Factors Affecting Entrustment and Autonomy in Emergency Medicine: “How much rope do I give them?”

INTRODUCTION: During residency, the faculty’s role is to provide supervision while granting the trainee autonomy. This concept is termed entrustment. The goal is appropriate progression from supervision to autonomy while decreasing oversight as residents train. The objective of this study was to better understand the factors affecting the degree of autonomy or supervision faculty choose to provide residents. METHODS: This was a qualitative study of resident and faculty perceptions. We conducted two faculty and two resident focus groups. We then transcribed the transcripts of the audiotaped discussions and coded them using grounded theory. RESULTS: Analysis of the transcripts yielded four major factors affecting entrustment of residents. Patient Factors included the acuity of the patient, sociomedical issues of patient/family, and complexity of risk with patient or procedure. For example, “sometimes there are families and patients who are exceedingly difficult that immediately sort of force me [to allow less autonomy].” Environmental Factors included patient volume and systems protocols (i.e., trauma). “If you’re very busy and you have a resident that you already trust, you will give them more rope because you’re trying to juggle more balls.” Resident Factors included the year of training, resident performance, clinical direct observation, and patient presentations. “But if you have a resident that you do not trust […] I tell them you’re going to do this, this, this, this, this.” Faculty Factors included confidence in his/her own practice, risk-averse attitude, degree of ownership of the patient, commitment to education, and personality (e.g., micro-manager). Significant variability in entrustment by faculty existed, from being “micromanagers” to not seeing the patients. One resident noted: “There are some attendings, no matter how much they like you and how much you’ve worked with them, they’re always going to be in your face in the trauma bay. And there’s some attendings that are going to be ghosts.” CONCLUSION: Multiple factors affect the amount of autonomy and entrustment given to residents and their level of supervision by faculty, leading to wide variability in entrustment. In the end, regardless of resident, patient, or environment, some faculty are more likely to entrust than others.