How much rope?
How to calibrate autonomy: the entrustment judgment via the RIME ladder, matched to the task and re-checked over time.
Reviewed July 2026 · verify against current guidelines
Entrustment
Trust is observed.
Calibrate to skill, not seniority
How closely you supervise is a judgment, not a default. Base it on what you have watched this intern do on this kind of problem, not on their PGY year.
Entrustment is
- Task-specific: solid on cellulitis, green on a GI bleed.
- Earned by demonstration, not granted by seniority.
- Dynamic: it moves as they show you more.
Give rope for what you have watched them handle. Hold it for what you have not.
The Entrustment Ladder
Where is this intern?
RIME: match the rope to the level
| Reporter | Gathers accurate data. Give the task; verify the facts and the plan. |
|---|---|
| Interpreter | Prioritizes the problem. Let them propose; you confirm the plan. |
| Manager | Chooses and adjusts the plan. Supervise by exception; still see the sick. |
| Educator | Leads and teaches. Delegate, and let them supervise others. |
Level is per problem, not per person. Re-place them for each new challenge.
RIME Reporter, Interpreter, Manager, Educator (Pangaro)
Calibrate in Real Time
Short leash, then loosen.
Find the level, then adjust
- Ask for the plan before they act; that tests interpretation and management.
- New intern or high-risk task: start close, loosen as they show you.
- Tighten again when acuity, complexity, or fatigue rises.
Watch once, then trust. Loosen deliberately; do not just drift.
Miscalibration
Where trust goes wrong.
- Trusting by PGY year instead of demonstrated skill.
- The same leash for every intern and every problem.
- A permanent short leash, so they never grow.
- Blanket trust you never re-check.
- Calibrating once and never updating it.
Under-trust stalls growth. Over-trust risks patients. Re-calibrate constantly.
Sources
Verify against current guidelines and local protocol before acting.
- Pangaro LN. A new vocabulary for descriptive in-training evaluations: the RIME framework. Acad Med 1999;74:1203-1207.
- ten Cate O. Entrustable professional activities (EPAs): entrustment scaled to demonstrated competence.
- ACGME Common Program Requirements: graduated, progressive supervision and autonomy for residents.
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