All right, so we've talked about the factors affecting entrustment. We talked about resident factors, patient factors, environment factors. In the end, I think all of these affect how the faculty entrust the care of patients to the resident or the trainee. So in the end, the faculty's the, the final common pathway. For example you can have a resident that's almost ready to graduate. A really simple patient in an environment that is not busy. And there may be some faculty who are still not willing to entrust. On the other hand, you could have you know, a resident who's not particularly good and a patient who's very sick, and the faculty may choose to entrust. So I think in the end, it's the faculty that is the finally common pathway as to how much entrustment the residents get. So I'm going to talk a little bit more about how to entrust. We start by going back to our study with some quotations from the focus groups about entrustment and not, and bad entrustment along the way. And then I'm going to try and give you some additional tips to of how to, how to be better entrusters of our, of our trainees. So not entrustment, you can't get to the end of your presentation before they've already formed an idea of how this is going to go. And at that point, they think they're completely tuned out to what you think about the case, how you might like to manage it. And so they just cut you off. They've completely circumvented your own decision making process and in some ways, your own learning in that case. You can see in that case that in it for the resident, the resident is not learning if the faculty is making that decision because they weren't ever listen to her at the. Thought or heard about about how they might approach it differently. So that's an example of not entrustment. Here's another one. This is, was an interesting one by one of our faculty of how he does entrust. And so he says, I try to hide in plain sight. So I mean if I happen to be on my way to see a patient in room four, and there's a resident behind a closed curtain talking to the patient in room five or six, it's. It's not that unusual for me to stop at the nursing station and just kind of hang out at the nursing station. Either pretending to do something else, or sort of listen and sort of spy. And so essentially they're watching surreptitiously. So trying to give the resident the autonomy to practice that they're being careful and doing this kind of silent observership. Another way to entrust. I like to sit down a lot, to observe. I feel like in a resuscitation situation, or a trauma situation, or a sedation, you know, somewhere where I'll be very present for the first couple minutes. And like I said, when we first started, I think the first few minutes how the resident establishes things, If I'm comfortable with the way that things are going, I tend to sort of just sit back in the corner and watch. So this is a faculty member who would maybe be close at the very beginning and then kind of step back. And it was interesting to talk to faculty about where they sit. And so some of the faculty would sit out of the line of sight of the patient, and, or out of the line of sight of the resident. So the resident really kind of feels like they're in the room alone, and then step forward. We demonstrated that in one of the videos. And so I think where the physic, where the faculty goes really kind of implies what, responsibility they're giving the residents. If I'm really kind of standing next next to my resident, then I'm probably there with them and I, while I trust them, I'm backing them up. If I'm all the way across the room, sometimes I sit on this low stool, then I'm really kind of giving them more room and more room practice, and so that's different ways that we can entrust better or worse. So we talked about the different factors that affect entrustment and we recognize that there's different levels of entrustment based on the resident, the faculty, the patient and the setting. But what we hope we can do is take, to, to kind of raise the level of entrustment of the, of most of the participants of this course and so we're going to do that by, first taking the, the thoughts and things that Dr. Oden, Dr. Wolf, and Dr. Carrid talked to us about and then moving on into just some simple kind of tricks to the trade if you want to think about entrustment. And so the first one is that we need to try to trust, right? We need to try to give over some of the responsibility and the authority. Authority and management of our patients, particularly if we're one of those kind of micro-managers who are uncomfortable with less control. So the first thing that we need to is really kind of trust. But along with that, comes this, what we call, trust but verify. And as we talk to the faculty members, it was really interesting those who will, kind of, sneak behind the resident and see what's going on. And so it may be that you might round on a patient on your own, without the team, just to make sure that everything is okay. You might do it by talking to the nurse to verify that the, that the resident is doing the right thing. You might verify by checking labs to make sure that they didn't miss anything important on the labs. And each of those things kind of allows the resident the the semblance of autonomy and they may not know that you're verifying behind them. But it also provides the safety for the patient, so it really is kind of a trust but verify. The next thing is the being a silent observer. And so that's the case of rn a trauma where you kind of sit off to the side. Or the, the faculty member who likes to sneak outside the room and, you know, listen through the curtain to see what's going on. And it's really that kind of I'm going to watch, I'm going to be here, I'm going to observe, but I'm going to let you have the control and let you kind of manage things along the way. And if you think back to what Josh and, and, Ashley said, you could hear some of that. That it was helpful for them to actually have them, have the faculty member in the room, but as a silent observer as an assistant along the way. Another thing to do is, this is really a to not do. One of the things that came up very strongly for the residents is when we, change the plan and we specifically say you're wrong. Because it makes the residents feel, I mean it takes, it completely takes the, the, the ru, you know, the rug out from under them when you say that you're wrong. And we don't actually often say it, well you're wrong. We simply say well no we're going to do this and we don't give any explanation. When you look at faculty practice, there is a wide variation of what people do. Meaning that some of us will be very conservative, and some of us will be less conservative. Some of us order a whole bunch of CAT scans for pulmonary embolism, and some of us order very few. And, there is a lot of practice variation. And so it's important when a resident chooses a practice variation that might, that is within the scope of practice of me or my colleagues, that I acknowledge that they are not wrong. But that the reason we're choosing to manage something this way, is because of my own individual preference for practicing. And so as long as they're not outside of that scope of practice and doing something completely wrong, I think it's important to simply say, you know, yes, I recognize that you might choose to it this way, but we're going to do it this way because and try and give a rational a rational reason for that. And it important to s, not say you were wrong, because the residents really as we were talking to then were much more acceptable of the faculty who would still hold to their own private practice patterns, but as long as they were accepting and recognizing that the resident wasn't wrong. If the residents were okay with that change in plan. The other one is, if you're a micromanager, just recognize that. And choose your hills to die on and choose your battles to fight and what sorts you're going to fight on. And at times just step back and say, I may not be completely comfortable with this, but as long as it's not going to hurt the patient and it's within the scope of practice of me and my colleagues, then it's okay. And just kind of step back and let them have, some responsibility and some autonomy and with that. And as we talked about earlier, acknowledge the variation in practice patterns. And so, recognize that if I do something differently than my colleagues, just say that to the resident. And sometimes you let them do it the way they want to, and sometimes I really don't feel comfortable with it, and I need to step in and say, you know, I know that other people do it this way, but this is the way we're going to do it this way because I, because I need to, for the safety of the patient. The other one is just, just think about as a shared ownership. If you really think about it as your patient, then you're probably not allowing the resident a lot of autonomy along the way. If you really think of it as their patient you may not be providing the safety that needs, that needs to happen. And so depending on the level of the resident, really kind of think of it as shared ownership. That we are sharing the care of this patient and that we both have equal responsibility for it. And finally set the expectations and communicate them. If the resident doesn't know that you expect them to kind of step up and do the work, and really just expect it to be your patient, particularly this happens with students, then they're not going to actually what you would hope them, that hope that they would do. And so in those cases when you're looking kind of lower level training is you want them to step up and have some degree of responsibility, it's important to set that expectation so you communicate them. And we talked about that previously in orienting a learner. And then just coming back to this. Think about each patient and say, where am I on this line? And can I get further to, it's the trainee's patient and less to it's my patient, particularly in the cases that matter. So now we're on to action plans. I want you now to take a few minutes, and on the discussion board, write your action plan. What are you going to do? So what are the you know, the five things that you're going to do to provide autonomy to trainees in your environment, in the next couple of weeks. I'm going to ask you to do that action plan and then as you know with the previous sessions, we'll be asking you to enter some of these in the Coursera system, as part of the course. And so take a few minutes, and make a plan for yourself about what you've learned. What you're going to do better to entrust your trainees.
