It had been about 6 months since my son’s last karate promotion to a new color belt. On our way to the dojo, he was excited at the prospect of possibly stepping up into the world of advanced brown belts! After some demonstrations and review, his instructor was proud of his work, but informed him that it would likely be another month or so of practice until he would be promoted. The very kind “sensei” (teacher) mentioned that his technique was good, but not yet consistent enough to be able to demonstrate reliably without support and model for other students.
In a parallel way, it made me carefully think about the pathway of lifelong learning that is part of a physician’s journey. As we acquire global knowledge, skills, and attitudes, we are able to develop competency in many defined domains. This acquisition is brought about through instruction, problem-solving, deep self-analysis, observation, and practice. Our “dojos” range from the classroom, to the conference room, to the bedside, to our technology devices, and to our internal reflections. Milestone descriptions of the behaviors observed as we progress toward mastery provide great guidewires for competency development and assessment of our skills. As learners and practicing physicians, we aim to use these tools to determine if (not simply when) we are ready to safely perform professional activities, and the core of making this determination is trustworthiness.
Trust, as a value, offers the foundation of our relationships in medicine, and in a way, cements the notion that our performance is continuously reliable, improving, and professionally responsible. There is a tangible quality to this that is always being assessed. Our patients assess this through our professional interactions and the relationships we develop in clinical environments. Our peers, auditors, and institutions have guardrails that organize all of this through quality improvement and peer review. Practitioners hopefully cultivate a self-awareness to know how and when to ask this question: do I trust my own skills to perform an activity and/or do I need to seek help or consultation?
While the benefits can be profoundly rewarding, through a deep sense of professional fulfillment and ongoing development of responsibilities, there is the caution of entrustment decisions that are made with poor definition or description and without coaching and mentoring. In other words, trust may be best aligned with standards, best practices, and reliably observed behaviors rather than simply relying on the amount of time one has been learning or practicing. Coaching and mentors are essential for both developing these standards and for helping determine this entrustment. Inevitably, there is a contractual nature to this quality of entrustment, in that we owe it to ourselves, our patients, and our professional community to demonstrate, maintain, and continuously curate this trust in our performance as physicians.
Yet, what outcome are we aiming for and with what audience? At every step of our training and career development, we hopefully have at least 3 sets of eyes on our performance: our supervisors or peers, our patients, and our own. We each hope that our ongoing skill building results in a progressive entrustment of activities that we perform. Physician learners are assessed through a variety of methods that address how entrusted they may (or may not) be in performing an activity, such as performing a procedure, creating a treatment plan, or handing over a patient’s care to another provider. In independent practice, and on our continual journey of lifelong learning, we hopefully have developed habits of thoughtful self-analysis, cultivated a community of peers and colleagues, and garnered participatory patient-centered feedback to critically appraise this entrustability. Our performance is what drives this, not simply how long we’ve been learning or in practice. This approach also requires the flexibility to adapt our learning plans, modify how we teach or supervise, and perhaps evaluate when we are able to perform or continue our activities.
The ride home that day from the dojo was a challenging one for me and my son. We were certain that enough time had passed to develop the skills needed for a new belt. We were also appreciative of the feedback and clear instructions on what was needed for my son to demonstrate that he was entrusted in not only performing those skills, but sharing and modelling them for others. A few weeks later, after some more rigorous practice and focus, he earned that advanced brown belt and has been helping out in class as a “senpai” (senior learner). I was certainly proud of his resolve, patience, and commitment to understanding that it was his performance that garnered the entrustment of the advanced brown belt, and not simply the time that had passed since his last promotion. It certainly has strengthened my own commitment to continually engender this professional entrustability as a physician from my patients, my teams, my peers, and myself!
Abhay Dandekar is a practicing pediatrician and a life-long learner. He likes sparking ideas and connecting people. He is also a former residency program director. For a great primer on entrustment in the clinical learning environment, go here.