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What should we mean by “allowed to supervise others” in entrustment scales?

“Twelve tips for the implementation of EPAs for assessment and entrustment decisions” (Peters et al. 2017) provides valuable guidance for the use of entrustable professional activities (EPAs). EPAs contextualize competencies in sets of activities constituent of a profession and align assessment around “entrustment”: what is a learner allowed to do, and at what level of supervision? Many current EPA assessments have adopted the five-level supervision scale (Ten Cate 2013) presented in expanded form in this paper. Notably, the five-level scale includes a top level of autonomy beyond unsupervised performance—Allowed to supervise others in practice of EPA—a difficult construct to align with graduated autonomy in training. In most specialties, residents in their second year are allowed (even required) to supervise medical students or more junior residents. Program directors trust residents to supervise before they trust them to practice unsupervised. Moreover, in several specialties, leading a clinical team is itself an EPA which a resident may practice under different levels of supervision. Instead, the true nature of this level should reflect not merely supervision, but additional entrustment in relation to the focal activity itself that goes beyond unsupervised practice of the activity. I propose that this final level is better conceptualized as “Allowed to determine the appropriate level of supervision for others in the practice of the activity.” In this formulation, level 5 goes beyond what we should expect of every physician-in-practice and illuminates a characteristic of the experienced preceptor or program director, one who not only knows the activity itself so thoroughly that s/he can interpret the graduated course of autonomous performance, but also understands assessment, and the particular learner, deeply enough to make judgments about where in that graduated course the learner is situated, and what kinds of experiences and performances will be necessary to entrust the learner further. Although it is likely that this fifth level would only develop through the practical experiences both of performing independently and of supervising less experienced practitioners, we may well entrust physicians to perform independently themselves or to supervise others without yet allowing them to judge the readiness of others to perform independently.