When I say “You can do it”

By: Olle ten Cate, PhD

A well-known feature of Medical Education is the “When I Say…” series. The brief papers in this series give insight, usually as a linguistic explanation that opens the eyes to a better understanding. The briefs have a personal touch (e.g. when I say entrustability)(1), but with the aim of a more generalized uptake.

I was triggered by a ‘you can do it’ expression that I recently read in a paper in the American Journal of Pharmaceutical Education’(2). I found the expression in a variant of the entrustment-supervision scale. There are many variations of this scale. This is the scale that the authors used for Australian interns in pharmacy education:

• Level 1: Observe only, even with direct supervision
• Level 2: Perform with direct, proactive supervision and intervention
• Level 3: Perform with indirect proximal (nearby) supervision, on request and quickly available
• Level 4: Perform with minimal supervision, available if needed, essentially independent performance
• Level 5: Can supervise more junior colleagues

The authors use it as a prospective ES scale(3), i.e. not reporting how much supervision was given during an observed event, but as a qualification of readiness for practice (a correct use, I would say).

However, my first reaction after seeing Level 5 was to think: here the authors stepped into the trap of defining a proficiency level instead of a readiness level, by using ‘can’, clearly a word for competence, rather than permission or readiness. Because I know one of the authors, wanted to remind myself of asking at a next interaction: why did you not say “permitted to act as the supervisor for more junior colleagues” or just “act as.. etc.”.

But then, the linguist in me started wondering ‘Can can be an uttering of permission?’  Of course! What if a trainee asks to attend a patient unsupervised and the supervisor answers: “sure, you can go ahead and do it”. So can is then used as permission: “you can be permitted to..”, in short, “you can..”. An linguistic eye-opener for me, at first sight.

But then still, why would I not recommend using ‘can’ in ES scales? First and foremost, it is bound to be misunderstood as measure of competence, rather than as an entrustment decision. Second, the expression ‘you can do it’, as sign of permission, really only serves the one-on-one ad hoc situation of granting autonomy, not when a clinical competency committee would decide upon a generalized permission to start acting under a specified level of supervision (including Level 5: be the supervisor of juniors). This wording would not work for summative entrustment decisions. When I (can) say something about ES scales it would be: avoid anchor wording that can be interpreted as a level of competence of the learner, rather than the target of permission for increased autonomy to support a decision of entrustment.

Refrences:

1. ten Cate O. When I say … entrustability. Med Educ. 2020 Feb;54(2):103–4.
2. Al-Diery T, Marotti S, Rowett D, Johnson JL. Entrusting pharmacy trainees: Exploring expectations of entrustment across the pharmacy intern year in Australia. Am J Pharm Educ. 2025 Jun;101437.
3. ten Cate O, Schwartz A, Chen HC. Assessing Trainees and Making Entrustment Decisions: On the Nature and Use of Entrustment-Supervision Scales. Acad Med. 2020 Nov;95(11):1662–9.

About the Author:

Olle ten Cate, PHD, is an emeritus professor of medical education at University Medical Center Utrecht, the Netherlands, interested in competency-based education, in the process of entrustment in health professions education, and in clarity of language use.

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