title: The greater good: how supervising physicians make entrustment decisions in the pediatric emergency department.
abstract: BACKGROUND
  Graduate medical education is transitioning to the use of entrustable professional activities to contextualize educational competencies. Factors influencing entrustment decisions have been reported in adult medicine. Knowing how such decisions are made in pediatrics is critical to this transition.
  
  
  OBJECTIVE
  To understand how supervisors determine the level of procedural supervision to provide a resident, taking into consideration simulation performance; to understand factors that affect supervisors' transparency to parents about residents' procedural experience.
  
  
  METHODS
  We conducted 18 one-on-one interviews with supervisors in a tertiary care pediatric emergency department, iteratively revising interview questions as patterns in the data were elucidated. Two researchers independently coded transcripts and then met with the investigative team to refine codes and create themes.
  
  
  RESULTS
  Five factors influenced supervisors' entrustment decisions: 1) resident characteristics that include self-reported confidence, seniority, and prior interactions with the resident; 2) supervisor style; 3) nature of the procedure/characteristics of the patient; 4) environmental factors; and 5) parental preferences. Supervisors thought that task-based simulators provided practice opportunities but that simulated performance did not provide evidence for entrustment. Supervisors reported selectively omitting details about a resident's experience level to families to optimize experiential learning for residents they entrusted to perform a procedure.
  
  
  CONCLUSIONS
  In pediatrics, supervisors consider various factors when making decisions regarding resident procedural readiness, including parental preferences. An educational system using entrustable professional activities may facilitate holistic assessment and foster expertise-informed decisions about residents' progression toward entrustment; such a system may also lessen supervisors' need to omit information to parents about residents' procedural readiness.
authors.affiliation: Department of Pediatrics, Yale University School of Medicine, New Haven, Conn. Electronic address: gunjan.kamdar@yale.edu.
authors.forename: Gunjan
authors.initials: G
authors.lastname: Tiyyagura
authors.affiliation: Department of Pediatrics, Baylor College of Medicine, Houston, Tex.
authors.forename: Dorene
authors.initials: D
authors.lastname: Balmer
authors.affiliation: Department of Pediatrics and Emergency Medicine, Mt Sinai Hospital, New York, NY.
authors.forename: Lindsey
authors.initials: L
authors.lastname: Chaudoin
authors.affiliation: Department of Pediatrics, Columbia University, New York, NY.
authors.forename: David
authors.initials: D
authors.lastname: Kessler
authors.affiliation: Department of Emergency Medicine, Stanford University, Stanford, Calif.
authors.forename: Kajal
authors.initials: K
authors.lastname: Khanna
authors.affiliation: Department of Pediatrics, UT Southwestern Medical Center, Dallas, Tex.
authors.forename: Geetanjali
authors.initials: G
authors.lastname: Srivastava
authors.affiliation: Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, Calif.
authors.forename: Todd P
authors.initials: TP
authors.lastname: Chang
authors.affiliation: Department of Pediatrics, Yale University School of Medicine, New Haven, Conn.
authors.forename: Marc
authors.initials: M
authors.lastname: Auerbach
mesh_terms: D001291:Attitude of Health Personnel; D002983:Clinical Competence; D003657:Decision Making; D004503:Education, Medical, Graduate / Q000379:methods*; D004636:Emergency Service, Hospital; D006801:Humans; D007396:Internship and Residency; D007400:Interprofessional Relations; D007407:Interviews as Topic; D010372:Pediatrics / Q000193:education*
keywords: entrustable professional activities; medical education; resident assessment; simulation