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Our objectives today are to describe the factors affecting entrustment of autonomy.
To be prepared to navigate the barriers to entrustment,
because it can be difficult sometimes.
And then to understand how to appropriately facilitate resident
autonomy and grant attorneys suitable entrustment of
patient care in order to enhance education.
So let's take a minute and talk about entrustment.
Entrustment is a concept that was started by Olle ten Cate from the Netherlands.
He talked about the responsibility that we give trainees in the clinical environment.
So it's what they're able to do within the clinical setting.
And he talked about it in terms of whether or not we're in the room.
Whether or not we're out of the room.
How much responsibility and autonomy do we give them.
You will find during the sessions, I will often use these words interchangeably.
But let's just take a minute and, and talk about what they mean.
So autonomy really means the operate, the ability to operate independently.
Responsibility is the trust and responsibility that we give our trainees.
And the entrustment is kind of the, the overarching concept that we're,
that we're addressing.
And so today we're going to be really talking about these three concepts,
of autonomy, responsibility, and entrustment.
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So lets talk a little bit more about entrustment.
The day that they graduate residents are able to practice independently.
However, in residency it's really unclear when a trainee is ready for
unsupervised practice.
So when they graduate, they get to actually go out and practice on their own,
but when they're in training we really kind of supervise them relatively closely.
And the question is,
when is that line crossed from being supervised to that piece of autonomy.
Because it's probably important that that doesn't just happen right at the first of
July or whenever the trainee is graduate.
It needs to be a gradual process of increasing responsibility in autonomy.
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And so, balanced with this,
it's really important to think about the safety of the patient.
So, on one side is independent practice on the other side it's supervised training.
But within that middle in that dynamic of autonomy and responsibility and
supervision, there is patient safety and patient care.
And so it's important to be thinking about where one is in
the dynamic process of this.
Keeping in mind that we must keep our patients safe.
But that the responsibility residents is also not only in training now but for
their future patients.
And so that it's important to grant autonomy,
while they're in training with some degree supervision.
So that when they do graduate that they can go out and practice independently.
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So what is entrustment?
Let's step back and talk about the process of patient care.
So patient care is complicated, right?
When you're taking care of a patient we think about data gathering, so
the information that we collect.
We think about the interpretation, the integration, and more data gathering.
So we get a little piece of information and then we start get more information and
we're trying to formulated differential diagnosis.
Trying to figure out what things mean.
So, it's a very complicated process.
And in that process we're taking pieces of information,
integrating it into a diagnosis and then coming up with a treatment plan.
So the question is, when you're dealing in a collaborative setting,
where there is both a resident and an attending, or
a house officer when attending, or maybe a junior house officer and
a senior house officer, or maybe a medical student and a senior resident.
There are all of these different configurations where you're going to
get different levels of training and different levels of responsibility.
And we're doing that same patient care process of
data gathering integration analysis, but we're doing it on multiple levels.
And the question in, with autonomy is what pieces do
we actually entrust to different trainees along the way?
So do we allow a medical student to get and figure out what the allergies are.
Do we do we ask a student to go and
talk to the family about what the patient's wishes might be?
Those sorts of things.
And so it's really this entrustment and responsibility that we
give from the trainees to the attending and back and forth.
So that together we're collaborating and providing patient care.
In this process there what I, what I often call tacit trust decisions.
So along the way we're deciding do I trust this learner to do the piece of,
the important piece of patient care or
responsibility that is necessary at this time?
Or do I really kind of not trust them and I'm in a pull back and
have a little bit more ownership of this piece rather than allowing them to do it?
So, entrustment is really this tacit trust decision of what responsibility we give to
the trainees along the way, and it can go from very minimal,
indirect supervision to having quite a lot of autonomy and responsibility for
the patients that we're taking care of.
But in the end, it is a collaborative process, and
it is very dynamic as we move forward in patient care.
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And so that's really what we mean by entrustment.
It is the trust and responsibility that we're giving our learners as we provide
care to the patients while maintaining safe and good patient care environment.
It is dynamic as we said before.
It's a give and a take.
It's adjusted and altered as we move along.
And it's not something that is actually,
actually exact that I can say always entrust in this way.
Or I always entrust in that way.
Because it is the recognition that learners need some degree of
supervision and a degree of supervision is based on a number of
different factors that we will talk about later.
But in the end, our goal is, that our trainees are ready for
unsupervised practice.
So, the next thing that we're going to do is,
we're going to think about entrustment from the trainees viewpoint.
And you're going to hear from Josh Glazier, and
Ashley Pablick, who are two residents in
our emergency medicine training program here at the University of Michigan.
They're going to tell you about some situations, or some patients,
in where they felt like the the faculty really provided good autonomy and
entrustment, and then a couple situations where they felt like it
was not optimal to their development or perhaps the patient care.
It's valuable to hear it from their point of view,
because I think we don't really think about what they're going through and what
is, what works for them and what doesn't work for them in terms of their training.
And we'll see you back once we've watched these videos.
Sally Santen, M.D., Ph.D.Associate Professor - Emergency Medicine
