Answer to "Who should initiate the process to arrive at an entrustment decision: a trainee, a supervisor, or a program or clerkship director?"

This question boils down to the issue of ownership of an educational program. Should it be the teacher or the trainee? In many cases one would say the educational institution creates the curriculum, hires the teachers, determines when assessments take place, determines trainee grades and controls its administration. However, as trainees mature, the case can be made that they should increasingly become the owner of their own learning/curriculum.

A process-oriented educational approach, implying a gradual transfer of learning functions from teachers to learners (Vermunt and Verloop, 1999) aligns with the more individualised approach to workplace learning that EPA-based curricula support. At this stage, trainees should assume control of their own educational process and start determining the what (objectives), why (motivation) and how (metacognitive techniques, strategies and regulation) of learning, in preparation for personal life-long learning. This includes trainee control of a learning portfolio, estimation of their own strengths and areas for development, and their determination of readiness to move to next discrete progress steps. This is not easy, as we know that humans find self-assessment difficult (Eva et al., 2004; Mann et al., 2011), so guidance remains important (Sargeant et al., 2010).

In conclusion, there are good reasons to stimulate trainees to initiate entrustment decisions. They should develop skills for 'informed self-assessment', which is only possible through personal agency and the pro-active request for evaluation of their readiness for entrustment. Supervisors may then provide a reality testing, similar to what driving instructors do when giving feedback to learners about their readiness for the driver’s license exam. Ultimately, a team (a clinical competency-committee in postgraduate training (Hauer et al., 2016; Weiss et al., 2016) or an entrustment committee in undergraduate education (Lomis et al., 2017; Obeso et al., 2018) awards the STAR (see FAQ#8). 



Eva, K. W., Cunnington, J. P. W., Reiter, H. I., Keane, D. R., et al. (2004) ‘How Can I Know What I Don’t Know? Poor Self Assessment in a Well-Defined Domain’, Advances in Health Sciences Education, 9(3), pp. 211–224.

Hauer, K. E., ten Cate, O., Boscardin, C. K., Iobst, W., et al. (2016) ‘Ensuring Resident Competence: A Narrative Review of the Literature on Group Decision Making to Inform the Work of Clinical Competency Committees’, Journal of Graduate Medical Education, 8(2), pp. 156–164.

Lomis, K., Amiel, J. M., Ryan, M. S., Esposito, K., et al. (2017) ‘Implementing an Entrustable Professional Activities Framework in Undergraduate Medical Education: Early Lessons From the AAMC Core Entrustable Professional Activities for Entering Residency Pilot’, Academic Medicine, 92(6), pp. 765–770.

Mann, K., van der Vleuten, C., Eva, K., Armson, H., et al. (2011) ‘Tensions in Informed Self-Assessment: How the Desire for Feedback and Reticence to Collect and Use It Can Conflict’, Academic Medicine, 86(9), p. 1120.

Obeso, V. T., Phillipi, C. A., Degnon, C. A., Carter, T. J., et al. (2018) ‘A Systems-Based Approach to Curriculum Development and Assessment of Core Entrustable Professional Activities in Undergraduate Medical Education’, Medical Science Educator, 28(2), pp. 407–416.

Sargeant, J., Armson, H., Chesluk, B., Dornan, T., et al. (2010) ‘The Processes and Dimensions of Informed Self-Assessment: A Conceptual Model’, Academic Medicine, 85(7), p. 1212.

Vermunt, J. D. and Verloop, N. (1999) ‘Congruence and friction between learning and teaching’, Learning and Instruction, 9(3), pp. 257–280.

Weiss, A., Ozdoba, A., Carroll, V. and DeJesus, F. (2016) ‘Entrustable Professional Activities: Enhancing Meaningful Use of Evaluations and Milestones in a Psychiatry Residency Program’, Academic Psychiatry, 40(5), pp. 850–854.