician nearing graduation should be entrusted with more responsibility than a first-year resident at the beginning of training
The goal is a new era of competency-based medical education (CBME), where trainees may theoretically be granted increasing levels of responsibility for independent practice based upon objective assessments
Other medical specialties and Canadian emergency medicine (EM) programs have begun to implement CBME to assign responsibility to residents based on demonstrated abilities, but this paradigm has not yet been widely adopted and no common set of entrustable professional activities (EPAs) has been defined for EM [5,6]

Summary

Introduction

Background/rationale It is relatively intuitive that a resident physician nearing graduation should be entrusted with more responsibility than a first-year resident at the beginning of training. Previous work has attempted to elucidate the ideal system for implementing graded responsibility within residency training through panel discussions and iterative theme generation [3]. Structured discussions yielded broad concepts and ideals that could promote graded responsibility, the panel was not instructed to enumerate specific practices that would exemplify the consensus themes that it put forward, and its findings and conclusions are not specific to emergency medicine (EM) residency programs. Other medical specialties and Canadian EM programs have begun to implement CBME to assign responsibility to residents based on demonstrated abilities, but this paradigm has not yet been widely adopted and no common set of EPAs has been defined for EM [5,6].

Objectives

Discussion

Conclusion