Gersten Jonker

186   Chapter 9 this period to optimize the development of physicians-not-in-training. The effect of the use of EPAs in this period on individualization of content and duration of time-variable postgraduate specialty training is of interest. Postgraduate training Future studies could look at the prevalence of false-positives with the certification of trainees, illuminate what aspects of competence are lacking, and what is needed to timely diagnose and remediate deficiencies. The grounded theory study, of which Chapter 7 reported preliminary results, offers a starting point. In CBME, it has been suggested that decisions about trainee progression ought to be team decisions [7, 98]. There is a growing body of literature on how clinical competence committees collate information from multiple sources and make such judgments [99- 101]. Promotion to a next training phase, e.g. the transition to senior trainee, poses a decision that involves portfolio data and team deliberations. Low-stakes assessments add up to a complete, valid, and reliable holistic picture of trainee competence that allows high-stakes summative decisions [102-108]. Of interest, clinical performance data not obtained via workplace assessments [109] also find ways into decisions on trainees [110]; a controversial topic that needs illumination. Summative judgments require not only solid assessment data but also a standard or criterion for performance that defines the entrustment decision [108] and takes potential risks of incompetent task performance into account [82]. How a standard is determined and a decision comes about requires further attention of researchers. Comparing certification, as the ultimate entrustment decision, with in-training entrustment decisions sheds light on the decision-making processes and may inform the design of certification processes. While a trainee is making progress in attaining competence in a set of EPAs, she should transform into a medical specialist. This calls for attention to markers of professional development. Recently, Ten Cate & Chen identified the entrustment-enabling factors agency, reliability, integrity, capability, and humility [111]. These factors are presumably difficult to assess in single observations, but demand longstanding relationships between trainee and supervisor. How these factors can be taken aboard in end-of- rotation evaluations, promotion decisions, and entrustment decisions is an area of further investigation. Currently, formative workplace assessments rarely pinpoint performance gaps and seldom provide an action plan for improvement [112], whereas this would provide guidance to navigate the zone of proximal development. Further research could study the effect of an EPA-program on quality and quantity of feedback. A portfolio