147to evaluate the resident’s self-assessment skills which are invaluable in developing
trust between the faculty and resident and for the resident’s lifelong learning. It will
also allow the faculty to gage the resident’s current emotional state which, as stated
previously, can have a significant impact on the feedback. The time immediately
after a difficult strenuous case with a negative outcome may not be the best time to
go over the fine points of particular surgical techniques. The feedback should be
based on specific observed behaviors (“you could improve on appropriate tissue
handling techniques”) and not on personality traits (“why are you so careless?”).
Similarly, suggestions for improvement should be specific and limited to an appro-
priate amount for the feedback session. Based on theories of cognitive load, this
would probably only be one or two well-defined objectives for after an assessment
of a single operative performance.
Entrustability
An area that deserves special mention in any medical education context and is vital
to operative training is that of entrustability. Entrustment is the act of confiding the
care of a person or thing or the execution of a task to an individual [ 31 ]. In the oper-
ating room, as in all of medicine, entrusting someone else with an aspect of patient
care has a measured degree of risk. This measured risk is viewed in the setting of all
the other various measured risks we take when caring for patients [ 9 , 32 ]. Any deci-
sion we make or intervention we perform or chose not to perform has possible risks
and benefits that we weigh against the odds of helping or harming our patients.
Entrustment is a constantly evolving process that is at work from very simple
tasks (i.e., entrusting someone else to cut a suture without cutting the knot) to the
entrustment of complex operations or difficult clinical decisions or ethical dilemmas.
Much of what goes in the development of entrustment during a resident’s education
is unspoken and poorly defined. We have the sense of trusting some residents more
than others, and hopefully entrustability increases over the course of a resident’s
tenure, but defining specific goals or objectives and assessing completion of those
goals in a way that guides residents toward high levels of entrustability can be diffi-
cult. As with skill competence, however, clear definitions of entrustability will lead
to more efficient progression toward the ultimate goal of independent practice.
The entrustable professional activity (EPA) concept gives a conceptual frame-
work to help guide appropriate increasing entrustment of trainees. EPAs are “units
of professional practice, defined as tasks or responsibilities to be entrusted to the
unsupervised execution by a trainee once he or she has attained sufficient specific
competence” and are “independently executable, observable, and measurable in
their process and outcome, and therefore, suitable for entrustment decisions” [ 33 ].
The EPA model does not replace competency, but rather helps to break down a par-
ticular competency and translate it into clinical practice [ 33 ]. In fact, keeping the
end competency goals in mind can help direct assessment of individual EPAs along
the road to independent clinical practice. The ACGME Milestones project [ 34 ] pro-
vides help to guide faculty assessment of EPAs (i.e., safe performance of
8 Teaching in the Operating Room