Faculty and Resident Perspectives on Using Entrustment Anchors for Workplace-Based Assessment

Assessing supervisor versus trainee viewpoints of entrustment through cognitive and affective lenses: an artificial intelligence investigation of bias in feedback

The entrustment framework redirects assessment from considering only trainees' competence to decision-making about their readiness to perform clinical tasks independently. Since trainees and supervisors both contribute to entrustment decisions, we examined the cognitive and affective factors that underly their negotiation of trust, and whether trainee demographic characteristics may bias them. Using a document analysis approach, we adapted large language models (LLMs) to examine feedback dialogs (N = 24,187, each with an associated entrustment rating) between medical student trainees and their clinical supervisors. We compared how trainees and supervisors differentially documented feedback dialogs about similar tasks by identifying qualitative themes and quantitatively assessing their correlation with entrustment ratings. Supervisors' themes predominantly reflected skills related to patient presentations, while trainees' themes were broader-including clinical performance and personal qualities. To examine affect, we trained an LLM to measure feedback sentiment. On average, trainees used more negative language (5.3% lower probability of positive sentiment, p < 0.05) compared to supervisors, while documenting higher entrustment ratings (+ 0.08 on a 1-4 scale, p < 0.05). We also found biases tied to demographic characteristics: trainees' documentation reflected more positive sentiment in the case of male trainees (+ 1.3%, p < 0.05) and of trainees underrepresented in medicine (UIM) (+ 1.3%, p < 0.05). Entrustment ratings did not appear to reflect these biases, neither when documented by trainee nor supervisor. As such, bias appeared to influence the emotive language trainees used to document entrustment more than the degree of entrustment they experienced. Mitigating these biases is nonetheless important because they may affect trainees' assimilation into their roles and formation of trusting relationships.

Accuracy of Entrustment-Based Assessment: Implications for Programs and Patients

Background Although entrustment-supervision ratings are more intuitive compared to other rating scales, it is not known whether their use accurately assesses the appropriateness of care provided by a resident. Objective To determine the frequency of incorrect entrustment ratings assigned by faculty and whether accuracy of an entrustment-supervision scale differed by resident performance when the scripted resident performance level is known. Methods Faculty participants rated standardized residents in 10 videos using a 4-point entrustment-supervision scale. We calculated the frequency of rating a resident incorrectly. We performed generalizability (G) and decision (D) studies for all 10 cases (768 ratings) and repeated the analysis using only cases with an entrustment score of 2. Results The mean score by 77 raters for all videos was 2.87 (SD=0.86) with a mean of 2.37 (SD=0.72), 3.11 (SD=0.67) and 3.78 (SD=0.43) for the scripted levels of 2, 3, and 4. Faculty ratings differed from the scripted score for 331of 768 (43%) ratings. Most errors were ratings higher than the scripted score (223, 67%). G studies estimated the variance proportions of rater and case to be 4.99% and 54.29%. D studies estimated that 3 raters would need to watch 10 cases. The variance proportion of rater was 8.5% when the analysis was restricted to level 2 entrustment, requiring 15 raters to watch 5 cases. Conclusions Participants underestimated residents' potential need for greater supervision. Overall agreement between raters and scripted scores were low.

The Assessment Burden in Competency-Based Medical Education: How Programs Are Adapting

Residents and faculty have described a burden of assessment related to the implementation of competency-based medical education (CBME), which may undermine its benefits. Although this concerning signal has been identified, little has been done to identify adaptations to address this problem. Grounded in an analysis of an early Canadian pan-institutional CBME adopter's experience, this article describes postgraduate programs' adaptations related to the challenges of assessment in CBME. From June 2019-September 2022, 8 residency programs underwent a standardized Rapid Evaluation guided by the Core Components Framework (CCF). Sixty interviews and 18 focus groups were held with invested partners. Transcripts were analyzed abductively using CCF, and ideal implementation was compared with enacted implementation. These findings were then shared back with program leaders, adaptations were subsequently developed, and technical reports were generated for each program. Researchers reviewed the technical reports to identify themes related to the burden of assessment with a subsequent focus on identifying adaptations across programs. Three themes were identified: (1) disparate mental models of assessment processes in CBME, (2) challenges in workplace-based assessment processes, and (3) challenges in performance review and decision making. Theme 1 included entrustment interpretation and lack of shared mindset for performance standards. Adaptations included revising entrustment scales, faculty development, and formalizing resident membership. Theme 2 involved direct observation, timeliness of assessment completion, and feedback quality. Adaptations included alternative assessment strategies beyond entrustable professional activity forms and proactive assessment planning. Theme 3 related to resident data monitoring and competence committee decision making. Adaptations included adding resident representatives to the competence committee and assessment platform enhancements. These adaptations represent responses to the concerning signal of significant burden of assessment within CBME being experienced broadly. The authors hope other programs may learn from their institution's experience and navigate the CBME-related assessment burden their invested partners may be facing.

"A whole other competence story": exploring faculty perspectives on the process of workplace-based assessment of entrustable professional activities

The centrality of entrustable professional activities (EPAs) in competency-based medical education (CBME) is predicated on the assumption that low-stakes, high-frequency workplace-based assessments used in a programmatic approach will result in accurate and defensible judgments of competence. While there have been conversations in the literature regarding the potential of this approach, only recently has the conversation begun to explore the actual experiences of clinical faculty in this process. The purpose of this qualitative study was to explore the process of EPA assessment for faculty in everyday practice. We conducted 18 semi-structured interviews with Anesthesia faculty at a Canadian academic center. Participants were asked to describe how they engage in EPA assessment in daily practice and the factors they considered. Interviews were audio-recorded, transcribed, and analysed using the constant comparative method of grounded theory. Participants in this study perceived two sources of tension in the EPA assessment process that influenced their scoring on official forms: the potential constraints of the assessment forms and the potential consequences of their assessment outcome. This was particularly salient in circumstances of uncertainty regarding the learner's level of competence. Ultimately, EPA assessment in CBME may be experienced as higher-stakes by faculty than officially recognized due to these tensions, suggesting a layer of discomfort and burden in the process that may potentially interfere with the goal of assessment for learning. Acknowledging and understanding the nature of this burden and identifying strategies to mitigate it are critical to achieving the assessment goals of CBME.

Validation of a form for assessing the professional performance of residents in cardiology by nurses

BACKGROUND

There is a strong need for transformation in our assessment systems from one that evaluates performance based on levels of training to another that focuses on professional competence to meet the expected requirements for the practice of the profession. The aim of this study is to validate for the first time a Spanish version of a new tool for assessing the professional performance of residents by nurses newly developed in the Ottawa Hospital (O-RON).

MATERIALS AND METHODS

After the author's written authorization, the original O-RON form was translated and cross-culturally adapted. Then we conducted a prospective observational study in two cardiology centers in the city of Buenos Aires. The validity of the tools was evaluated by the ability of the instrument to discriminate the level of experience of the residents according to their post-graduate year level. Data is expressed as percentages and frequencies of the qualifications obtained in the different questions. The chi-square test was used to assess the significance of the differences obtained. A generalizability test was used to evaluate reliability. Feasibility was defined as a minimum of 4 assessments per resident per evaluation round. Satisfaction of evaluators was assessed using a survey with a 10-point scale designed by the authors.

RESULTS

A total of 838 evaluations were performed. Regarding validity, the 15-item form could significantly discriminate the experience of the residents according to their postgraduate year level (P < 0,005). Thirty evaluations per resident are required to obtain reliable results. The tool is feasible to implement and an average of 4.55 assessment per resident per evaluation round were achieved throughout the entire experience. This value remained stable during the 8 rounds (1st: 4.65; 2nd: 4.34; 3^rd: 4.47; 4^th: 6.17; 5^th: 4.56; 6^th: 4.08; 7^th: 4.36; 8^th: 3.91). The levels of satisfaction among the evaluators were acceptable.

CONCLUSION

The Spanish version of the O-RON form can provide residents with a valuable source of feedback from the eyes of nurses on important aspects of their professional training. This tool, positively assessed by the raters, significantly discriminates residents' experience. Its implementation is feasible in our environment, and it is user-friendly, though it requires a considerable number of assessments to achieve high reliability.

Can Rater Training Improve the Quality and Accuracy of Workplace-Based Assessment Narrative Comments and Entrustment Ratings? A Randomized Controlled Trial

PURPOSE

Prior research evaluating workplace-based assessment (WBA) rater training effectiveness has not measured improvement in narrative comment quality and accuracy, nor accuracy of prospective entrustment-supervision ratings. The purpose of this study was to determine whether rater training, using performance dimension and frame of reference training, could improve WBA narrative comment quality and accuracy. A secondary aim was to assess impact on entrustment rating accuracy.

METHOD

This single-blind, multi-institution, randomized controlled trial of a multifaceted, longitudinal rater training intervention consisted of in-person training followed by asynchronous online spaced learning. In 2018, investigators randomized 94 internal medicine and family medicine physicians involved with resident education. Participants assessed 10 scripted standardized resident-patient videos at baseline and follow-up. Differences in holistic assessment of narrative comment accuracy and specificity, accuracy of individual scenario observations, and entrustment rating accuracy were evaluated with t tests. Linear regression assessed impact of participant demographics and baseline performance.

RESULTS

Seventy-seven participants completed the study. At follow-up, the intervention group (n = 41), compared with the control group (n = 36), had higher scores for narrative holistic specificity (2.76 vs 2.31, P < .001, Cohen V = .25), accuracy (2.37 vs 2.06, P < .001, Cohen V = .20) and mean quantity of accurate (6.14 vs 4.33, P < .001), inaccurate (3.53 vs 2.41, P < .001), and overall observations (2.61 vs 1.92, P = .002, Cohen V = .47). In aggregate, the intervention group had more accurate entrustment ratings (58.1% vs 49.7%, P = .006, Phi = .30). Baseline performance was significantly associated with performance on final assessments.

CONCLUSIONS

Quality and specificity of narrative comments improved with rater training; the effect was mitigated by inappropriate stringency. Training improved accuracy of prospective entrustment-supervision ratings, but the effect was more limited. Participants with lower baseline rating skill may benefit most from training.

Implementation of Entrustable Professional Activities assessments in a Canadian obstetrics and gynecology residency program: a mixed methods study

BACKGROUND

Since the implementation of competency-based medical education (CBME) across residency training programs in Canada, there has been limited research understanding how entrustable professional activity (EPA) assessments are used by faculty supervisors and residents.

OBJECTIVE

This study examines how EPA assessments are used in an Obstetrics and Gynecology residency program and the impact of implementation on both groups.

METHODS

A mixed methods study design was used. Part one involved the aggregation of descriptive data of EPA assessment completion for postgraduate year 1 and 2 residents from July 2019 to May 2020. Part two involved a thematic analysis of semi-structured interviews of residents and faculty.

RESULTS

There was significant uptake of EPA assessments across community and teaching hospitals with widespread contribution of assessment data from faculty. However, both residents and faculty reported that the intended design of EPA assessments as low-stakes assessments to provide formative feedback is not how EPA assessments are experienced. Residents and faculty noted the increased level of administrative burden and related perceived stress amongst the resident group.

CONCLUSIONS

The implementation of EPA assessments is feasible across a variety of sites. However, previous measurement challenges remain. Neither residents nor faculty perceive the value of EPAs to improve feedback, despite their intended nature.

Examining the validity argument for the Ottawa Surgical Competency Operating Room Evaluation (OSCORE): a systematic review and narrative synthesis

The Ottawa Surgical Competency Operating Room Evaluation (OSCORE) is an assessment tool that has gained prominence in postgraduate competency-based training programs. We undertook a systematic review and narrative synthesis to articulate the underlying validity argument in support of this tool. Although originally developed to assess readiness for independent performance of a procedure, contemporary implementation includes using the OSCORE for entrustment supervision decisions. We used systematic review methodology to search, identify, appraise and abstract relevant articles from 2005 to September 2020, across MEDLINE, EMBASE and Google Scholar databases. Nineteen original, English-language, quantitative or qualitative articles addressing the use of the OSCORE for health professionals' assessment were included. We organized and synthesized the validity evidence according to Kane's framework, articulating the validity argument and identifying evidence gaps. We demonstrate a reasonable validity argument for the OSCORE in surgical specialties, based on assessing surgical competence as readiness for independent performance for a given procedure, which relates to ad hoc, retrospective, entrustment supervision decisions. The scoring, generalization and extrapolation inferences are well-supported. However, there is a notable lack of implications evidence focused on the impact of the OSCORE on summative decision-making within surgical training programs. In non-surgical specialties, the interpretation/use argument for the OSCORE has not been clearly articulated. The OSCORE has been reduced to a single-item global rating scale, and there is limited validity evidence to support its use in workplace-based assessment. Widespread adoption of the OSCORE must be informed by concurrent data collection in more diverse settings and specialties.

Workplace-Based Entrustment Scales for the Core EPAs: A Multisite Comparison of Validity Evidence for Two Proposed Instruments Using Structured Vignettes and Trained Raters

PURPOSE

In undergraduate medical education (UME), competency-based medical education has been operationalized through the 13 Core Entrustable Professional Activities for Entering Residency (Core EPAs). Direct observation in the workplace using rigorous, valid, reliable measures is required to inform summative decisions about graduates' readiness for residency. The purpose of this study is to investigate the validity evidence of 2 proposed workplace-based entrustment scales.

METHOD

The authors of this multisite, randomized, experimental study used structured vignettes and experienced raters to examine validity evidence of the Ottawa scale and the UME supervisory tool (Chen scale) in 2019. The authors used a series of 8 cases (6 developed de novo) depicting learners at preentrustable (less-developed) and entrustable (more-developed) skill levels across 5 Core EPAs. Participants from Core EPA pilot institutions rated learner performance using either the Ottawa or Chen scale. The authors used descriptive statistics and analysis of variance to examine data trends and compare ratings, conducted interrater reliability and generalizability studies to evaluate consistency among participants, and performed a content analysis of narrative comments.

RESULTS

Fifty clinician-educators from 10 institutions participated, yielding 579 discrete EPA assessments. Both Ottawa and Chen scales differentiated between less- and more-developed skill levels (P < .001). The interclass correlation was good to excellent for all EPAs using Ottawa (range, 0.68-0.91) and fair to excellent using Chen (range, 0.54-0.83). Generalizability analysis revealed substantial variance in ratings attributable to the learner-EPA interaction (59.6% for Ottawa; 48.9% for Chen) suggesting variability for ratings was appropriately associated with performance on individual EPAs.

CONCLUSIONS

In a structured setting, both the Ottawa and Chen scales distinguished between preentrustable and entrustable learners; however, the Ottawa scale demonstrated more desirable characteristics. These findings represent a critical step forward in developing valid, reliable instruments to measure learner progression toward entrustment for the Core EPAs.

Exploring how feedback reflects entrustment decisions using artificial intelligence

CONTEXT

Clinical supervisors make judgements about how much to trust learners with critical activities in patient care. Such decisions mediate trainees' opportunities for learning and competency development and thus are a critical component of education. As educators apply entrustment frameworks to assessment, it is important to determine how narrative feedback reflecting entrustment may also address learners' educational needs.

METHODS

In this study, we used artificial intelligence (AI) and natural language processing (NLP) to identify characteristics of feedback tied to supervisors' entrustment decisions during direct observation encounters of clerkship medical students (3328 unique observations). Supervisors conducted observations of students and collaborated with them to complete an entrustment-based assessment in which they documented narrative feedback and assigned an entrustment rating. We trained a deep neural network (DNN) to predict entrustment levels from the narrative data and developed an explainable AI protocol to uncover the latent thematic features the DNN used to make its prediction.

RESULTS

We found that entrustment levels were associated with level of detail (specific steps for performing clinical tasks), feedback type (constructive versus reinforcing) and task type (procedural versus cognitive). In justifying both high and low levels of entrustment, supervisors detailed concrete steps that trainees performed (or did not yet perform) competently.

CONCLUSIONS

Framing our results in the factors previously identified as influencing entrustment, we find a focus on performance details related to trainees' clinical competency as opposed to nonspecific feedback on trainee qualities. The entrustment framework reflected in feedback appeared to guide specific goal-setting, combined with details necessary to reach those goals. Our NLP methodology can also serve as a starting point for future work on entrustment and feedback as similar assessment datasets accumulate.

Comparing Entrustment and Competence: An Exploratory Look at Performance-Relevant Information in the Final Year of a Veterinary Program

Workplace-based assessments and entrustment scales have two primary goals: providing formative information to assist students with future learning; and, determining if and when learners are ready for safe, independent practice. To date, there has not been an evaluation of the relationship between these performance-relevant information pieces in veterinary medicine. This study collected quantitative and qualitative data from a single cohort of final-year students (n = 27) across in-training evaluation reports (ITERs) and entrustment scales in a distributed veterinary hospital environment. Here we compare progression in scoring and performance within and across student, within and across method of assessment, over time. Narrative comments were quantified using the Completed Clinical Evaluation Report Rating (CCERR) instrument to assess quality of written comments. Preliminary evidence suggests that we may be capturing different aspects of performance using these two different methods. Specifically, entrustment scale scores significantly increased over time, while ITER scores did not. Typically, comments on entrustment scale scores were more learner specific, longer, and used more of a coaching voice. Longitudinal evaluation of learner performance is important for learning and demonstration of competence; however, the method of data collection could influence how feedback is structured and how performance is ultimately judged.

The Ottawa Resident Observation Form for Nurses (O-RON): Assessment of Resident Performance through the Eyes of the Nurses

OBJECTIVE

Most work-place based assessment relies on physician supervisors making observations of residents. Many areas of performance are not directly observed by physicians but rather by other healthcare professionals, most often nurses. Assessment of resident performance by nurses is captured with multi-source feedback tools. However, these tools combine the assessments of nurses with other healthcare professionals and so their perspective can be lost. A novel tool was developed and implemented to assess resident performance on a hospital ward from the perspective of the nurses.

DESIGN

Through a nominal group technique, nurses identified dimensions of performance that are reflective of high-quality physician performance on a hospital ward. These were included as items in the Ottawa Resident Observation Form for Nurses (O-RON). The O-RON was voluntarily completed during an 11-month period. Validity evidence related to quantitative and qualitative data was collected.

SETTING

The Orthopedic Surgery Residency Program at the University of Ottawa.

PARTICIPANTS

49 nurses on the Orthopedic Surgery wards at The Ottawa Hospital (tertiary care).

RESULTS

The O-RON has 15 items rated on a 3-point frequency scale, one global judgment yes/no question regarding whether they would want the resident on their team and a space for comments. 1079 O-RONs were completed on 38 residents. There was an association between the response to the global judgment question and the frequency of concerns (p < 0.01). With 8 forms per resident, the reliability of the O-RON was 0.80. Open-ended responses referred to aspects of interpersonal skills, responsiveness, dependability, communication skills, and knowledge.

CONCLUSIONS

The O-RON demonstrates promise as a work-place based assessment tool to provide residents and training programs with feedback on aspects of their performance on a hospital ward through the eyes of the nurses. It appears to be easy to use, has solid evidence for validity and can provide reliable data with a small number of completed forms.

Exploring the use of rating scales with entrustment anchors in workplace-based assessment

PURPOSE

Competency-based medical education (CBME) has prompted widespread implementation of workplace-based assessment (WBA) tools using entrustment anchors. This study aimed to identify factors that influence faculty's rating choices immediately following assessment and explore their experiences using WBAs with entrustment anchors, specifically the Ottawa Surgical Competency Operating Room Evaluation scale.

METHOD

A convenience sample of 50 semi-structured interviews with Emergency Medicine (EM) physicians from a single Canadian hospital were conducted between July and August 2019. All interviews occurred within two hours of faculty completing a WBA of a trainee. Faculty were asked what they considered when rating the trainee's performance and whether they considered an alternate rating. Two team members independently analysed interview transcripts using conventional content analysis with line-by-line coding to identify themes.

RESULTS

Interviews captured interactions between 70% (26/37) of full-time EM faculty and 86% (19/22) of EM trainees. Faculty most commonly identified the amount of guidance the trainee required as influencing their rating. Other variables such as clinical context, trainee experience, past experiences with the trainee, perceived competence and confidence were also identified. While most faculty did not struggle to assign ratings, some had difficulty interpreting the language of entrustment anchors, being unsure whether their assessment should be retrospective or prospective in nature, and if/how the assessment should change whether they were 'in the room' or not.

CONCLUSIONS

By going to the frontline during WBA encounters, this study captured authentic and honest reflections from physicians immediately engaged in assessment using entrustment anchors. While many of the factors identified are consistent with previous retrospective work, we highlight how some faculty consider factors outside the prescribed approach and struggle with the language of entrustment anchors. These results further our understanding of 'in-the-moment' assessments using entrustment anchors and may facilitate effective faculty development regarding WBA in CBME.

Generalizability of the Ottawa Surgical Competency Operating Room Evaluation (O-SCORE) Scale to Assess Medical Student Performance on Core EPAs in the Workplace: Findings From One Institution

PURPOSE

Assessment of the Core Entrustable Professional Activities for Entering Residency (Core EPAs) requires direct observation of learners in the workplace to support entrustment decisions. The purpose of this study was to examine the internal structure validity evidence of the Ottawa Surgical Competency Operating Room Evaluation (O-SCORE) scale when used to assess medical student performance in the Core EPAs across clinical clerkships.

METHOD

During the 2018-2019 academic year, the Virginia Commonwealth University School of Medicine implemented a mobile-friendly, student-initiated workplace-based assessment (WBA) system to provide formative feedback for the Core EPAs across all clinical clerkships. Students were required to request a specified number of Core EPA assessments in each clerkship. A modified O-SCORE scale (1 = "I had to do" to 4 = "I needed to be in room just in case") was used to rate learner performance. Generalizability theory was applied to assess the generalizability (or reliability) of the assessments. Decision studies were then conducted to determine the number of assessments needed to achieve a reasonable reliability.

RESULTS

A total of 10,680 WBAs were completed on 220 medical students. The majority of ratings were completed on EPA 1 (history and physical) (n = 3,129; 29%) and EPA 6 (oral presentation) (n = 2,830; 26%). Mean scores were similar (3.5-3.6 out of 4) across EPAs. Variance due to the student ranged from 3.5% to 8%, with the majority of the variation due to the rater (29.6%-50.3%) and other unexplained factors. A range of 25 to 63 assessments were required to achieve reasonable reliability (Phi > 0.70).

CONCLUSIONS

The O-SCORE demonstrated modest reliability when used across clerkships. These findings highlight specific challenges for implementing WBAs for the Core EPAs including the process for requesting WBAs, rater training, and application of the O-SCORE scale in medical student assessment.

How Do Clerkship Students Use EPA Data? Illuminating Students' Perspectives as Partners in Programs of Assessment

INTRODUCTION

The implementation of programs of assessment based on Entrustable Professional Activities (EPAs) offers an opportunity for students to obtain unique data to guide their ongoing learning and development. Although authors have explored factors that contribute to trust-based decisions, learners' use of assessors' decisions about the level of supervision they need has not been fully investigated.

METHODS

In this study, we conducted semi-structured interviews of clerkship students who participated in the first year of our EPA program to determine how they interpret and use supervision ratings provided in EPA assessments. Content analysis was performed using concept-driven and open coding.

RESULTS

Nine interviews were completed. Twenty-two codes derived from previous work describing factors involved in trust decisions and 12 novel codes were applied to the interview text. Analyses revealed that students focus on written and verbal feedback from assessors more so than on supervision ratings. Axial coding revealed a temporal organization that categorized how students considered the data from EPA assessments. While factors before, during, and after an assessment affected students' use of information, the relationship between the student and the assessor had impact throughout.

CONCLUSIONS

Although students reported varying use of the supervision ratings, their perspectives about how assessors and students interact and/or partner before, during, and after assessments provide insights into the importance of an educational alliance in making a program of assessment meaningful and acceptable to learners.

Twelve tips for learners to succeed in a CBME program

The international movement to competency-based medical education (CBME) marks a major transition in medical education that requires a shift in educators' and learners' approach to clinical experiences, the way assessment data are collected and integrated, and in learners' mindsets. Learners entering a CBME curriculum must actively drive their learning experiences and education goals. For some, this expectation may be a significant change from their previous approach to learning in medicine. This paper highlights 12 tips to help learners succeed within a CBME model.

Comparing the Ottawa Emergency Department Shift Observation Tool (O-EDShOT) to the traditional daily encounter card: measuring the quality of documented assessments

OBJECTIVES

The Ottawa Emergency Department Shift Observation Tool (O-EDShOT) is a workplace-based assessment designed to assess a trainee's performance across an entire shift. It was developed in response to validity concerns with traditional end-of-shift workplace-based assessments, such as the daily encounter card. The O-EDShOT previously demonstrated strong psychometric characteristics; however, it remains unknown whether the O-EDShOT facilitates measurable improvements in the quality of documented assessments compared to daily encounter cards.

METHODS

Three randomly selected daily encounter cards and three O-EDShOTs completed by 24 faculty were scored by two raters using the Completed Clinical Evaluation Report Rating (CCERR), a previously published 9-item quantitative measure of the quality of a completed workplace-based assessment. Automated-CCERR (A-CCERR) scores, which do not require raters, were also calculated. Paired sample t tests were conducted to compare the quality of assessments between O-EDShOTs and DECs as measured by the CCERR and A-CCERR.

RESULTS

CCERR scores were significantly higher for O-EDShOTs (mean(SD) = 25.6(2.6)) compared to daily encounter cards (21.5(3.9); t(23) = 5.2, p < 0.001, d = 1.1). A-CCERR scores were also significantly higher for O-EDShOTs (mean(SD) = 18.5(1.6)) than for daily encounter cards (15.5(1.2); t(24) = 8.4, p < 0.001). CCERR items 1, 4 and 9 were rated significantly higher for O-EDShOTs compared to daily encounter cards.

CONCLUSIONS

The O-EDShOT yields higher quality documented assessments when compared to the traditional end-of-shift daily encounter card. Our results provide additional validity evidence for the O-EDShOT as an assessment tool for capturing trainee on-shift performance that can be used as a stimulus for actionable feedback and as a source for high-quality workplace-based assessment data to inform decisions about emergency medicine trainee progress and promotion.

Assessing Trainees and Making Entrustment Decisions: On the Nature and Use of Entrustment-Supervision Scales

Clinical teachers are continuously entrusting trainees with care responsibilities in health care settings. Entrustable professional activities employ entrustment decision making as an approach to assessment in the workplace.Various scales have been created to measure "entrustment," all basically expressing the level or type of supervision a trainee requires for safe and high-quality care. However, some of these scales are only weakly related to the purpose of making decisions about the autonomy trainees will be granted. The authors aim to increase understanding about the nature, purpose, and practice of supervision scales aimed at entrustment.After arguing for entrustment as a component of workplace-based assessment, the distinction between ad hoc entrustment decisions (daily decisions in health care settings) and summative entrustment decisions (with a certifying nature) is clarified. Next, the noncontinuous nature of entrustment-supervision (ES) scales, as opposed to most workplace-based assessment scales, is explained. ES scales have ordinal, rather than interval, properties and focus on discrete decisions. Finally, some scales are retrospective ("how much supervision was provided?"), and others are prospective ("how much supervision will be needed in the near future?"). Although retrospective scales reflect observed behavior, prospective scales truly focus on entrustment and ask for more holistic judgment, as they include a broader evaluation and a risk estimation to enable a decision about increase of autonomy.The analysis concludes with a discussion about entrustment for unsupervised practice and supervision of others, as well as the program, context, and specialty specificity of scales.

The Ottawa Emergency Department Shift Observation Tool (O-EDShOT): A New Tool for Assessing Resident Competence in the Emergency Department

OBJECTIVES

The outcome of emergency medicine (EM) training is to produce physicians who can competently run an emergency department (ED) shift. However, there are few tools with supporting validity evidence specifically designed to assess multiple key competencies across an entire shift. The investigators developed and gathered validity evidence for a novel entrustment-based tool to assess a resident's ability to safely run an ED shift.

METHODS

Through a nominal group technique, local and national stakeholders identified dimensions of performance that are reflective of a competent ED physician and are required to safely manage an ED shift. These were included as items in the Ottawa Emergency Department Shift Observation Tool (O-EDShOT), and each item was scored using an entrustment-based rating scale. The tool was implemented in 2018 at the University of Ottawa Department of Emergency Medicine, and quantitative data and qualitative feedback were collected over 6 months.

RESULTS

A total of 1,141 forms were completed by 78 physicians for 45 residents. An analysis of variance demonstrated an effect of training level with statistically significant increases in mean O-EDShOT scores with each subsequent postgraduate year (p < 0.001). Scores did not vary by ED treatment area. Residents rated as able to safely run the shift had significantly higher mean ± SD scores (4.8 ± 0.3) than those rated as not able (3.8 ± 0.6; p < 0.001). Faculty and residents reported that the tool was feasible to use and facilitated actionable feedback aimed at progression toward independent practice.

CONCLUSIONS

The O-EDShOT successfully discriminated between trainees of different levels regardless of ED treatment area. Multiple sources of validity evidence support the O-EDShOT as a tool to assess a resident's ability to safely run an ED shift. It can serve as a stimulus for daily observation and feedback making it practical to use within an EM residency program.

The future is here! Pediatric surgery and the move to the royal college of physicians and surgeons of Canada's competence by design

This interactive session was held at the 51st Annual Meeting of the Canadian Association of Pediatric Surgeons (CAPS) in preparation for the transition of Pediatric Surgery training in Canada to Competency by Design (a CBME-based model of residency training developed by the Royal College of Physicians and Surgeons of Canada).