The purpose of this course is to improve feedback, clinical teaching, and assessment of clinical skills.
04.06 - Other Factors Affecting Entrustment
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Teaching and Assessing Clinical Skills
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UNIT 4 - ENTRUSTMENT AND AUTONOMY
The objectives for this module are that after you actively engage in the activities, you will be able to: 1. Describe the factors affecting autonomy 2. Be prepared to navigate the barriers to entrustment 3. Understand how to appropriately facilitate resident autonomy and grant trainee suitable entrustment of patient care to enhance education.
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Sally Santen, M.D., Ph.D.Associate Professor - Emergency Medicine
University of Michigan Medical School
So the next thing we're going to look at is specifically the trainee.
So these are trainee factors.
We just went through some of the facility factors and in the end is
probably the facility factors that's most important, but the next one is,
is the trainee factors and so depending on who the trainee is or what they.
What they're able to do, will depend on how much entrustment I might give them.
So, if indeed I have this trainee who doesn't quite know what to do with this
stethoscope, there's a reasonable chance that I am not going to give him a lot
of autonomy if he's wearing his stethoscope on his head like this.
So there's a number of factors for this.
And so, one of the probably the important one is what the relationship is with
the residents, so if this is a resident who I know well and
then I'm more likely to trust them to do patient care things.
If I hardly know them at all, then I'm probably going to watch quite a bit more
closely, I'm going to keep that leash a little bit shorter until I feel like I
have a sense of what they're able to do and not do.
The next thing is the Level of Training.
So if I don't actually know the resident, or I know them just peripherally then I
may choose the level of training as a surrogate.
So I may say, you know this is a medical student, or
this is an intern, or a first year resident.
And so based on their level of training I may.
And give more or less autonomy based on what level they're in.
This may or may not be appropriate because interns are great and
some interns are not.
And when you really think about it, it's really based on the individual case.
It's just because someone is a fourth year resident,
does not mean that they've seen a case of fiber toxicosis.
Right? They may not have any idea how to
manage that.
And so it can be a little bit of a fallacy along the way, but it is one of
the ways that we determine how much in trust that we're going to give them.
The other one is experience, and so if one of the residents has not been at my
site for a long time, I've been practicing at the University of Michigan, but
let's say the, the residents had been at St. Joe's or one of the other hospitals.
Then I may get them more of less experience.
More or less autonomy, based on their experience and to also.
Kind of with level of training.
If they're brand new then I may give them less,
if they have quite a bit of experience I may give them more.
You know, some of our residents have actually done a couple years of
orthopedics first, so clearly I'm going to give them more autonomy than others
simply based on their previous training.
Another thing is their Communication Skills.
This is something that really does affect,
how much investment that we give a trainee?
If they can't really communicate well with us,
then we're going to assume that they don't really know whats going on and
we're probably not going to trust them very much.
For example if a resident or a student gives a completely jumbled up history and
physical and then comes up with a plan that might be organized,
I'm really going to think that they don't really know what's going on.
And I'm probably going to trust them less.
So I would probably go and
take a history more rapidly than I would if they really gave me a clear history.
I'm going to go back and
double check a number of issues on their case, so that I can get a better picture.
So really based on what the patient presentation is,
we get a sense of what they know and don't know.
Which may or may not be correct, because the,
the resident could have been completely incorrect about what they found, but
if they can present it in an organized pattern then I'm going to trust what they
have to say, so be careful about that.
and, which is why we always go back and trust and verify what we're going through,
what we're going through.
Another thing is the Direct Observation.
So if, if I'm in a room and the resident seems to be doing a really nice job and
taking an organized history and
just seems clear about their the, the problem that they're coming up with.
And they're, you know, good in the information that they're taking,
they've taken good communi,
communication skills, then I may actually step out of the room rather rapidly.
Even if it is a critical patient,
because through that direct observation I decided that I could trust them.
And then it also is related to what we talked about previously as
patient presentation.
So I think as faculty members we look very carefully about the true competence and
ability of the trainee, by the way that they present themselves or
present their patients and when we watch them.
Through direct observation and
each of those relate to how much interest that we give them.
The other one is kind of estimated experiences,
that kind of comes back to level.
If they've done a month of anesthesia, then I'm probably going to be
more willing to let the more innovative patient, whereas if they haven't done any
anesthesia, I may not be able, willing to let them do an insubation so clearly.
And another thing is whether or not they ask for help.
I think residents often feel like asking for help is maybe a sign of weakness, but
for me as a faculty member when a resident asks for
help, it really says to me that they understand their limitations.
And so.
It lets me know that I can trust them to you know,
to really kind of let out the leash, to give them more reign, so that they'll,
because I know that they'll come to me and ask a question when they have a question.
And so whether or not they're asking for help,
we'll probably give them, I'll give them more autonomy rather than less autonomy.
Another thing is just what their Medical Knowledge is.
So, if it appears as though they don't really know anything about
paratixocoxis then I'm probably going to give them less autonomy at that time.
And so, if they're demonstrating their medical knowledge or, you know?
They, they seem to be well read.
Or choosing appropriate antibiotics those are things that
they're going to give them more.
autonomy, which really is that it's a gestalt, right?
It's a general medical competence.
If I think they're doing okay, I'll give them more leash.
If I think they're really having an issue,
then I will probably re-approach more carefully with it.
And with this comes kind of an apparent self-confidence.
It is interesting, we often talk about residents' kind of confidence to
competence ratio.
You want residents to be competent and confident.
But sometimes they get too confident, and
they can get kind of cocky and be over sure about what they're doing.
And so if, if a resident is.
Appearing to be over-confident and just kind of glib with what they're doing and
not careful with the details.
Then I will actually probably entrust them a bit less.
So apparent self-confidence in some ways can really help a resident, so if they're,
if they're timid and, and nervous then you may not give them a lot of trust.
But if they're over-confident, you're probably going to close,
re-approach as well and be, be less entrusting in those cases.
The other thing is this sense of kind of working proficiency.
And if they seem to have everything in hand, and
they're keeping all the balls in the air, and they're managing pretty well.
I'm going to kind of step back and just let them do their job,
because that's what they're doing well and that's what allows them to train the best.
So there is this thing though called betrayal of trust, which is that and
we discovered this in our, in our focus groups with faculty.
And it was, and it was a pretty strong thing, and
it was the sense that sure I'm going to give these residents autonomy, and
I'm going to trust them to take really good care of patients.
But if they betray my trust, then I'm not letting that leash out again for
a long time for that resident.
And so an example might be something such as in, you know,
if we go back our patient with pulmonary embolism and so we're taught, you know,
they do a good patient presentation and we decide together that we're not going to
get a CAT scan looking for pulmonary embolism and then when I go back and
I talk to the patient, I discover that she is, you know, broke her ankle and is.
Been in a cast and is on birth control pills,
both of which are strong risk factors for pulmonary embolism.
But if the resident didn't tell me,
then I'm going to consider that to be a betrayal of trust and I'm actually going
to pull that leash in quite a bit tighter than it was previously.
Because to me they have said.
I can't trust you, to know what history to be able to take and
to make the decisions that need to happen.
And so it tends to be both, maybe a faculty factor and
a resident factor, it's somewhere in-between.
But it is the sense that if there's a betrayal of trust we
tend to pull in really closely, and not trust the residents as much.
Based on that.
Now that I think about it, it's probably more of a faculty factor.
But it's the residents who do us and they betray our trust.
And, so what we're really kind of talking about is trustworthiness.
Do we trust the residents to permanently care for
the patients that we're dealing with.
And the final thing is really kind of reliability, you know?
Do they follow up,
do they get their charts done, do they do those sorts of things?
And I think a resident who tends to unreliable or are late.
We're probably not going to trust them as much.
Because we don't trust them to complete what needs to happen.
So finally I'm going to talk a little bit about or I'm going to give you
a couple of examples under the resident category of personality.
And so here's one.
So AA I think is a very good resident, but he's a really glib resident at times, and
so my trust of him is high but
my double-checking of him is also very high, if that makes sense.
And what that faculty meant is that we have a resident who's quite good, and so
we're going to kind of just let him go and do what he needs to do.
But you're always kind of behind his back and
check, check, checking, because sometimes he's over-confident.
Another one is BB is unreadable and silent.
But again, 90 to 95% he's right on the money.
So because I've worked with him enough, and
he's been correct the vast majority of the time, I probably give him the most rope.
Which is that sense of.
And knowing the residents, and having relationship with them, and
understanding what they're able to do.
And so I think as we start to get to know the residents better,
we're willing to give them more trust.
So the next category is Patient Factors.
Patient factors, are related to how sick the patient is or
what the expectations are?
And that is going to significantly affect how much autonomy we give.
And so if I have you know, a 20 year old with a sore throat, I'm probably going to
give that resident quite a bit of autonomy to take care of the sore throat.
If I have a two-year-old, I might actually be a little bit more careful because of
the risk of other, of bad things happen, or because of parent expectations.
And so here's an example of this.
Sometimes there are families and
patients who are exceedingly difficult that immediately sort of force me to have
a conversation with the trainee and, like you said, we're going to do it this way.
Not because you couldn't do it yourself, not because I don't trust you,
but because the family is pushing us and this is the right thing to do now.
Because in the end, it's the faculty who ends up being kind of
the final definition the final discriminator when family is upset or
when patients are upset, and so there are times that we actually do
Provide less autonomy because of the family or the patient that's there.
And there is a recognition of that.
Think of some patient acuity, right?
So, they're really sick patients, I'm going to be much closer.
I'm going to be in the room, and be watching what's doing.
I'm going to be more direct supervision, rather than indirect supervision.
Specifically when the patients are sicker.
When they're not so sick, I may not be as close to the to a supervision.
Or if the patient problem is less complex I may not have as much o,
I may not have as much supervision in tho, in those cases.
And final factor that was described by Light and
Conti and that we found as well is really kind of the environment.
Working in an environment is a Balancing Act.
If it's really busy, I can actually be more entrusting or less entrusting
depending on the resident and the patient and the, and the way that I am that day.
So when it's really busy, it's tempting just to stay and the resident go,
you know, go forth and do whatever you need to do.
however, it is equally as tempting to say, here do this, this, this, and
this because then.
I've actually been much more efficient in that, and so in a really busy
environment it's, they're going to be either more or less investment.
A same things is true in the, if it's quiet.
You know, so if there are not a lot of patients,
you know, it gives me the change to actually do some direct observation.
Now.
A direct observation is really kind of a lack of entrustment, but
it can be a good teaching point.
And so, you know, if it's not busy, we may actually entrust more, may,
we may entrust less, depending on that.
The other thing is that there is some so, so when it gets crazy busy,
I think that we tend to kind of alternate between that, you know,
lots of supervision versus lots of not supervision.
The other thing is, who is in The Team?
There are times when I wont use my nurses for entrustment, and
so if it's a nurse that is particular good I can really just step out of the room,
and I know that the nurse will come and get me if there is a problem or
will alert to the resident that hey did you think about this?
And so who the team is and
the environment, also effects the entrustment I give.
And in the same way at times they're kind of environment and
sysytem factors that demand that we be there, for
example in the United States supervision for
the purpose of billing is huge, and so they're things that the environment or
the system requires us to do that are not entrusting along the way.
So all of those things can affect the environment.
The other thing is kind of the culture.
I mean I think there's some cultures where the.
Faculty really kind of give trust to the residents.
The residents own those patients, and
I think there are other environments that tend to be highly supervised.
Where the the residents don't have a lot of autonomy.
I think one of our pediatric transplant surgeons appropriately says.
You know, these parents brought that child to me, at the University of Michigan.
To see me, not to see a medical student, but to see me.
And so that becomes difficult in terms of,
how do we train our students well in that environment?
And I think there's some tricks to it that we'll talk too about in the future.
So finally, I think culture is the final thing for the one of the factors.
So we've now been through some of the factors that affect entrustment.
Since they were faculty, trainee, patient and environment.
We'll just take a few minutes using discussion forum, and
note how the factors affect entrustment in your setting.
So how does it change what you do, and are there other factors that
we've not gone over might more strongly affect your setting?
Because I know that everybody is practicing in a different,
setting with different trainees.
So take a few minutes and
go to the discussion forum and let's have a discussion about this.
Thank you.
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