A "Totally Different Beast": The Effect of Time Variability on Clinical Competency Committee Decision-Making.

Purpose: Competency-based, time-variable training (CBTVT) uses educational outcomes rather than time to determine learner readiness to progress through training. Clinical competency committees (CCCs) are critical components of CBTVT because they ultimately render time-variable promotion decisions. However, the effect of time variability on CCC member decision-making remains unclear. In this study, the authors explored the effect of time variability on the decision-making of CCC members at an internal medicine residency program.

Method: The authors used an evaluative case study approach to study the University of Cincinnati internal medicine residency program's CBTVT pilot, called Transitioning in Internal Medicine Education Leveraging Entrustment Scores Synthesis (TIMELESS), with 2 to 3 residents per postgraduate year participating longitudinally between October 2020 and March 2022. Taking a constructionist worldview, the authors used semistructured interviews with members of the TIMELESS CCC to explore how time variability affected their decision-making about resident promotion. Interviews and observations were completed between February 2021 and January 2022.

Results: In total, the authors completed 16 interviews with 11 unique CCC members. Participants reported that time variability significantly affected their decision-making process. The authors developed 3 related themes. First, time variability created a sense of increased stakes of promotion decisions. Second, the increased perceived stakes of decisions led to more deliberate decision-making. Third, time in training and clinical experience still influenced time-variable promotion decisions.

Conclusions: Time variability changed CCC member perception of the decision-making (more risk, higher stakes), with subsequent change in their behaviors (in-depth review, active decision-making). Although many time-based programs make entrustment determinations that are not linked to tangible consequences (i.e., Would I trust?), TIMELESS asked CCC members to make entrustment decisions that were consequential (i.e., Will I trust?).