Design of a new competency-based entrustment scale for the evaluation of resident performance
Authors: Skulsampaopol Janissardhar , Rabski Jessica , Saha Ashirbani , Cusimano Michael D. 
Published: July 2023

Abstract
Purpose
Recent changes in the design and evaluation of residents to a more competency or mastery-based framework requires frequent observation, evaluation and documentation of residents by busy clinician teachers. Evaluating and determining competent performance is essential for formative evaluation and must be defensible and sound for summative purposes. We sought out experienced Faculty perspectives regarding: (1) important resident performance markers for demonstrating competent attainment of an EPA; (2) the standard of performance expected of graduating residents; (3) evidence for the validity of our purposed entrustment scale; and (4) necessary components required to provide feedback to residents in guiding the development of competent performance of an EPA.

Methods
We surveyed Canadian 172 neurosurgical Faculty who had publicly available email addresses and received 67 questionnaire responses, 52 of which were complete responses regarding resident performance markers and our proposed entrustment scale (ES) which consisted of five levels of graded achievement focused on resident performance.

Results
Being able to “perform safely” was consistently rated as the most important element of competence that Faculty stated was the critical marker of competence that should be rated, and was found in the D and E Levels of our scale. Our scale does not include any commentary on “performing without supervision” which was rated as the least important marker of performance. For the graduating neurosurgical resident, 90.4% of Faculty indicated that residents should be capable of adapting performance or decisions in response to contextual complexities of the activity independently and safely (Level E) (67.3%) or being able to perform a procedure safely without complexities independently (level D) (21.3%). Eighty percent indicated that the descriptions of competence levels described in our ES (Level A through Level E) represent the appropriate progression of entrustment required demonstrating competent attainment of an EPA. Forty-four percent of Faculty had considerable concern about liability issues with certification of competence based on an ES that is based on descriptions of decreased or no supervision of residents. “Documenting a few weaknesses,” “providing contextual comments of the case,” “providing suggestions for future learning,” and “providing a global assessment for an EPA with one-rating” were rated as the most necessary components in providing effective feedback.

Conclusion
Our proposed entrustment global rating scale is easily understood by Faculty who indicate that its graded levels of competence reflect appropriate surgical resident progression in a feasible way. Faculty clearly indicated that the standard of a graduating resident should reflect the ability to perform safely beyond simply performing a case and be able to apply clinical judgments to be able to respond and alter behaviour in response to the clinical and contextual complexities of a case. Our scale focuses on evaluation of resident performance, rather than assessing the supervisor’s degree of involvement. This study has implications for the certification of competence of surgeons and physicians.