Medical Education From a Succession Perspective

This Scholarly Perspective frames workplace-based training in medical education as a succession concept and explores how the benefits of the traditional apprenticeship model can integrate with modern competency-based medical education. In 2024, the author broadened the construct of medical competence into 3 semihierarchical layers: canonical, contextual, and personalized. Canonical competence (the canon that all professionals should know) relates to knowledge and skills that meet generalized, context-independent standards, assessed with methods of high psychometric quality. Personalized competence has a focus on the individual pursuit of excellence. The focus of this article is on contextual competence (the ability to work in a patient care context). Contextual competence requires workplace-based assessment and judgments by professionals with relevant expertise and experience. Central is the notion of entrustment. The aim of workplace-based training and assessment is bringing learners to a level of readiness to be entrusted with health care tasks, beyond the standards for canonical competence. Entrustment with units of practice (entrustable professional activities [EPAs]) implies providing autonomy to learners, which requires a prospective focus (Is the learner ready for patient care?) rather than a retrospective focus (Has the learner completed all tasks as assigned?). Autonomy, relevant for identity formation, can be modulated by providing a deliberate decrease of supervision and by starting with small part-tasks (nested EPAs), later subsumed in broader EPAs. An apprenticeship model of workplace-based training and assessment with a prospective aim requires, along with supervisory effort, a rotational structure that allows for sufficient acquaintance with the trainees to enable entrustment with patient care. When entrustment is taken seriously, pivotal points arise when learners start to contribute to care and thus take over the work of their supervisors. Not only is this a return on investment, but it also can enhance learner motivation and supervisor satisfaction; however, it requires a curricular transformation.