• Lindsay Melvin, James Rassos, Lynfa Stroud, and Shiphra Ginsburg.
• L. Melvin is assistant professor, Department of Medicine, University of Toronto, Toronto, Ontario, Canada. J. Rassos is a fifth-year resident, general internal medicine subspecialty training program, Department of Medicine, University of Toronto, Toronto, Ontario, Canada. L. Stroud is associate professor, Department of Medicine, and education researcher, Wilson Centre for Education, University of Toronto, Toronto, Ontario, Canada. S. Ginsburg is professor, Department of Medicine, and scientist, Wilson Centre for Education, University of Toronto, Toronto, Ontario, Canada.
• Acad Med. 2020 Apr 1; 95 (4): 609-615.

PurposeA key unit of assessment in competency-based medical education (CBME) is the entrustable professional activity. The variations in how entrustment is perceived and enacted across specialties are not well understood. This study aimed to develop a thorough understanding of the process, concept, and language of entrustment as it pertains to internal medicine (IM).MethodAttending supervisors of IM trainees on the clinical teaching unit were purposively sampled. Sixteen semistructured interviews were conducted and analyzed using constructivist grounded theory. The study was conducted at the University of Toronto from January to September 2018.ResultsFive major themes were elucidated. First, the concepts of entrustment, trust, and competence are not easily distinguished and sometimes conflated. Second, entrustment decisions are not made by attendings, but rather are often automatic and predetermined by program or trainee level. Third, entrustment is not a discrete, point-in-time assessment due to longitudinality of tasks and supervisor relationships with trainees. Fourth, entrustment scale language does not reflect attendings' decision making. Fifth, entrustment decisions affect the attending more than the resident.ConclusionsA tension arises between the need for a common language of CBME and the need for authentic representation of supervision within each specialty. With new assessment instruments required to operationalize the tenets of CBME, it becomes critically important to understand the nuanced and specialty-specific language of entrustment to ensure validity of assessments.

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