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Formal Versus Informal Judgments: Faculty Experiences With Entrustment in Graduate Medical Education.

Background
Entrustment of residents has been formalized in many competency-based graduate medical education programs, but its relationship with informal decisions to entrust residents with clinical tasks is unclear. In addition, the effects of formal entrustment on training practice are still unknown.


Objective
Our objective was to learn from faculty members in training programs with extensive experience in formal entrustment how formal entrustment relates to informal entrustment decisions.


Methods
A questionnaire was e-mailed to all Dutch obstetrics and gynecology program directors to gather information on how faculty entrusts residents with clinical independence. We also interviewed faculty members to explore the relationship between formal entrustment and informal entrustment. Interviews were analyzed with conventional content analysis.


Results
Of 92 programs, 54 program directors completed the questionnaire (59% response rate). Results showed that formal entrustment was seen as valuable for generating formative feedback and giving insight into residents' progress in technical competencies. Interviewed faculty members (n = 12) used both formal and informal entrustment to determine the level of resident independence. Faculty reported they tended to favor informal entrustment because it can be reconsidered. In contrast, formal entrustment was reported to feel like a fixed state.


Conclusions
In a graduate medical education program where formal entrustment has been used for more than a decade, faculty used a combination of formal and informal entrustment. Informal entrustment is key in deciding if a resident can work independently. Faculty members reported being unsure how to optimally use formal entrustment in practice next to their informal decisions.