Evaluating Clinical Trainees in the Workplace: On Supervision, Trust and the Role of Competency Committees

Background: Despite the promise of competency-based medical education (CMBE) to ensure that trainees achieve desired outcomes of training, challenges have arisen in the implementation of this educational framework. Drawing on conceptual work on social cognitive theory by Bandura, Billett’s and Dornan’s studies of workplace learning, Vygotsky’s zone of proximal development, and theories of group functioning, this thesis examines trust through qualitative exploratory and quantitative empirical studies. Purpose: The aim of the thesis is to elucidate and provide guidance about incorporation of trust to inform both clinical supervision and learners’ development in the clinical workplace. Methods: This thesis includes: (1) a literature-based overview of trust, drawing on studies in psychology, nursing, business and medical education; (2) a survey study using a modified Delphi technique to identify entrustable professional activities (EPAs) for a large internal medicine residency; (3) a pilot and feasibility evaluation of two EPAs implemented for competency-based assessment in the same residency program; (4) a qualitative interview study of how supervisors experience trust in their clinical trainees; and (5) two qualitative studies with residency program directors to explore their procedures for group review of resident performance. Results: (1) The literature identified five factors contributing to supervisors’ trust in their trainees: aspects of the supervisor, trainee, supervisor-trainee relationship, context, and task. These inter-related factors together explain how entrustment enables trainees’ clinical participation and learning. (2) The Delphi study identified 17 EPAs with full consensus as essential internal medicine physician tasks. (3) The EPA implementation study generated information about the benefits and barriers to the use of EPAs. (4) Interviews with clinical supervisors showed that the concept of trust resonated strongly with supervisors as a familiar and frequently used way of determining the amount and nature of supervision needed. Successful trust formation evolved supervisors’ roles away from direct supervision toward more consultation and teaching duties, enhanced residents’ independence, and influenced the entire team’s experience. (5) Residency program director interviews identified two guiding paradigms for group decision-making about resident performance: a problem identification model, which predominated, and a developmental model. The literature on group decision-making in diverse fields informed an analysis of the risks and opportunities for committees making decisions about resident advancement. Discussion: Emergent themes from the work in this thesis are:Trust, and therefore assessment, as a forward-looking judgment; trust as a multilevel process in training: an individual judgment and a program’s certification of readiness for advancement; trust formation within a relationship; evolution of trust over time;trust as a learning tool; and barriers to using trust as the basis for assessment. Understanding of the key contributors to judgments of trust and implications of that trust from the literature and studies with clinical supervisors and program directors inform recommendations for designing clinical training environments that promote trainee competence.