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percutaneous nephrolithotomy) and waypoints along the path to those goals that are
both technical (i.e., demonstration of correct assembly and handling of endoscopic
equipment or safely achieving percutaneous access) and nontechnical (i.e., deciding
what imaging to order in the workup of a patient suspected to have a kidney stone).
A single EPA will typically include multiple core competencies such as medical
knowledge, patient care, and system-based practice and therefore is a useful model
for the integration of the competencies in clinical practice.
Fostering the increasing entrustability that is necessary for resident growth from
new intern to independent clinician is a delicate balance. It may be more difficult to
define and assess than medical knowledge of technical skill but is arguably of equal,
if not greater, importance to medical education. Because entrustability is more dif-
ficult to define, the chasm that must be crossed to reach the goal of independent
practice seems especially wide. Vygotsky’s concept of the zone of proximal devel-
opment (ZPD) may be helpful in this context because it breaks down the discrep-
ancy between a trainee’s starting point and eventual goal by more narrowly defining
the space between their current status and their next level in development [ 35 , 36 ].
The real work of teaching then is safely and efficiently helping residents move along
each transition point. Doing this requires the appropriate interplay between the
teacher’s guidance and expectations and the learner’s efforts to meet those expecta-
tions and openness to honest feedback. If faculty provide too little room for resident
autonomy, growth will be hindered. If this continues over years, there is a risk that
residents will not be ready for independent practice. Alternatively, if given too much
autonomy too soon, there is a risk to patient safety as well as the possibility for a
significant setback in the entrustability relationship between the faculty and the resi-
dent that may slow progress in the long term. As the one controlling the teaching
relationship and the operating room, the faculty member has the most important role
in establishing the entrustability framework for the resident. The resident, however,
must then reciprocate by demonstrating their trustworthiness by preparing for tasks
assigned, independently seeking learning opportunities, and being open to correc-
tion from faculty. As residents move across each individual ZPD, there will be a
gradual shift from their role as observer to participant, to semiautonomous surgeon,
and to independent clinician. The faculty will have a reciprocal shift from instructor
to advisor and to active observer. This means that as a resident moves through train-
ing, it will be important for the faculty member not merely to correct mistakes but
eventually observe how the resident self-corrects during a case and problem solves
without the aid of faculty input. This will help ensure that when we graduate resi-
dents, we can say with confidence not only that we can vouch for what they have
done but what they will do in the future.
Learning Environment
The operating room can be an intimidating and busy environment. Depending
on the level of the resident, this can be a very fresh or very familiar space. We
often don’t recognize that our first year and second year residents have limited
M. Mirza and J.F. Koenig