Entrustment Ratings in Internal Medicine Training: Capturing Meaningful Supervision Decisions or Just Another Rating?

  • Rose HatalaEmail author
  • Shiphra Ginsburg
  • Karen E. Hauer
  • Andrea Gingerich


The implementation of Entrustable Professional Activities has led to the simultaneous development of assessment based on a supervisor’s entrustment of a learner to perform these activities without supervision. While entrustment may be intuitive when we consider the direct observation of a procedural task, the current implementation of rating scales for internal medicine’s non-procedural tasks, based on entrustability, may not translate into meaningful learner assessment. In these Perspectives, we outline a number of potential concerns with ad hoc entrustability assessments in internal medicine post-graduate training: differences in the scope of procedural vs. non-procedural tasks, acknowledgement of the type of clinical oversight common within internal medicine, and the limitations of entrustment language. We point towards potential directions for inquiry that would require us to clarify the purpose of the entrustability assessment, reconsider each of the fundamental concepts of entrustment in internal medicine supervision and explore the use of descriptive rather than numeric assessment approaches.


Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.


  1. 1.
    Frank JR, Snell LS, ten Cate O, et al. Competency-based medical education: theory to practice. Med Teach. 2010; 32:638–645.CrossRefGoogle Scholar
  2. 2.
    ten Cate O, Scheele F. Competency-based postgraduate training: can we bridge the gap between theory and clinical practice? Acad Med. 2007;82(6):542–547.CrossRefGoogle Scholar
  3. 3.
    ten Cate O, Chen HC, Hoff RG, Peters H, Bok H, van der Schaaf M. Curriculum development for the workplace using Entrustable Professional Activities (EPAs): AMEE Guide No. 99. Med Teach. 2015;37(11):983–1002.CrossRefGoogle Scholar
  4. 4.
    Hauer KE, Oza SK, Kogan JR, et al. How clinical supervisors develop trust in their trainees: a qualitative study. Med Educ. 2015;49(8):783–795.CrossRefGoogle Scholar
  5. 5.
    Goldszmidt M, Faden L, Dornan T, Van Merrienboer J, Bordage G, Lingard L. Attending physician variability: a model of four supervisory styles. Acad Med. 2015;90(11):1541–1546.CrossRefGoogle Scholar
  6. 6.
    Kogan JR, Conforti LN, Bernabeo E, Iobst W, Holmboe E. How faculty members experience workplace-based assessment rater training: a qualitative study. Med Educ. 2015;49(7):692–708.CrossRefGoogle Scholar
  7. 7.
    Gingerich A, Daniels V, Farrell L, Olsen S-R, Kennedy T, Hatala R. Beyond hands-on and hands-off: supervisory approaches and entrustment on the inpatient ward. Med Educ. 2018;91(2):1028–1040.Google Scholar
  8. 8.
    Rekman J, Gofton W, Dudek N, Gofton T, Hamstra SJ. Entrustability Scales: Outlining Their Usefulness for Competency-Based Clinical Assessment. Acad Med. 2016;91(2):186–190.CrossRefGoogle Scholar
  9. 9.
    Crossley J, Johnson G, Booth J, Wade W. Good questions, good answers: construct alignment improves the performance of workplace-based assessment scales. Med Educ. 2011;45(6):560–569.CrossRefGoogle Scholar
  10. 10.
    Beard JD, Marriott J, Purdie H, Crossley J. Assessing the surgical skills of trainees in the operating theatre: a prospective observational study of the methodology. Health Technol Assess. 2011;15(1):1–194.CrossRefGoogle Scholar
  11. 11.
    MacEwan MJ, Dudek NL, Wood TJ, Gofton WT. Continued Validation of the O-SCORE (Ottawa Surgical Competency Operating Room Evaluation): Use in the simulated environment. Teach Learn Med. 2015;28(1):72–79.CrossRefGoogle Scholar
  12. 12.
    Sebok-Syer SS, Chahine S, Watling CJ, Goldszmidt M, Cristancho S, Lingard L. Considering the interdependence of clinical performance: implications for assessment and entrustment. Med Educ. 2018;52(9):970–980.Google Scholar
  13. 13.
    Bernabeo EC, Holtman MC, Ginsburg S, Rosenbaum JR, Holmboe ES. Lost in transition: The experience and impact of frequent changes in the inpatient learning environment. Acad Med. 2011;86(5):591–598.CrossRefGoogle Scholar
  14. 14.
    ten Cate O, Hart D, Ankel F, et al. Entrustment Decision Making in Clinical Training. Acad Med. 2016;91(2):191–198.CrossRefGoogle Scholar
  15. 15.
    Duijn CCMA, Welink LS, Bok HGJ, ten Cate OTJ. When to trust our learners? Clinical teachers' perceptions of decision variables in the entrustment process. Perspect Med Educ. 2018;7(3):192–199.CrossRefGoogle Scholar
  16. 16.
    Holmboe ES. Realizing the Promise of Competency-Based Medical Education. Acad Med. 2015;90(4):411–413.CrossRefGoogle Scholar
  17. 17.
    Kennedy TJT, Lingard L, Baker GR, Kitchen L, Regehr G. Clinical oversight: conceptualizing the relationship between supervision and safety. J Gen Intern Med. 2007;22(8):1080–1085.CrossRefGoogle Scholar
  18. 18.
    Kane MT. Validating the Interpretations and Uses of Test Scores. J Educ Meas. 2013;50(1):1–73.CrossRefGoogle Scholar
  19. 19.
    Cook DA, Brydges R, Ginsburg S, Hatala R. A contemporary approach to validity arguments: a practical guide to Kane's framework. Med Educ. 2015;49(6):560–575.CrossRefGoogle Scholar
  20. 20.
    ten Cate O. Entrustability of professional activities and competency-based training. Med Educ. 2005;39(12):1176–1177.CrossRefGoogle Scholar
  21. 21.
    Warm EJ, Mathis BR, Held JD, et al. Entrustment and mapping of observable practice activities for resident assessment. J Gen Intern Med. 2014;29(8):1177–1182.CrossRefGoogle Scholar
  22. 22.
    Warm EJ, Held JD, Hellmann M, et al. Entrusting observable practice activities and milestones over the 36 months of an internal medicine residency. Acad Med. 2016;91(10):1398–1405.CrossRefGoogle Scholar
  23. 23.
    Halman S, Rekman J, Wood T, Baird A, Gofton W, Dudek N. Avoid reinventing the wheel: implementation of the Ottawa Clinic Assessment Tool (OCAT) in Internal Medicine. BMC Med Educ. 2018; 18:218.CrossRefGoogle Scholar
  24. 24.
    Cook DA, Kuper A, Hatala R, Ginsburg S. When assessment data are words: validity evidence for qualitative educational assessments. Acad Med. 2016; 91:1359–1369.Google Scholar
  25. 25.
    Holmboe ES. Competency-based medical education and the ghost of Kuhn. Academic Medicine. 2018;93(3):350–353.CrossRefGoogle Scholar
  26. 26.
    Dauphinee WD, Boulet JR, Norcini JJ. Considerations that will determine if competency-based assessment is a sustainable innovation. Adv in Health Sci Educ.

Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Rose Hatala
    • 1
    • 2
    Email author
  • Shiphra Ginsburg
    • 3
  • Karen E. Hauer
    • 4
  • Andrea Gingerich
    • 5
  1. 1.Department of Medicine University of British ColumbiaVancouverCanada
  2. 2.St. Paul’s HospitalVancouverCanada
  3. 3.Department of Medicine, Faculty of MedicineUniversity of TorontoTorontoCanada
  4. 4.Department of MedicineUniversity of California at San FranciscoSan FranciscoUSA
  5. 5.Northern Medical ProgramUniversity of Northern British ColumbiaPrince GeorgeCanada

Personalised recommendations