Helping Students Grapple with Mixed Messages

By: Olle ten Cate (@olletencate)

I have always felt uneasy toward teachers who complain that today’s students are less motivated (..”than we were”..) and merely focused on exams. This recurrent complaint, that could also be heard a century ago, reflects a tension in expectations that teachers and schools themselves create. It is odd to call medical students, known as a most dedicated and focused category of learners, less motivated than they should be. What actually happens is that schools and teachers send mixed messages. They set undisputable (and, btw, legitimate) requirements, without which students cannot progress, and at the same time they expect that students show interest in content matter that will not be tested. We reward students who work hard to complete a course or program with the highest scores with a cum laude or honors, and also excel in extra-curricular activities. With some exaggerations: we like students who show passion for our research interests, but despise them if they fail exams. My reaction is usually to follow John Bigg’s classic recommendation1 to create constructive alignment: make sure what you teach is what you test and is what you find important objectives. Then, working for exams is exactly what you want. But some mixed messages are less easily addressed.

In this blog I would like to highlight one particular category of mixed messages. When we study entrustment decision making (not as scores on a scale, but the actual decisions to entrust leaners with clinical responsibilities), it becomes clear that a myriad of factors affect such decisions. Besides the variance caused by supervisors and contextual circumstances2, several student characteristics have been stressed as important by clinical supervisors. In a 2008 study Tara Kennedy found four features that determine trustworthiness (knowledge & skill, discernment of limitations, conscientiousness and truthfulness)3. Later studies added to these findings, resulting in five factors that have recently been summarized in ‘A RICH entrustment decision’: Agency (self-confidence, proactive attitude toward work, team, safety, and personal development), Reliability (being conscientious, predictable, accountable, responsible), Integrity (being truthful, benevolent and patient-centered), Capability (having the required knowledge and skill; experience; adaptive expertise), Humility (observing own limitations, willingness to ask help, being receptive to feedback).4

So, if we want to help students becoming ready to be entrusted with critical tasks, we must tell them to show capability, but also humility and integrity. Traditionally we reward doing well, being competent, achieving high scores; and naturally, that is what student like to show; a pretty clear message on first sight. But humility and integrity are critical too. Many clinicians would not trust learners with critical patient care activities if they do not ask for help if needed5, or if they are not open to feedback, from supervisors, from peers and from interprofessional colleagues. That requires humility, which may conflict with showing superiority. To make it even more complicated, students who feel superior and just pretend to be humble may not be as truthful (component of integrity) as we expect them to be. And continuously asking for help to show humility does not align well with agency and a proactive attitude. So, are we sending all sorts of mixed messages to trainees?

There are reasons not to turn the conditions for a rich entrustment decision into a new scoring rubric or a rating scale, but to consider the features in a holistic way.4 One is that these features may not show at the same time. At some moments, trainees must show agency, at other moments humility; and reliable behavior does not have to be in conflict with flexible and adaptive behavior. Brief observations cannot capture this variety; longitudinal monitoring of students may do this.

Educators must help students understand what the expectations of trustworthiness are. It will not be sufficient for them to excel at moments of overt observation (i.e. just ‘prepare for the test’) but also at unexpected moments, in a variety of ways. Some expectations may seem contradictory, but those who take the continuously changing circumstances in the workplace into account will understand that such contrasts are part of clinical life. Learners must be aware that not all features can be directly observed at planned moments, but depend on the demands of the moment. The holistic picture or gestalt of trustworthiness, both in general, and for specific activities or EPAs, will be needed for a summative entrustment.6

About the author: Olle ten cate, PhD, is a senior scientist at the Center for Research and Development of Education Universiteit Utrecht, the Netherlands.


1.Biggs J. Aligning Teaching and Assessing to Course Objectives. Assess Eval High Educ. 2003;38(5):1–16.

2. Hauer KE, O ten Cate, C Boscardin, DM Irby, W Iobst, PS O’Sullivan. Understanding trust as an essential element of trainee supervision and learning in the workplace. Adv Heal Sci Educ. 2014;19(3).

3. Kennedy TJT, G Regehr, GR Baker, L Lingard. Point-of-Care Assessment of Medical Trainee Competence for Independent Clinical Work. Acad Med. 2008 Oct;83(Supplement):S89–92.

4. ten Cate O, HC Chen. The ingredients of a rich entrustment decision. Med Teach. 2020;42(12):1413–20.

5. Schumacher DJ, C Michelson, AS Winn, DA Turner, E Elshoff, B Kinnear. Making prospective entrustment decisions: Knowing limits, seeking help and defaulting. Med Educ. 2022;56(9):892–900.

6. Touchie C, B Kinnear, D Schumacher, H Caretta-Weyer, SJ Hamstra, D Hart, et al. On the validity of summative entrustment decisions. Med Teach. 2021;43(7):780–7.

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