Damodaran Arvin, Shulruf Boaz, Jones Philip
Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.
Office of Medical Education, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.
Med Educ. 2017 Sep;51(9):892-902. doi: 10.1111/medu.13339. Epub 2017 May 10.
Health care delivery, and therefore medical education, is an inherently risky business. Although control mechanisms, such as external audit and accreditation, are designed to manage risk in clinical settings, another approach is 'trust'. The use of entrustable professional activities (EPAs) represents a deliberate way in which this is operationalised as a workplace-based assessment. Once engaged with the concept, clinical teachers and medical educators may have further questions about trust.
This narrative overview of the trust literature explores how risk, trust and control intersect with current thinking in medical education, and makes suggestions for potential directions of enquiry.
Beyond EPAs, the importance of trust in health care and medical education is reviewed, followed by a brief history of trust research in the wider literature. Interpersonal and organisational levels of trust and a model of trust from the management literature are used to provide the framework with which to decipher trust decisions in health care and medical education, in which risk and vulnerability are inherent.
In workplace learning and assessment, the language of 'trust' may offer a more authentic and practical vocabulary than that of 'competency' because clinical and professional risks are explicitly considered. There are many other trust relationships in health care and medical education. At the most basic level, it is helpful to clearly delineate who is the trustor, the trustee, and for what task. Each relationship has interpersonal and organisational elements. Understanding and considered utilisation of trust and control mechanisms in health care and medical education may lead to systems that maturely manage risk while actively encouraging trust and empowerment.
医疗服务的提供，以及因此而来的医学教育，本质上是一项具有风险的业务。尽管诸如外部审计和认证等控制机制旨在管理临床环境中的风险，但另一种方法是“信任”。可托付专业活动（EPA）的使用代表了一种将其作为基于工作场所的评估加以实施的有意方式。一旦接触到这一概念，临床教师和医学教育工作者可能会对信任有进一步的疑问。
本对信任文献的叙述性综述探讨了风险、信任和控制如何与医学教育中的当前思维相互交织，并为潜在的研究方向提出建议。
除了EPA之外，还回顾了信任在医疗保健和医学教育中的重要性，随后简要介绍了更广泛文献中信任研究的历史。人际层面和组织层面的信任以及管理文献中的一个信任模型被用来提供一个框架，以便解读医疗保健和医学教育中存在固有风险和脆弱性的信任决策。
在工作场所学习和评估中，“信任”一词可能比“能力”一词提供了更真实、更实用的词汇，因为临床和专业风险得到了明确考虑。医疗保健和医学教育中还有许多其他的信任关系。在最基本的层面上，明确界定谁是信任方、受托方以及针对什么任务是很有帮助的。每种关系都有人际和组织因素。理解并审慎利用医疗保健和医学教育中的信任和控制机制，可能会带来能够成熟管理风险同时积极鼓励信任和赋权的系统。
