A. Schwartz is Michael Reese Endowed Professor of Medical Education and research professor, pediatrics, University of Illinois College of Medicine, Chicago, Illinois, and network director, Association of Pediatric Program Directors (APPD) Longitudinal Educational Assessment Research Network (LEARN), McLean, Virginia; ORCID: http://orcid.org/0000-0003-3809-6637 .
E. Borman-Shoap is associate professor, residency program director, and vice chair of education, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota; ORCID: https://orcid.org/0000-0001-7514-7793 .
Acad Med. 2021 Jul 1;96(7S):S42-S49. doi: 10.1097/ACM.0000000000004095.
To describe trajectories in level of supervision ratings for linked entrustable professional activities (EPAs) among pediatric learners in medical school, residency, fellowship.
The authors performed secondary analyses of 3 linked datasets of level of supervision ratings for the Core EPAs for Entering Residency, the General Pediatrics EPAs, and the Subspecialty Pediatrics EPAs. After identifying 9 activities in common across training stages and aligning the level of entrustment-supervision scales across the datasets, piecewise ordinal and linear mixed effects models were fitted to characterize trajectories of supervision ratings.
Within each training period, learners were rated as needing less supervision over time in each activity. When transitioning from medical school to residency or during the first year of residency, learners were rated as needing greater supervision in activities related to patient management, teamwork, emergent care, and public health/QI than in earlier periods. When transitioning from residency to fellowship, learners were always rated as needing greater supervision than they had been accorded at the end of residency and sometimes even more than they had been accorded at the start of residency.
Although development over training is often imagined as continuous and monotonically increasing competence, this study provides empirical evidence supporting the idea that entrustment is a set of discrete decisions. The relaxation of supervision in training is not a linear process. Even with a seamless curriculum, supervision is tightly bound to the training setting. Several explanations for these findings are discussed.
描述医学院、住院医师规范化培训和专科住院医师培训中儿科学习者在可授权专业活动（EPA）的监管级别上的轨迹。
作者对进入住院医师规范化培训的核心 EPA、普通儿科 EPA 和专科儿科 EPA 的 3 个相关数据集的监管级别进行了二次分析。在确定了培训阶段共有的 9 项活动，并在数据集之间调整了授权-监管量表的级别后，使用分段有序和线性混合效应模型来描述监管评级轨迹。
在每个培训阶段内，学习者在每项活动中的监管需求随着时间的推移而减少。从医学院到住院医师规范化培训或住院医师规范化培训的第一年过渡期间，学习者在与患者管理、团队合作、紧急护理和公共卫生/QI 相关的活动中需要更多的监督，而在早期阶段则需要较少的监督。从住院医师规范化培训到专科住院医师规范化培训过渡期间，学习者总是被评为需要比住院医师规范化培训结束时更多的监督，有时甚至比住院医师规范化培训开始时更多的监督。
尽管培训中的发展通常被想象为连续的和单调递增的能力，但本研究提供了实证证据，支持了授权是一系列离散决策的观点。培训中监管的放松不是一个线性过程。即使有一个无缝的课程，监管也与培训环境紧密相关。对这些发现有几种解释。
