Does the Concept of Entrustment Offer Our Educational System a Reframing of Meritocracy?

• In Event: Entrustment as Workplace-Based Assessment in Health Professions Education: Taking the Consequences of Assessment Seriously

Abstract

“The provision of educational services generates the supply of an educated workforce to meet the demand for professionals to work in the [health] system.”1 Although such a statement may seem obvious, our US educational system –and financing thereof– includes elements of consumerism and individualism that can distract from the goal of fostering a population of informed citizens and preparing our national workforce.
Selection for escalating educational placements has been framed as a meritocracy: those who do well in the system are rewarded with opportunity. Recently, we are increasingly acknowledging flaws in our concept of merit. Traditional meritocracy fuels a desire to finely distinguish among learners, creating pressure for normative rankings. Although professional assessors are careful to discuss the limits of any assessment tool, consumers of assessment data are often not as sophisticated, leading to misuse. One example of misuse of an assessment in medicine relates to Step 1 of the United States Medical Licensing Examination. To sort candidates for residency training in the context of rising numbers of applications, leaders of graduate medical education programs placed increasing weight on slight differences in the 3-digit score previously reported for that exam. Acknowledging that the examination was not designed for that purpose, the responsible organization converted to pass/fail reporting to prevent ongoing misuse of scores2.
Despite calls for holistic review, efforts to efficiently screen applicants for such review are typically not holistic, making screening vulnerable to construct-irrelevant decision-making and limiting the ultimate holistic goal3. Further confronted with increasing evidence of inequity in our assessment systems4, with cascading downstream consequences5, we must question our conceptualization of merit. Who and what defines “the best” and how accurately can we truly distinguish among learners?
Entrustment offers a different framing of merit. Rather than expressing one learner’s worth relative to another (e.g., “best”), entrustment prompts consideration of the learner’s readiness for specific duties. Entrustment is forward-looking and is not honorific. It focuses on the increasing responsibility of the learner. Such framing around readiness to be entrusted with the care of patients reflects the societal contract of the medical educational institution.
This presentation will explore how the concept of entrustment might apply earlier in the educational continuum and to other forms of higher education:
• What benefits to society do we expect from our educational investments?
• What resources and opportunities are being entrusted to the learner as they advance through the educational system?
• What attributes indicate that the learner will make the most of those opportunities6?
• What novel assessments could be applied to capture these attributes to inform advancement?
• Does the current construct of meritocracy inadvertently inhibit the development and expression of these desired attributes? If so, how must we change?

Author

• Kimberly D. Lomis, American Medical Association
  Presenting Author