130
The last two stages of the Dreyfus model place much of the responsibility on the
learner. At the stage of proficiency, the learner must trust his or her instincts while
also being aware of his or her limitations and the point in which additional help is
needed. At this stage the teacher must follow Barbara Lourie Sand’s astute observa-
tion that she describes in her book Teaching Genius. Here she states that the secret
of success teaching is to train “pupils to think, and to trust their ability to do so
effectively [ 40 , 41 ].” As the learner reaches the stage of expert or master, he or she
gains increasing experience and exposure to complex and difficulty cases and con-
tinues to grow through continued self-directed learning.
Granting Autonomy
Traditionally, surgical residents’ education occurred through a graduated system of
increased responsibility and awarded autonomy. As described above, recent studies
have provided evidence that many surgical graduates are not prepared to enter fel-
lowship or independent practice or at a minimum are not confident in their ability to
do so. Teman et al. [ 42 ] identified factors that influence attending surgeons’ deci-
sion to entrust the resident with increased autonomy. The most important factors
were the observed clinical skill of the resident, the attending surgeon’s confidence
level with the procedure, and the ease of the operation. The greatest barrier prevent-
ing entrustment of responsibility was the increased focus on patient outcomes fol-
lowed by a desire for increased efficiency and the patient’s or institution’s expectation
of attending involvement. The same likely holds true for chief residents and other
senior residents teaching junior residents and medical students. As a chief resident,
one feels a great responsibility for not only the care and successful outcome of his
or her patients but also to meet the expectation placed on him or her by the faculty.
Recognizing these barriers, the authors recommended that the focus be placed on
entrustment of responsibilities by defining and measuring entrustable professional
activities (EPAs).
Entrustable Professional Activities
Entrustable professional activities are defined, concrete tasks that can be observed
and assessed by the teacher [ 43 , 44 ], for example, consenting a patient for a laparo-
scopic appendectomy or placing a central venous line. Unlike the ACGME’s core
competencies which can be abstract ideas that are difficult to measure, EPAs are
distinct tasks identified in the learner’s regular workflow that can be evaluated. They
are “units of professional activity.” Using an EPA model, one can determine when
the learner is prepared for increased responsibility, greater complexity of tasks, and
further independence.
This is not only true for how attending surgeons approach teaching residents but
also how a chief resident should teach the other members of his or her team. For
example, at the beginning of one’s first year in residency, the resident learner
J. Feimster et al.