Answer to "Should trainees be prohibited from practicing an EPA alone if they do not have a STAR? And can they be allowed to practice an EPA autonomously before the completion of training if they do have a STAR? Should there be no supervision anymore after a STAR?"

A Statement of Awarded Responsibility (STAR) is the terminology used when a summative entrustment decision has been made to grant a trainee responsibility for an EPA from that moment.(1) STARs, sometimes envisioned as digital badges (2,3), signify in postgraduate medical education, the moment that the trainee has reached, for that EPA, the level of proficiency that would be sufficient to meet the expectations for completion of the program. In other words, the learner can now be trusted to execute the task without further supervision. A STAR in undergraduate medical education may vary based on local regulations, but is generally limited to a permission to act without direct supervision in the room, but with supervision quickly available for help when needed.

 

Before a STAR can be awarded, trainees must practice. A golden rule in clinical education should be that trainees should have sufficient experience in doing something with supervision before they have the permission to do it without supervision (or with indirect supervision in UME). So the answer to the first question is definitely, YES. An even stronger statement is that this practice experience should be mandatory. In all cases where trainees practice an EPA before achieving the STAR for that EPA, supervisors must evaluate the circumstances and judge whether the context is adequately safe. This requires an ad-hoc decision of entrustment.(4–6)

 

After a STAR is awarded, trainees should be permitted to have the responsibility, and some autonomy, to practice the EPA. However, as long as the individual is in training, and does not have the formal license or certification for autonomy, supervision cannot be totally abandoned. Regulations require supervision to be in place, and that is a good for patient safety. While summative entrustment decisions and STARs mark pivotal moments in a training program, the trainee’s development in competence is gradual, as is their feeling of confidence in what they can or cannot do. It is very likely that, after a STAR has been awarded, the learning curve speeds up, as the trainee now realizes they need to work with less help. From an educational theory perspective, that has been called the "commitment dimension of the context."(7) More generally, it maintains a zone of proximal development (8,9) toward full proficiency, even if a trainee has passed a threshold of entrustment.(10) Supervisors will need to find the delicate balance in supervision that allows the trainee to experience full responsibility while also guarding the patient's safety (11,12). This holds not only within a training program, but also beyond, even when medical specialists are fully certified. Transitioning to new contexts (hospitals, countries), even when all STARs have been awarded, should at least require some form of initial supervision, as competence is not absolute but in part context-dependent. (10,13–15)

 

 Studies in surgery show that trainees, even when they have finished postgraduate training, do not always feel safe to practice the range of their specialty without supervision (16), and supervising specialist attendings acknowledge this (17–19). The effect of an accelerated learning curve after STARs is illustrated with this quote: "I work with chief residents daily. Very few are competent to practice surgery independently without first doing a fellowship. There seems to be more surgical maturation taking place in the 2 years of fellowship than in the 5 clinical years of residency" ((19)p1072.e.10). It also reflects how, for the sake of patient safety, supervision over the decades has become much more strict, but sometimes at the cost of adequate learning and development.(20) An interesting expert discussion about autonomy, risk and supervision in surgery has been published as supplement with a study from George et al.

 

REFERENCES

  1. ten Cate O, Scheele F. Competency-Based Postgraduate Training: Can We Bridge the Gap between Theory and Clinical Practice? Acad Med. 2007;82(6):542–7.

  2. Mehta NB, Hull AL, Young JB, Stoller JK. Just imagine: new paradigms for medical education. Acad Med. 2013 Oct;88(10):1418–23.

  3. Mejicano GC, Bumsted TN. Describing the Journey and Lessons Learned Implementing a Competency-Based, Time-Variable Undergraduate Medical Education Curriculum. Acad Med. 2018;93(3):S42-48.

  4. ten Cate O, Hart D, Ankel F, Busari J, Englander R, Glasgow N, et al. Entrustment Decision Making in Clinical Training. Acad Med. 2016;91(2):191–8.

  5. ten Cate O. Nuts and Bolts of Entrustable Professional Activities. J Grad Med Educ. 2013 Sep 21;5(1):157–8.

  6. ten Cate O. Managing risks and benefits: key issues in entrustment decisions. Med Educ. 2017;51(9):879–81.

  7. Koens F, Mann KV, Custers EJFM, Ten Cate OTJ. Analysing the concept of context in medical education. Med Educ. 2005;39(12).

  8. Vygotsky LS. Mind in society. The development of higher psychological processes. Cambridge, MA: Harvard University Press; 1978.

  9. Chaiklin S. The Zone of Proximal Development in Vygotsky’s Analysis of Learning and Instruction. In: Kozulin A, Gindis B, Ageyev V, Miller S, editors. Vygotsky’s Educational Theory in Cultural Context. Cambridge UK: Cambridge University Press; 2003. p. 39–64.

  10. ten Cate O, Snell L, Carraccio C. Medical competence: the interplay between individual ability and the health care environment. Med Teach. 2010 Jan;32(8):669–75.

  11. Babbott S. Commentary: watching closely at a distance: key tensions in supervising resident physicians. Acad Med. 2010 Sep;85(9):1399–400.

  12. Balmer DF, Giardino AP, Richards BF. The Dance Between Attending Physicians and Senior Residents as Teachers and Supervisors. Pediatrics. 2012;129:910–5.

  13. Gingerich A, Kogan J, Yeates P, Govaerts M, Holmboe E. Seeing the ‘black box’ differently: assessor cognition from three research perspectives. Med Educ. 2014 Nov;48(11):1055–68.

  14. ten Cate O, Regehr G. The Power of Subjectivity in the Assessment of Medical Trainees. Acad Med.

  15. Ten Cate O, Billett S. Competency-based medical education: Origins, perspectives and potentialities. Med Educ. 2014;48(3).

  16. Fronza JS, Prystowsky JP, Darosa D, Fryer JP. Surgical residents’ perception of competence and relevance of the clinical curriculum to future practice. J Surg Educ. 2012;69(6):792–7.

  17. Mattar SG, Alseidi AA, Jones DB, Jeyarajah DR, Swanstrom LL, Aye RW, et al. General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors. Ann Surg. 2013 Sep;258(3):440–9.

  18. George BC, Bohnen JD, Williams RG, Meyerson SL, Schuller MC, Clark MJ, et al. Readiness of US General Surgery Residents for Independent Practice. Ann Surg. 2017;266(4):582–94.

  19. Napolitano LM, Savarise M, Paramo JC, Soot LC, Todd SR, Gregory J, et al. Education: Are General Surgery Residents Ready to Practice? A Survey of the American College of Surgeons Board of Governors and Young Fellows Association. J Am Coll Surg. 2014;218:1063–1072.e31.

  20. Halpern SD, Detsky AS. Graded Autonomy in Medical Education — Managing Things That Go Bump in the Night. N Engl J Med. 2014;370(12):1086–9.

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