When to Trust Trainees to Practice on Their Own

Entrustable professional activities (EPAs) describe the routine and essential activities physicians perform in practice and help program directors determine when trainees can be trusted to perform these activities. Although scales (to determine if trainees can work unsupervised) for EPAs had been proposed, they had not been validated — until now. Two new studies, one involving fellows and the other involving general pediatric residents, shed light on the best uses of EPAs. 


In a study led by Richard B. Mink, MD, MACM, and conducted by the Subspecialty Pediatrics Investigator Network (SPIN), researchers created new supervisory scales for six of the seven common pediatric subspecialty EPAs and then examined their validity by having pediatric fellowship program directors and Clinical Competency Committees across the country use them to evaluate fellows in fall 2014 and spring 2015. The study was published online ahead of print on July 11, 2017, in Academic Medicine.

“When we talk about how we assess fellows, it’s different from residency,” says Dr. Mink, Chief of the Division of Pediatric Critical Care and Director of the Pediatric Critical Care Fellowship Program at Harbor-UCLA Medical Center, and Professor of Pediatrics at the David Geffen School of Medicine at the University of California-Los Angeles. “While there are some published scales looking at the required level of supervision, these have never been validated and may not be suitable for fellows. Fellows work with the same core group of attending physicians over three years, making a trust assessment easier because of the longitudinal experience.”

SPIN determined that one supervisory scale would not fit all EPAs, so it created separate scales for each of six EPAs. Dr. Mink says not only did the new scales address direct versus indirect supervision, but also considered the complexity of the case. 

“Fellows might need direct supervision for a complex case, but they’re okay working alone for a simple case,” Dr. Mink explains. For example, he says caring for a baby who has respiratory syncytial virus (RSV) is usually fairly straightforward. “I may feel comfortable with a fellow six months into pediatric critical care fellowship doing that and taking care of that baby without me being there. But if a child comes in with an overwhelming infection and septic shock, I may say ‘Let me help you with this one’ or ‘Let me watch you a little bit more closely.’” 

The study assessed fellows from more than 200 programs at 80 institutions in each year of training. For each time period and EPA, there was a progressive increase in entrustment levels. Second-year fellows were rated higher than first-year fellows, and third-year fellows rated higher than second-year fellows. 

The research provided strong evidence for the validity of the scales as effective supervisory tools and showed an excellent correlation between levels of supervision and performance levels on milestones.


Assistant Professor of Pediatrics at Cincinnati Children’s Hospital Daniel Schumacher, MD, MEd, is leading a research study that explores how program directors assess their residents using EPAs. The study involves 22 general pediatrics residency programs that vary in size and geographic location. Twice a year, the Clinical Competency Committee for each program reports on six EPAs. 

“We ask them to review assessment data about their residents and make a decision on the level of supervision needed to safely and effectively perform each EPA,” Dr. Schumacher says. “Following a cohort of residents from each of these programs through their three years of training will help to set performance standards that will provide consistency in skills needed to advance to the next level of training or go on to practice.”

Dr. Schumacher designed a second component of this study as a large multi-institutional quality improvement project to enhance the quantity and the quality of the data collected. He applied for ABP approval so that Clinical Competency Committee members with meaningful participation in the study could apply to earn MOC Part 4 credit from the ABP.

The study will be completed in spring 2019.