Behaviors or Beetles? Exploring the limits of entrustment

By: Benjamin Kinnear (@Midwest_MedPeds)

One of my favorite MedEd articles was written by Dr. Mario Veen et al. in 2020.1 This thought-provoking piece centers around an analogy that philosopher Ludwig Wittgenstein used to demonstrate the inaccessibility of private experiences  such as pain, hunger, etc. to people outside ourselves. Wittgenstein summarizes the analogy (quoted by Veen et al.) as such;

Suppose everyone had a box with something in it: we call it a ‘beetle’. No one can look into anyone else’s box, and everyone says he knows what a beetle is only by looking at his beetle.—Here it would be quite possible for everyone to have something different in their box. One might even imagine such a thing constantly changing.”2

The point is that some personal experiences  or attributes are difficult to observe (or are unobservable), and any attempt to access them through shared language or experience creates a distortion. Veen et al. note multiple beetles in health professions education such as integrity, professionalism, empathy, reflection, etc. And this is where entrustment comes in.

Entrustment has gained significant traction within HPE over the last decade, used in multiple ways (e.g. frontline assessment tools vs competence committee ratings, formative vs summative, etc.) in programs of assessment. Multiple factors influence entrustment decisions, including the assessor, clinical context, task being assessed, interpersonal relationships, and learner trustworthiness.3-5 In 2020, Ten Cate and Chen published a brilliant state-of-the-art review of the factors that affect entrustment decisions,6 and they developed five themes to describe learner qualities that enable trust: capability, integrity, reliability, humility, and agency.

Adapted from ten Cate and Chen, 2020.

As an associate program director and frontline educator/assessor, these themes resonate strongly with my experiences. So here’s the question – are all of these attributes observable or inferable from behaviors? Or are some of them beetles, inaccessible to an assessor?

Many assessment approaches in CBME rely on observation, such as workplace-based assessment, OSCEs, simulation, etc. Certainly things like clinical judgment and skill (under “Capability” above) seem somewhat inferable through direct observation. But what about benevolence? Or conscientiousness? Or curiosity? Or enthusiasm? Indeed, some educators argue that these “non-cognitive” attributes are of the utmost importance for our learners and should be assessed. And yet, they may be beetles that are inaccessible by our usual observation methods.

One might argue, “But, can’t we infer these attributes from the resulting behaviors that should follow from them? If a learner asks lots of questions, aren’t they enthusiastic and curious? If they hold a patient’s hand and use empathic statements, don’t they have empathy?” Unfortunately no. Veen et al. note that when we attempt to transform beetles into observable knowledge and skills for purposes of measurement, we potentially run into the “zombie problem”. Learners may show behaviors that that do not authentically reflect their inner attributes. If a student knows a supervisor expects them to hold a patient’s hand and use reflective statements, they can learn to do so even if they are not experiencing empathy. Extrinsic motivators (e.g. grades) that are common in HPE can incentivize zombified behaviors over truly learning beetles.

So, the full problem falls together like this: If beetles are inherent to trustworthiness, and trustworthiness is inherent to entrustment, should we be using entrustment in HPE assessment?

In my opinion, it depends on your philosophical worldview. Are beetle attributes truly “within” a learner, objective and measurable if we only use the right tools? Or are they subjectively constructed by and between learners and assessors? The former description would align with positivist or post-positivist views, with an emphasis on finding objective “truth” that is out in the world. The latter would be aligned with constructionist views, with an emphasis on authenticity, credibility, and transferability rather than objectivity. No worldview is “right” or “best”, but we should make our worldviews (and underlying assumptions) explicit to ensure our assessment practices align with our philosophical beliefs. Tavares et al. have called this a “compatibility principle, which they define as “the obligation to recognize that different philosophical positions can exist between and within assessment plans and that these positions commit assessment designers to particular ideas, assumptions and commitments.”

So, if you hold positivist or post-positivist worldviews when thinking about assessment, perhaps the aforementioned beetle conundrum makes entrustment limiting, at least when using methods that rely on learner observation. However, if you hold constructionist worldviews, beetles are not hidden in a box, but socially developed with learners in a specific context. Entrustment then makes sense to use, particularly if the context (i.e. people, task, situation) in which the learner was observed is well described. I tend to hold constructionist views with HPE assessment, so I find entrustment to be a very useful tool. You may be different. The most important thing is that you make assessment design choices that align with your worldview so that you’re not chasing beetles that you can’t ever catch.

About the author: Benjamin R. Kinnear, MD, MEd, is Associate Professor of Internal Medicine and Pediatrics in the Divisions of Hospital Medicine at the University of Cincinnati Medical Center and Cincinnati Children’s Hospital Medical Center.


1.Veen M, Skelton J, de la Croix A. Knowledge, skills and beetles: respecting the privacy of private experiences in medical education. Perspectives on Medical Education. 2020:1-6.

2. Wittgenstein L. Philosophical Investigations. 1953.

3. Hauer KE, ten Cate O, Boscardin C, Irby DM, Iobst W, O’Sullivan PS. Understanding trust as an essential element of trainee supervision and learning in the workplace. Advances in Health Sciences Education. 2014;19(3):435-456.

4. Choo KJ, Arora VM, Barach P, Johnson JK, Farnan JM. How do supervising physicians decide to entrust residents with unsupervised tasks? A qualitative analysis. J Hosp Med. 2014;9(3):169-175.

5. Holzhausen Y, Maaz A, Cianciolo AT, ten Cate O, Peters H. Applying occupational and organizational psychology theory to entrustment decision-making about trainees in health care: a conceptual model. Perspectives on medical education. 2017;6(2):119-126.

6. Ten Cate O, Chen HC. The ingredients of a rich entrustment decision. Medical teacher. 2020;42(12):1413-1420.

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