Gersten Jonker

An agenda for development and research   161 8 TABLE 2: Levels of proficiency for an EPA [20, 25, 26] I Resident has knowledge and some skill, but is not allowed to perform the EPA independently; mostly observes the EPA being performed by their supervisor II Resident may act under proactive, ongoing, full supervision. Supervisor present in the same room III Resident may act under reactive supervision, i.e. on request. Supervisor readily available IV Resident may act relatively independent from supervisor, under postponed or backstage supervision V Resident may act as a supervisor and instructor At reaching level IV, a formal decision is to be made to delegate an EPA to a resident to carry out without close supervision [18, 20]. This decision to delegate should be made after assessment of the performance of that particular EPA, and based on several assessments by a number of assessors. It should be recorded in the resident’s portfolio. Decisions todelegatemaybedesignatedas STARs (Statement of AwardedResponsibility) [18] or digital badges [27]. This method is in sharp contrast to the traditional situation, which is characterized by implicit, informal and uninformed delegation. Although a resident may be viewed as competent after reaching level IV, the proficiency of this trainee is likely to further increase with added experience (Figure 1) [20]. After the removal of close supervision, the resident should still be able to ask for help and assistance from someone more experienced if necessary, just as permanent staff might do. Premature, unsupervised care provided by residents adversely influences patient safety, healthcare costs and liability of supervisors [28]. Conversely, an overprotective approach until the completion of training means that junior attending specialists will not have learned to bear critical clinical responsibilities. With the use of EPA, deliberate decisions to delegate based on many assessments by multiple assessors can be made for specific tasks. This makes graded assumption of responsibility during residency training possible[16] and enhances learning [19, 24, 28]. For a training program, a vision of a developmental timeline of levels of supervision is possible (Table 3). The timeline indicates which level of proficiency (Table 2) a resident would be expected to have at specified stages in training. In addition, it would show the expected timing of decisions to dispense with close supervision.