Letters to the Editor
To the Editor:
Residency programs should offer standardized procedural instruction in tandem with team training. Why do we propose this? Consider: At academic medical centers throughout the United States, residents perform the majority of invasive bedside procedures (e.g., central venous catheter insertion, lumbar puncture). Learning typically follows the apprenticeship model of “see one, do one, teach one,” and instruction is based on the variable approaches of their teachers. Additionally, achieving confidence and competence in the performance of these procedures is unique to each trainee. Some may approach mastery yet never attain it, and thus they are identified as unable to perform specific procedures independently at the conclusion of their training.
Some training programs have found ways to improve on this traditional learning approach by redefining procedural education. Simulation-based training1 (with feedback in a protected environment), ultrasound guidance2 (to minimize mechanical and infectious complications), use of a checklist3 (ensuring patient safe practice by adherence to critical steps), and team training4 (including direct observation) have been reported separately as beneficial. We and our colleagues at the University of Miami–Jackson Memorial Hospital combined these elements into a four-pronged approach, translating the knowledge and skill learned in the simulation center to the patient's bedside where residents can develop the last piece of learning and proceed to mastery under attendings' supervision. This combined approach enables residents to practice procedures both through simulation training and direct observation, to improve their confidence and competence, and ultimately to provide safer patient care.
Joshua D. Lenchus, DO, RPh, FACP
Assistant professor of medicine, Division of Hospital Medicine, Department of Medicine, University of Miami Miller School of Medicine, associate program director, Jackson Memorial Hospital Internal Medicine Residency Training Program, and associate director, University of Miami–Jackson Memorial Hospital Center for Patient Safety, Miami, Florida; firstname.lastname@example.org.
David J. Birnbach, MD, MPH
Professor of anesthesiology and public health, University of Miami Miller School of Medicine, and director, University of Miami–Jackson Memorial Hospital Center for Patient Safety, Miami, Florida.
1 Barsuk JH, Cohen ER, Feinglass J, McGaghie WC, Wayne DB. Use of simulation-based education to reduce catheter-related bloodstream infections. Arch Intern Med. 2009;169:1420–1423.
2 Duncan DR, Morgenthaler TI, Ryu JH, Daniels CE. Reducing iatrogenic risk in thoracentesis: Establishing best practice via experiential training in a zero-risk environment. Chest. 2009;135:1315–1320.
3 Huang GC, Newman LR, Schwartzstein RM, et al. Procedural competence in internal medicine residents: Validity of a central venous catheter insertion assessment instrument. Acad Med. 2009;84:1127–1134.
4 Salas E, Klein C, King H, et al. Debriefing medical teams: 12 evidence-based best practices and tips. Jt Comm J Qual Patient Saf. 2008;34:518–527.