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#KeyLIMEpodcast 144: Entrustment at the Beginning of Training [KeyLIME Live! @CGEA Conference, Part 2]

CGEAPart 2 of a live session recorded at the 2017 CGEA Conference in Chicago with special guest hosts Anna Cianciolo, Larry Gruppen, John Mahan and Brian Mavis!

Part 2 finds Jason and the guest hosts mulling over a major question in medical education today: how do supervising physicians make decisions regarding who and how much to trust trainees and students who report to them.

Check out the podcast here (or on iTunes!) to hear the conversation.


KeyLIME Session 144 – Article under review:

Listen to the podcast

View/download the abstract here.

Sheu L, O’Sullivan PS, Aagaard EM, Tad-Y D, Harrell HE, Kogan JR, Nixon J, Hollander H, Hauer KE. How Residents Develop Trust in Interns: A Multi-Institutional Mixed-Methods Study.  Academic Medicine. 2016 Oct;91(10):1406-1415.

Reviewers: John Mahan(@mededMahan) & Larry Gruppen(@lgruppen)



A major question in medical education today, particularly in graduate medical education, is how do supervising physicians, whether they are attending, fellow or senior resident level, make decisions regarding who and how much to trust trainees and students who report to them?  Academic Medicine recently published this interesting mixed-methods exploration on the topic of: how do residents develop trust in interns?   This is an important question  for medical educators as “progressive autonomy” is now part of the ACGME lexicon regarding residency program requirements and the ultimate goal – the ability to gain trust (or entrustment) for unsupervised practice – is of course the definitive aim of our education and assessment of medical trainees.


This paper explores the mechanisms by which senior residents develop trust in interns they supervise.  The authors note that important teaching and supervision of junior residents comes from senior residents, as well as attending physicians.  They also note that senior residents typically receive little formal education about how to best supervise more junior trainees and yet spend a significant portion of their time in this role.  The authors employ a multi-institutional mixed-methods design, rooted in the frameworks of situated learning and workplace learning, to explore how senior residents develop trust in the junior residents interns they supervise.

Type of Paper


Key Points on Methods

  • The research team relied upon concepts of situated learning and workplace learning to develop hypotheses that interactions, activities, and work practices are major influences on how residents develop trust in their junior learners (interns).
  • This paper represents a mixed-methods study with an exploratory sequential design conducted by a research team consisting of an internal medicine resident, clinician–educators with experience supervising resident teams, a residency program director, and a medical education researcher. This is actually an excellent example of how mixed methods can be truly “mixed” rather than simply run in parallel. This study uses the results of one method to inform the design and interpretation of the other method.
  • This is a team of medical education research heavyweights with expertise in both the topic of entrustment and resident education and in the methodologies used in this study.
  • The reporting of the factor analysis leaves out several details that would be needed to replicate this study, such as whether they applied a factor rotation algorithm and, if so, what type.
  • The data only reflect resident perceptions. Neither faculty nor other health professionals were surveyed to obtain data to triangulate the findings.

Key Outcomes

  • Factor analysis yielded 11 factors that influence trust.
  • Residents, when indicating factors important to granting trust, rated intern characteristics (reliability, competence, and propensity to make errors) highest and then contextual factors (access to an electronic medical record, duty hours, and patient characteristics) next highest.
  • The authors found some discrepancies in the results from their qualitative and quantitative approaches. This raises the intriguing question of which results you “buy.” The authors tend to rely more on their qualitative results, but a case could also be made to lean more heavily on the quantitative findings.

Key Conclusions

Residents form trust based on primarily intern- and context-specific factors. Residents appear to consider trust in a way that prioritizes interns’ execution of essential patient care tasks safely within the complexities and constraints of the hospital environment.  These important constructs deserve further exploration and grounding in further evaluation of the wisdom of such ‘entrustment’ decisions and resultant patient outcomes.

Spare Keys – other take home points for clinician educators

This paper is an excellent example of writing multiple articles based on a program of research on a major medical education phenomenon.

This is how mixed methods research in medical education should be done!

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