CBME, by the ICBME Collaborators, Competency-based medical education
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Unlocking the Potential of Interprofessional Entrustment Decision Making – The Time is Now

By: Marije P Hennus

In the ever-evolving world of healthcare, the concept of interprofessional teamwork is more vital than ever before. As healthcare professionals, we understand that the quality of patient care is a reflection of our collective effort as a team. We’ve all heard the saying: we’re only as strong as our weakest link. This realization has been the driving force behind my mission to inspire and support healthcare professionals, including future ones, on their journey to becoming the best providers they can be. To me, teaching is the key, and my vision is a world where all healthcare professionals learn from, with, and about each other.

Fortunately, interprofessional education has gained a lot of attention in the world of health professions education1. In contrast however, competency-based education and entrustable professional activities (EPAs) have shown a rather siloed development. Over the past fifteen years, postgraduate medical education has evolved from a time-based towards a competency-based training paradigm 2,3. This shift aims to provide healthcare professionals with the skills, knowledge, and attitudes needed to excel in their roles as medical specialists. However, the challenge with competencies, by their nature, is that they describe the qualities of individuals, not the performance of specific clinical tasks. Bridging this gap between competencies and real-world clinical practice called for something new, something innovative. This is where EPAs, the building blocks of professional practice, came in to play. They represent tasks that a learner can be entrusted to perform independently once they’ve demonstrated the required competence4. Think of them as essential checkpoints on the path to becoming a specialist. Master them, and you’re on your way to graduation and independent practice. Historically, EPAs have been crafted by professionals within the same specialty. Program directors and experienced supervisors have typically led the charge in developing EPAs for specialist training programs.

However, here’s the twist: becoming a health care professional is a complex journey that unfolds within the realm of interprofessional clinical practice. In fact, physicians in (specialty) training often spend more time working with interprofessional team members than with their physician supervisors. If you doubt this: you’ve just finished a regular night shift, how many hours did you actually spend in close proximity to your trainee, compared to your pillow? Even though multisource feedback, which involves input from supervisors, peers, interprofessional team members, and even patients, has become a cornerstone of health profession education, limited attention has been given to the role of these interprofessional team members in formally assessing medical trainees. This brings us to a pivotal question: why do we only seek feedback from our interprofessional team members and why don’t they have a role in the formal and often summative entrustment decision-making process? This decision to trust a medical trainee with the critical responsibility to care for a patient namely, is fundamental to clinical training5.

To be honest, I couldn’t and still can’t find a single irrefutable argument against this notion. However, there is an important condition to consider: for inter-professional entrustment decisions to hold value, it’s imperative that all members of the inter-professional team comprehend the concept of EPAs and the responsibilities they encompass. Misunderstandings or differences in interpretation when assessing a trainee’s readiness for an EPA namely, could lead to unintended consequences, affecting both patient safety and trainee autonomy.

In a recent study, we demonstrated that non-medical team members and physicians generally share a common understanding of which specific entrustable professional activities constitute the pediatric intensive care fellows’ training program6. What’s even more interesting is that input from our non-medical colleagues would have improved the clarity of our EPA descriptions. These findings support the involvement of non-medical team members in the development and validation process of entrustable professional activities for (sub)specialty training programs. Building on these findings, we made an exciting decision: as soon as we introduced EPAs in our institution, we welcomed our physician assistants and nurse specialists to join our team of preceptors for pediatric intensive care fellows, mirroring the role of the pediatric intensive care physicians. I’m proud to say, that this decision has consistently produced positive and rewarding results for everyone involved, and it has now become a standard practice.

In conclusion, this journey towards inter-professional entrustment decision making is an exciting one. As we move forward, it’s clear that involving inter-professional team members in the development, validation and entrustment of EPAs for (specialty) training programs is not just a good idea; it’s essential for the future of healthcare. Together, we can unlock the full potential of our healthcare teams and provide safe, effective, and sustainable care for all.

About the author: Marije Hennus, M.D., Ph.D., M.Sc., is a Pediatric Intensive Care (PICU) Physician at the University Medical Center Utrecht. She is interested in (interprofessional) clinical education, faculty development, workplace-based teaching, learning and assessment, the latter with a focus on entrustable professional activities.

References:

  1. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. The Lancet. 2010;376(9756):1923-1958. doi:10.1016/S0140-6736(10)61854-5
  2. Jardine D, Deslauriers J, Kamran SC, Khan N, Hamstra S, Edgar L. Milestones Guidebook for Residents and Fellows.; 2017. Accessed March 7, 2019. https://www.acgme.org/Portals/0/PDFs/Milestones/MilestonesGuidebookforResidentsFellows.pdf
  3. Frank JR, Snell L, Englander R, Holmboe ES. Implementing competency-based medical education: Moving forward. Med Teach. 2017;39(6):568-573. doi:10.1080/0142159X.2017.1315069
  4. ten Cate O. Entrustability of professional activities and competency-based training. Med Educ. 2005;39(12):1176-1177.
  5. ten Cate O, Hart D, Ankel F, et al. Entrustment Decision Making in Clinical Training. Academic Medicine. 2016;91(2):191-198. doi:10.1097/ACM.0000000000001044
  6. van Keulen SG, de Raad T, Raymakers-Janssen P, ten Cate O, Hennus MP. Professional Activities for Pediatric Intensive Care Fellows: A Proof-Of-Concept Study. Teach Learn Med. Published online 2023. doi:10.1080/10401334.2023.2200760

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