Entrustment decision-making is a fundamental goal of competency-based medical education (CBME). How supervisors engage their ‘rater cognition’ when judging for entrustment using workplace-based and simulation-based assessments is unclear. We carried out an interview-based, constructivist grounded theory-informed qualitative study that aimed to explore how supervisors make entrustment decisions in both settings using endoscopic polypectomy as a relevant entrustable professional activity (EPA). Gastroenterology supervisors completed EPAs for endoscopic polypectomy after both a single workplace-based and simulation-based assessment and were interviewed after each. Transcribed data were coded iteratively using constant comparison to generate themes. We found participants had difficulty making entrustment decisions and scored EPAs idiosyncratically due to variable personal meanings of entrustment. Each setting was found to have unique strengths in entrustment decision-making when combined in a program of assessment. These data support re-evaluation of the current usage of EPA assessments within CBME systems.M.Sc
