Abstract
Background: Entrustable Professional Activities (EPAs) translate competency into graded clinical autonomy, yet their application in resource-constrained postgraduate settings in low and middle income countries (LMICs) remains poorly understood. This study examines how supervisors and trainees in a Fellowship of the College of Physicians and Surgeons (FCPS) Internal Medicine programme in Bannu, Pakistan, conceptualise, enact and experience entrustments decisions.
Methods: An interpretive descriptive design grounded in constructivist epistemology was employed. Eleven participants ─ five consultants supervisors six postgraduate trainees (Years 2-4) ─ participated in indvidual semistructured interviews lasting 40-60 minutes.Data were verbatim-transcribed and analysed using Braun and Clarke,s six-phase reflexive thematic analysis.Rigour was established through reflexivity, methodological triangulation, peer debriefing and member-checking.
Results: Four themes emerged: (1) Intuitive entrustment (gut feeling; experimental heuristics); (2) Ambigous expectations (absent explicit criteria; heirarchial opacity); (3) Multifactorial determinants of trust (competence; treliability task-risk calliberation); and (4) Systemic constraints (workload pressure; supervisor scarcity).Entrustment occurred regularly but implicity, driven by instituional necessity rather than structured competency assessment. Twelve illustrative participant extracts ground these themes directly in the data.
Conclusion: In this LMIC postgraduate context, entrustment is prevasive yet unaccountable, creating developmental inequity and unrecognised clinical risk. Context sensitive EPA framework and structured faculty developmental are urgently needed to formalise entrusment practice within the FCPS programme.