Critical care medicine is undergoing a quiet but consequential shift in how it trains its specialists, and a new scientific letter published in Intensive Care Medicine argues that the moment has come to move decisively beyond the familiar language of “competence” toward a framework built on “entrustment.” Written by Marco Maggiorini of University Hospital Zurich, Lennie Derde of University Medical Center Utrecht, Frantisek Duska of Charles University in Prague, Gizella Melania Istrate of the European Society of Intensive Care Medicine in Brussels, and Pedro Povoa of NOVA Medical School in Lisbon, the letter lays out how the European Society of Intensive Care Medicine’s educational framework can be strengthened by embedding clinical autonomy, supervision, and graded trust into the very architecture of specialist training. The argument, published in Volume 52 of the journal, arrives at a time when intensive care units across Europe face mounting workforce pressures, increasingly complex patients, and a growing recognition that what matters at the bedside is not simply what a trainee knows or can do in isolation, but whether an experienced clinician is willing to let that trainee act alone when it counts.
The conceptual foundation of the letter rests on a distinction that has been maturing in medical education research for two decades but has only now been brought squarely into the intensive care arena. Competency-based medical education, which underpins most modern training programmes, defines what a trainee should be able to do: the knowledge, skills, and attitudes expected at each stage. Entrustment, by contrast, asks a different and arguably more clinically meaningful question: given what we know about this trainee, are we prepared to entrust them with a specific professional activity, unsupervised, on a given day, with a given patient? The idea traces back to Olle ten Cate’s influential 2005 work on “entrustable professional activities,” which proposed that the unit of assessment should not be an abstract competency but a concrete, observable task such as managing a patient in septic shock, performing an endotracheal intubation, or leading a family meeting about withdrawing life-sustaining treatment. Trust, in this model, becomes the operational currency of training, and the level of supervision a trainee requires is itself the outcome being measured.
The authors anchor their argument in the lineage of the Competency-Based Training in Intensive Care in Europe project, known as CoBaTrICE, which in 2006 published a core set of competencies for an international training programme in intensive care medicine. That initiative, described in Intensive Care Medicine, represented a landmark consensus effort: dozens of contributors from across Europe distilled the sprawling practice of critical care into defined competencies that national training bodies could adopt. A follow-up analysis in 2009 examined the educational environment for training in intensive care across the European region, cataloguing the structures, processes, outcomes, and persistent challenges that shape how specialists are actually produced. In 2022, Povoa and colleagues, writing with the CoBaTrICE collaboration, argued that updated competency-based training could even serve as a step toward a healthcare union in Europe, harmonising standards so that an intensivist trained in one member state could practise safely in another. The new letter extends this arc: the competencies have been defined, updated, and harmonised, but the authors contend that the framework’s next evolutionary step is to specify how those competencies translate into trusted, autonomous clinical action.
The technical logic of the entrustment model deserves careful unpacking, because it changes what assessment actually means. In a conventional competency-based system, a trainee might be judged on a rating scale for a skill such as central venous catheter insertion, and once a threshold score is reached, the competency is signed off. But a threshold score on a simulation checklist says little about how the trainee will behave at 3 a.m. when the catheter must be inserted in a hypotensive, coagulopathic patient with difficult anatomy and no senior immediately available. Entrustment scales address this by describing levels of supervision required, typically ranging from a trainee who must be directly observed at all times, through one who needs only indirect supervision and immediate availability of a senior, up to one who can perform the activity unsupervised and even supervise junior colleagues. The supervisory level a trainee has earned, rather than a numeric score, becomes the critical safety-relevant variable for rota planning, duty assignments, and, ultimately, patient protection. In a discipline like intensive care, where decisions are compressed into minutes and errors propagate rapidly, this distinction is not academic; it is structural.
The letter also draws on the Dreyfus model of skill acquisition, the five-stage framework originally developed in 1980 by Hubert and Stuart Dreyfus to describe how learners progress from novice to advanced beginner, competent performer, proficient performer, and finally expert. The model’s relevance to critical care lies in its account of how expertise actually behaves: novices follow rules rigidly, competent practitioners plan deliberately and troubleshoot, while proficient and expert clinicians perceive situations holistically, recognise patterns, and act intuitively, often unable to fully articulate why a particular intervention feels right. A purely competency-based system, with its atomised checklists, captures the rule-following end of this spectrum well but risks undervaluing the pattern recognition and contextual judgement that distinguish the expert intensivist. Entrustment-based assessment, because it is anchored in real professional activities performed in real clinical contexts, is better positioned to capture this progression, since the decision to entrust inherently incorporates the supervisor’s holistic judgement of the trainee’s reliability, discernment about when to seek help, and ability to manage uncertainty, not merely technical execution.
A third pillar of the framework discussed in the letter is the model of planning and assessment articulated by Moore, Green, and Gallis in their 2009 work on achieving desired results and improved outcomes through continuing education. Their framework insists that learning activities be designed with explicit linkage between the identified educational gap, the learning objectives, the teaching methods, and the outcomes to be measured, across multiple levels ranging from the learner’s participation and satisfaction through to changes in competence, performance in the real clinical setting, and ultimately patient health outcomes. Read through this lens, the ESICM educational framework is being asked to close a specific gap: trainees may demonstrate competence in summative assessments, yet the actual performance of graduated autonomy in the workplace, and its downstream effect on patient outcomes, has often gone unmeasured. The entrustment approach makes that link explicit, because each entrustment decision is simultaneously an assessment of performance and a formalisation of the autonomy a trainee may exercise in future clinical duties.
The practical implications for intensive care training programmes are substantial. If entrustment is adopted as the organising principle, curriculum designers would define a set of entrustable professional activities specific to critical care, such as initial resuscitation of the critically ill patient, ventilator management, haemodynamic support, sedation and analgesia, management of the dying patient, and leadership of the daily multidisciplinary round. For each activity, programmes would specify the expected trajectory of supervision levels, and faculty would make regular, documented entrustment decisions based on direct workplace observation rather than isolated examination events. This demands more of supervisors: entrustment decisions require calibrated judgement, shared standards across assessors, and explicit training for faculty in how to make and record these decisions defensibly. The authors’ institutional affiliations, spanning Zurich, Utrecht, Prague, Brussels, and Lisbon, reflect precisely the kind of cross-border consensus that such standardisation requires, and the ESICM’s role as the pan-European professional body positions it to coordinate this transition.
The timing of the letter is also significant against the backdrop of European workforce realities. Intensive care units emerged from the COVID-19 pandemic with strained staffing and heightened awareness that the boundary between supervised and independent practice is a patient-safety frontier. Harmonised, entrustment-based standards offer a mechanism by which a supervising intensivist in Lisbon can have confidence that a colleague trained in Prague, Utrecht, or Zurich has been formally entrusted with the same core professional activities to the same supervisory thresholds. The earlier CoBaTrICE vision of competency-based training as a step toward a healthcare union in Europe thus finds its completion in entrustment: shared competencies define the content of training, while shared entrustment standards define its trustworthiness across borders. The letter, which received no specific funding and was handled by the journal with the declared caveat that corresponding author Pedro Povoa is a section editor for Intensive Care Medicine but took no part in its own review or selection, reads as a deliberate milestone in that longer project.
What emerges from the letter is ultimately a reframing of what the endpoint of medical training should be. Competence, the authors suggest, is a necessary but insufficient target; a specialist can be competent on paper yet remain, in the eyes of their supervisors, someone who requires a watching brief on critical tasks. Entrustment converts that tacit, often inconsistent judgement into a transparent, graded, and documented process, aligning what training programmes certify with what units actually allow their clinicians to do. For a specialty in which the gap between supervision and autonomy can be measured in minutes and lives, that alignment is not a matter of educational fashion. It is a mechanism for making clinical autonomy explicit, defensible, and safe, and the ESICM framework’s evolution from competence to entrustment may well become the template for how European critical care certifies the trust it places in its newest specialists.
Subject of Research: People
Subject of Research: Medicine
Article Title: From competence to entrustment: strengthening clinical autonomy within the ESICM educational framework
Article References: Maggiorini, M., Derde, L., Duska, F., Istrate, G. M., & Povoa, P. (2026). From competence to entrustment: strengthening clinical autonomy within the ESICM educational framework. Intensive Care Medicine, 52(8), 1821-1823. https://doi.org/10.1007/s00134-026-08438-x
Image Credits: AI Generated
DOI: 10.1007/s00134-026-08438-x
Keywords: intensive care medicine, medical education, competency-based training, entrustable professional activities, clinical autonomy, supervision, ESICM, CoBaTrICE, patient safety, specialist training, Dreyfus model, Europe
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Ophelia Keating. (September 4, 2026). Building trust: advancing clinical autonomy in ESICM training. Scienmag. https://scienmag.com/building-trust-advancing-clinical-autonomy-in-esicm-training/
Ophelia Keating. “Building trust: advancing clinical autonomy in ESICM training.” Scienmag, 4 September 2026, https://scienmag.com/building-trust-advancing-clinical-autonomy-in-esicm-training/. Accessed 4 September 2026.
Ophelia Keating. “Building trust: advancing clinical autonomy in ESICM training.” Scienmag. September 4, 2026. https://scienmag.com/building-trust-advancing-clinical-autonomy-in-esicm-training/
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