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A “Watershed” Moment in Critical Care Training

Woo, Michael MD; Tung, Avery MD, FCCM

doi: 10.1213/ANE.0000000000000656
Editorials: Editorial

From the Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois.

Accepted for publication January 1, 2015.

Funding: Internal/no funding.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Avery Tung, MD, FCCM, Department of Anesthesia and Critical Care, University of Chicago, 5841 S. Maryland Ave., MC4028, Chicago, IL 60637. Address e-mail to atung@dacc.uchicago.edu.

The new milestone-based assessment paradigm for residents and fellows has required educators to clearly define both the expected skills of program graduates and how to evaluate those skills. Instead of vague global assessments of competency in patient care and medical knowledge, training program faculty in anesthesiology must now define the specific skills graduates need to practice and determine how to accurately measure those skills.1–3 In particular, “see one, do one, teach one” strategies or simple counts of procedures performed are increasingly inadequate for defining, teaching, and assessing procedural competence.

Applying milestone metrics to evolving technologies such as ultrasonography introduces yet another challenge, because new technologies may dramatically change the skill set expected of graduating trainees. Five years ago, a graduating resident able to perform interscalene, axillary, and femoral nerve blocks using ultrasonography might be considered well equipped for practice. Today an adequately skilled resident might be expected to use ultrasonography for adductor canal blocks, transversus abdominis plane blocks, and paravertebral blocks as well. Similarly, although a resident of 5 years ago might have needed to understand complex technical aspects of 2-dimensional ultrasonography such as focal length or frequency, today’s resident may only need to know where the “on,” gain, and Doppler controls are located and what a low-frequency probe looks like. With technology evolving faster than the 3-year period of an anesthesia residency, both teachers and students are under pressure to keep up with new technology and the procedures they enable.

Nowhere is this challenge more apparent than in the rapid growth of diagnostic ultrasonography for critical care. Although the use of diagnostic ultrasonography dates back to the early 1970s,4 today ultrasonography may be used to assess hemodynamic performance and volume responsiveness5; to diagnose tamponade,6 pneumothorax,7 and pleural effusions8; and to guide decision-making during trauma resuscitation.6 In this issue of Anesthesia & Analgesia, Fagley et al.9 provide a snapshot of the clinical use of critical care ultrasonography and the current state of critical care ultrasonography training in anesthesia critical care fellowships. Leading a team of anesthesia critical care experts, Fagley et al. offer a detailed proposal for defining what competencies should be part of the anesthesia critical care toolkit and how such competencies should be taught and assessed.

How does critical care ultrasonography training look in 2014? Fagley et al. begin with a survey of critical care program directors that is striking in the practice diversity it reveals and the challenges identified in teaching diagnostic ultrasonography. Among the 50% of program directors who responded, nearly all (90%) offered critical care ultrasonography training, but 82.5% also noted that <50% of faculty use critical care ultrasonography frequently to guide therapy. Nineteen of 40 program directors reported that many attending intensivists responsible for teaching were not comfortable using critical care ultrasonography. Even more concerning, Fagley et al. note that 25 programs (63% of respondents and 30% of all Anesthesiology Critical Care Medicine fellowship training programs) would need help from other departments to deliver the appropriate training, 6 programs noted that cardiology or radiology divisions were reluctant to train Anesthesiology Critical Care Medicine fellows, and 2 programs noted that transthoracic cardiac ultrasonography was forbidden institutionally unless performed by a cardiologist. Taken together, these findings suggest that developing a consistent, uniform training program for intensive care ultrasonography may be difficult.

In part to address this difficulty, Fagley et al. lay out in impressive detail the spectrum of critical care ultrasonography competencies judged to be essential by the writing group of critical care ultrasonography experts. These skills include vascular ultrasonography for access and diagnosis; abdominal ultrasonography for diagnosis of catastrophes; pulmonary ultrasonography for pneumothorax, hemothorax, effusion, and other abnormalities; transthoracic/transesophageal cardiac ultrasonography; and ultrasonography for evaluation during cardiac arrest and sepsis. It is easy to see that a multidisciplinary effort will be required for nearly all training programs, because no one department is likely to have vascular, abdominal, cardiac, trauma, and thoracic ultrasonography skills. Fagley et al. finish with a detailed discussion of training particulars, including didactic, bedside, and small group learning recommendations; suggestions on equipment; and strategies for evaluation/feedback.

The potential impact of this document on anesthesiology critical care practice is considerable. In addition to legitimizing the skill set of anesthesiology-based intensivists (and thus our value) at the point of care, anesthesiology-based intensivists and fellows will now have support from their professional organization regarding training norms. Such support and the accumulating experience of newly trained fellows may (among other effects) persuade skeptical nonanesthesiologists to cross-train anesthesiology residents.

Although Fagley et al.’s effort is a watershed moment in the drive to define curricular and learning expectations for this evolving field, widespread implementation of these recommendations runs the risk of creating a different, “ischemic” watershed by penalizing programs that cannot meet these standards. How will the directors of a program without expertise in abdominal or vascular diagnostic ultrasonography persuade a reluctant radiology department to cross-train their fellows? And, if they cannot, potential fellowship applicants may look elsewhere, threatening such programs with obsolescence. Maybe that “survival of the fittest” is a good thing, and programs that cannot keep up with the necessary training requirements should shut their doors. Given the inadequate supply of critical care subspecialty-trained physicians relative to demand, however, closing doors because of inadequate critical care ultrasonography training alone may be counterproductive.

We hope that advances in simulation and technology may soon solve the problem of delivering high-quality training to eager learners. Already, residents learning to perform ultrasonography-guided blocks may go to excellent websites to understand the anatomy and watch high-quality videos of the block being performed. Trainees learning critical care ultrasonography also have a multitude of online and multimedia resources at their fingertips. Might Fagley et al. establish a network of teachers for programs in need and then deliver much of that content via online methods? The 21st century paradigm for “See one, do one, teach one” might then be “Learn one online, see one online, see one for real, do one for real, teach one for real, and (finally) upload the video to YouTube.”

We look forward to that day!

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RECUSE NOTE

Dr. Avery Tung is the Section Editor for Critical Care, Trauma, and Resuscitation for Anesthesia & Analgesia. This manuscript was handled by Dr. Steven L. Shafer, Editor-in-Chief, and Dr. Tung was not involved in any way with the editorial process or decision.

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DISCLOSURES

Name: Michael Woo, MD.

Contribution: This author helped design the study and write the manuscript.

Attestation: Michael Woo approved the final manuscript.

Name: Avery Tung, MD, FCCM.

Contribution: This author helped design the study and write the manuscript.

Attestation: Avery Tung approved the final manuscript.

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