Trust is the basis on which Gurjit Sandhu, Ph.D., a faculty member in the Department of Surgery at Michigan Medicine, conducts much of her research.
She’s gained the trust of surgical teams to observe and describe the give and take between faculty and residents in operating rooms, filming and analyzing teaching and learning styles. Based on that work, she and collaborators developed a framework called OpTrust to enhance faculty-resident interactions across key domains: types of questions asked, operative plans, instruction, problem solving and leadership by the surgical resident. The ultimate goal is to move teams toward entrustment and surgical trainees toward autonomy.
Could the work that goes into such entrustment help with residents achieving competency? Sandhu and her team are beginning to investigate that question now that entrustable professional activities (EPAs) are rolling out to surgery training programs across the country.
“Since EPAs are now required for our interns and we have this professional development program, we wondered how we could use that OpTrust framework to help faculty queue up their learners to establish goals in line with EPAs,” Sandhu said.
A new framework for assessing milestones for competency
EPAs were created by the American Board of Surgery as a way to assess surgical residents on observable tasks and measure their progress toward competency. So far, EPAs have been rolled out for general surgery residents and are tied to 18 activities from diagnosing and managing appendicitis to performing surgical consultations.
This is a pivot from using traditional methods of tracking toward competency, such as case volume and duration of training.
“The traditional training model was a fixed educational approach that resulted in variability in the competency outcomes of graduates. However, with variability baked into the educational process of training, residents can be individually supported to advance their knowledge and skills, leading to more consistency in the competency of graduates,” Sandhu said.
Evaluations are done via an app, with residents pushing requests for evaluations for specific activities to faculty. Assessments range from limited participation (for example, a resident only observed a case) to practice ready (a resident conducted a case with only oversight from faculty). General surgery residents will eventually need to achieve competency in all 18 EPAs before sitting for their written qualifying exam.
The American Board of Surgery EPA (ABS EPA) app was developed by the SIMPL Collaborative. (Brian George, M.D., M.A.Ed., an acute care surgeon at Michigan Medicine is the executive director of SIMPL.)
An opportunity to examine a key linkage
With competency being evaluated in real time, Sandhu is interested in seeing whether or how the OpTrust framework nudges surgical residents toward competency.
“We saw that there could be an opportunity to link teaching and learning optimization with competency-based education,” Sandhu said.
What might OpTrust in action look like in the setting of EPAs?
In an ideal state, Sandhu said, residents will have reviewed a case to identify EPAs applicable to it and identified a goal based on behaviors delineated in the EPA. They then would share the goal with the faculty ahead of the case. This allows the faculty ask questions of the resident and review previous SIMPL data to determine whether the goal is appropriate or if it needs to be revised. The faculty could create opportunities for the resident to move toward the established goal – for example, identifying planes to select mesh placement for a hernia repair.
“Faculty are getting quite sophisticated in how they’re creating those opportunities. Some will move the case forward quickly so they can slow down to work on the goal. Another might say ‘I’m going to give you 15 minutes to move this goal along and then step in’ so that a resident doesn’t feel like a case has been taken away from them,” Sandhu said.
Sandhu’s hope is that such behavior becomes “sticky” such that residents and faculty alike carry it over to non-EPA cases and specialties.
Ryan Howard, M.D., a general surgery resident in his final year of training, is among residents who’ve enthusiastically taken to the EPA process. Howard submits them for any eligible case, and has found the process a useful way to reflect on his own comfort level with a case.
“It’s been helpful in solidifying my confidence as I approach graduation. Having faculty rate me as ‘practice ready’ makes me more comfortable navigating the transition to independent practice,” Howard said.
According to Howard, faculty and residents haven’t deliberately changed how they approach interactions in the setting of EPA’s.
Will his competency have a link to what those interactions look like? That’s why Sandhu and her team will be back in the operating rooms.
The opportunity: Back to observing
Sandhu’s team will observe faculty-resident teaching and interactions in the operating room over several months, targeting a variety of EPA case types and as many different faculty-resident pairings as possible, video recording cases when possible.
One of the research aims is to explore the relationship between OpTrust ratings of faculty and resident intraoperative behaviors and ABS EPA assessments.
Sandhu anticipates that the link between interactions and how residents rate on EPAs will become clearer two or three years into observation.
“We’ll look at behaviors that accelerated some folks, and for some who may not be moving as quickly, ask what the differences are there,” Sandhu said.
No matter what the data show, Sandhu said learners and faculty need to see the value in the system and that there needs to be buy-in to move toward entrustment and toward competency.
“What’s most valuable to both of them? Time. How can we take things off the faculty's plate? How can we move residents along in this time crunch and safely give them more of what they want, which is autonomy?”
Time, and research, will tell.
