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More Learners, Finite Resources, and the Changing Landscape of Procedural Training at the Bedside

Gisondi, Michael, A., MD; Regan, Linda, MD; Branzetti, Jeremy, MD; Hopson, Laura, R., MD

doi: 10.1097/ACM.0000000000002062
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There is growing competition for nonoperative, procedural training in teaching hospitals, due to an increased number of individuals seeking to learn procedures from a finite number of appropriate teaching cases. Procedural training is required by students, postgraduate learners, and practicing providers who must maintain their skills. These learner groups are growing in size as the number of medical schools increases and advance practice providers expand their skills to include complex procedures. These various learner needs occur against a background of advancing therapeutic techniques that improve patient care but also act to reduce the overall numbers of procedures available to learners. This article is a brief review of these and other challenges that are arising for program directors, medical school leaders, and hospital administrators who must act to ensure that all of their providers acquire and maintain competency in a wide array of procedural skills. The authors conclude their review with several recommendations to better address procedural training in this new era of learner competition. These include a call for innovative clinical rotations deliberately designed to improve procedural training, access to training opportunities at new clinical sites acquired in health system expansions, targeted faculty development for those who teach procedures, reporting of competition for bedside procedures by trainees, more frequent review of resident procedure and case logs, and the creation of an institutional oversight committee for procedural training.

M.A. Gisondi is associate professor and vice chair of education, Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California; ORCID: http://orcid.org/0000-0002-6800-3932.

L. Regan is associate professor, vice chair of education, and residency director, Department of Emergency Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland; ORCID: http://orcid.org/0000-0003-0390-4243.

J. Branzetti is assistant professor and residency director, Department of Emergency Medicine, New York University School of Medicine, New York, New York; ORCID: http://orcid.org/0000-0002-2397-0566.

L.R. Hopson is associate professor and residency director, Department of Emergency Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan; ORCID: http://orcid.org/0000-0003-1745-0836.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Michael A. Gisondi, MD, Department of Emergency Medicine, Stanford University, 900 Welch Rd., Suite 350, Palo Alto, CA 94304; telephone: (650) 721-4023; e-mail: mgisondi@stanford.com; Twitter: @MikeGisondi.

Procedural training and the development of procedural competency are among the foundational training experiences of graduate medical education across many specialties. As program directors, we are observing increased competition for the training resources required to ensure procedural competency for learners of nonoperative bedside procedures.

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Introduction

The Accreditation Council for Graduate Medical Education (ACGME) maintains that physicians-in-training must be able to competently perform core procedures required for their field of training.1 Many bedside procedures are initially learned in simulation labs with a variety of models and instructional methods. Eventually, however, these training experiences must occur at the bedside with patients to demonstrate residents’ competency.2

Clinical training environments at large academic medical centers have changed in recent years with respect to the increased number of individuals competing to learn procedures from a finite number of appropriate teaching cases. The ACGME Common Requirements explicitly state that “the presence of other learners (including, but not limited to, residents from other specialties, subspecialty fellows, PhD students, and nurse practitioners) in the program must not interfere with the appointed residents’ education.”1 At our own institutions, we have noted a sharp rise in competition for bedside procedures from many learners not traditionally associated with advanced procedures, including physician assistant (PA) and nurse practitioner (NP) students and PA residency program trainees. Attending physicians and advanced practice providers (APPs) also have a continued demand for procedures for maintenance of certification (MOC) and skill maintenance, adding to the observed rise in competition.3 These various learner needs occur against a background of advancing therapeutic techniques that improve patient care but also act to reduce the overall numbers of necessary bedside procedures.

This article is a brief review of the challenges that are arising for program directors, medical school leaders, and hospital administrators who must act to ensure that all of their providers acquire and maintain competency in a wide array of procedural skills.

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Who Are Contemporary “Learners,” and What Are Their Learning Needs?

The number of medical schools in the United States is increasing, and many new clinical training sites are needed for these additional students.3 The definition of an “academic medical center” has broadened: It now includes a variety of teaching hospitals that lack a research mission, and those that may be administered by corporations rather than universities. Residency and fellowship positions currently seem to be keeping pace with the demand of additional allopathic medical school graduates.4,5 However, many educators believe that graduate medical education (GME) expansion is insufficient to match the combination of allopathic, osteopathic, and qualified international graduates seeking entry positions in the National Resident Matching Program.6 We can be certain that over the next decade there will be more medical students and more residents, with a commensurate demand for appropriate new clinical experiences and procedural training.

The educational silos of teaching hospitals are also evolving. Those who oversee GME education cannot simply consider the educational needs of medical students and residents alone. APPs are widely viewed as one of the main solutions to our national physician shortage, with use of APPs rapidly increasing since the introduction of the 2003 ACGME resident duty hours.7 As APPs have been postulated to be a fiscally responsible solution to expanding workforce needs, APP training programs are rapidly expanding: Over 200 new PA programs and 350 NP programs were accredited in the last 50 years.8,9 Specialization programs, such as PA residency programs, are also increasing in number, many with expectations for competency in procedures once only performed by physicians (e.g., central venous catheterization).10

Physicians and APPs who may perform the same procedure have very different training standards. There is no requirement for PAs to complete specialty-specific postgraduate training, and there is an inadequate number of PA residency positions for all new graduates. A significant portion of PA clinical experience, including procedural training, must be obtained on the job after graduation.11 The same can be said for NPs, where many states require that new graduates be supervised by physicians or work only with physician consultation, for time frames ranging from one to three years.12 These variable standards for training APPs add to the burden of “credentialed” providers who are still in need of substantive procedural training once practicing in the clinical setting.

The neglected group of learners that also need to be considered in this dilemma are providers-in-practice who must maintain their own procedural skills, hospital credentialing, and board certification. For physician faculty members at teaching hospitals, it is common to go months, or longer, without directly performing certain procedures that are expected in one’s specialty. Instead, these physicians are supervising students and residents as they perform procedural tasks.13 Therefore, physicians-in-practice may experience skill decay, particularly for uncommon, high-risk procedures. There are no national MOC standards for minimum case numbers for most procedures, nor is there an expectation to demonstrate continued procedural competency. Continuing medical education (CME) programs, while sometimes offering opportunities to refresh procedural skills, rarely include in-depth training opportunities because of the high costs of supplies and personnel required.14 Thus, procedurally oriented conferences come with especially high price tags and limited registrations compared with the number of physicians-in-training.15,16

For the purposes of discussion in this article, we thus define “learners” to include students who need procedural training to initially become competent (medical students, NP students, PA students, etc.), postgraduate trainees (physician residents, PA residents, etc.), and those who must maintain skills (providers-in-practice.)

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Are There Fewer Opportunities to Learn Procedures?

Coupled with the increasing number of learners needing procedural experience are forces reducing the actual number of those training opportunities. For example, tracheal intubation was a standard intervention for most forms of respiratory failure 20 years ago. Now treatment options include noninvasive techniques such as bilevel positive airway pressure and humidified high-flow oxygen, each of which has demonstrated benefit in reducing endotracheal intubations.17–19 Advanced airway management techniques have expanded into the prehospital environment, further reducing the number of patients presenting to the emergency department with airway compromise.20,21 Central venous catheterizations are now less common, with options for venous access that include peripherally inserted central catheters placed by dedicated nursing and interventional radiology teams, ultrasound-guided peripheral intravenous lines (PIVs), and intraosseous lines during resuscitations.22 Advances in imaging have also reduced indications for other procedures, such as the use of the latest generation of computed tomography scans to reduce lumbar punctures in the diagnosis of subarachnoid hemorrhage.23

Many residency review committees (RRCs) of the ACGME have revised their procedure training expectations over the past two decades. There is a consistent trend of decreasing procedural standards across specialties, with requirements generally representing only a minimal threshold. For example, the RRC for pediatrics requires the demonstration of competence for many procedures; however, minimum case numbers for each procedure are not required.24 Additionally, some lifesaving procedures such as pediatric intubations are rare, raising concern that clinical experiences alone are inadequate to develop and maintain skills.25 The emergency medicine (EM) RRC requires minimum numbers for key procedures, but up to 30% of these procedures may be completed in a simulated environment. Additionally, all EM training in the rare procedures of cricothyrotomy, pericardiocentesis, and cardiac pacing may be conducted using cadavers or simulators.26 Within obstetrics–gynecology, the minimum number for certain procedural experiences is based on “what the RRC believes is merely an acceptable exposure during residency” rather than on expectations based on any cited evidence.27 In gastroenterology, the minimum numbers for endoscopic ultrasounds are noted to be “derived from studies on training in endoscopic ultrasounds, published expert opinion, and the consensus of the Standards of Practice committees.”28 Finally, the RRC for internal medicine now requires competence only in the performance of procedures mandated by the American Board of Internal Medicine, which includes advanced cardiac life support (ACLS), drawing venous and arterial blood, placement of a PIV, and Pap smear.29,30 A growing number of residency graduates are entering fellowship training programs with minimal procedural experience, moving the burden of basic bedside procedure training from residency to fellowship.31

Several other forces have altered the clinical environment in ways that decrease learner exposure to bedside procedures. Although variation exists among medical centers, some hospitals are adding proceduralist services in which a small group of physicians provide procedural expertise for an entire hospital. There are also data showing that APPs are becoming proceduralists, which has implications for access to procedural opportunities for other practitioners.32,33

Daily work rounds are now focused on completion of time-consuming electronic health records rather than on direct patient care.34 Residents may be mandated to sign out from urgent procedures that arise at the end of their scheduled shifts for fear of ACGME duty hours violations.35,36 And lastly, in the name of quality and safety, nurses and patients have expectations that procedures be performed only by the most qualified team members. These shifting expectations have created a culture that pressures both supervisors and learners to limit exposure to potential teaching cases and reduces opportunities for junior learners to perform bedside procedures.37

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What Factors Determine Procedural Skill Acquisition and Decay?

Procedural training has progressed significantly beyond the Halstedian adage of “see one, do one, teach one.”38 The evolving science of skill acquisition, the integration of simulation into medical training, and the focus on patient safety have led to a sea change in the approach to teaching and learning procedures.39 The regulation of procedural training for physicians is far more robust as well: Residency training requirements include national and institution-specific guidelines that specify procedural frequency, availability of expert backup, and observation and assessment expectations for credentialing.1

The science of skill acquisition and decay are important factors to consider in the clinical training environment. Conceptual frameworks describe the progression of skill acquisition both for general tasks40 and for procedural skills.41,42 Implicit to most of these conceptual frameworks is the assumption that skill acquisition occurs along a continuum, with multiple factors affecting acquisition. Such factors may include learner type and duration of practice,43 procedure type, guidance and feedback,44 learning environment (simulated vs. actual patients),45 number of attempts,46 and spacing of practice.47,48

Skill decay refers to the loss of acquired skills after periods of nonuse.49 Evidence suggests that skills decay at different rates depending on a host of factors, which can be broadly divided into two categories. The first is context dependent, which includes time sensitivity of the procedure,50 stress level associated with completing the procedure, and type of learning encounter (e.g., first attempt vs. refreshing skills).51 The second category is procedure specific and includes the complexity of the procedure and whether the task involved in the procedure is “continuous” (without a distinct start/stop and more resistant to decay) versus “discrete” (a procedure with a distinct start, stop, and specific steps to follow, and more prone to decay).51 For example, during a laparoscopic cholecystectomy, camera manipulation (continuous task) would be more resistant to decay than the series of steps required to successfully remove the gallbladder (discrete task), and a first-time learner would decay faster than an expert refreshing after a lapse in practice.

Decay timing can vary among different procedures, or even within a given set of skills. For instance, ACLS knowledge and skills may decay anywhere between 2 weeks and 14 months.52–54 Various methods to address skill decay have been investigated, such as just-in-time training,55 rolling refreshers,56 dress rehearsals,57 or booster training,58 but none are widely applied or proven clearly superior in the clinical environment.

Therefore, it is important to consider not only skill acquisition when determining the quantity of procedural experience required for a learner but also individual learner characteristics and the need to maintain a high level of procedural competency. This article focuses primarily on the initial acquisition of procedural skills and competency, yet it is important to recognize that there is a large pool of experienced practitioners who require continued procedural opportunities to maintain their proficiency.

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Possibilities for Addressing the New Era of Learner Competition

Where once GME educators could send our learners to various clinical services and expect that they could attain adequate procedural experiences by chance, we need to be much more deliberate. We must design our curricula to better select rotations that have ample opportunities for procedures. This will require improved integration of learners on clinical services that offer procedural training, such as anesthesia and interventional teams, rather than inpatient services. Though these procedure-based clinical teams may have trainees of their own, there is a point at which their clinical experience saturates and opportunities for additional learners may be available. Institutional review of procedure logs across programs may identify such opportunities.

Faculty development is also critically important. Supervising physicians must be trained to optimize each procedural learning opportunity.59 For example, faculty members may choose to prepare learners in simulated environments using mastery learning methodology before they attempt procedures with live patients.2 Instructional methods that augment learning at the bedside include preparation using a mise en place approach, discussion of potential complications, review of informed consent discussions with patients, and structured debriefing after the procedure.59,60 Video-enhanced equipment allows all members of the team a view that increases their understanding of the procedure, whether they are the performer or not (e.g., video laryngoscopy, ultrasound-guided procedures, laparoscopic operative procedures, video-enhanced slit lamp examinations). Teaching points can be directed to the level of the trainee, with increasing complexity. Participation in advanced procedural training opportunities should be commensurate with the learners’ needs based on their level of training. Finally, separate training experiences are preferred for those in-training as opposed to providers-in-practice.

We recommend that semiannual resident meetings in the final years of training focus on the adequacy of procedure logs or case logs, as well as milestone progression in ACGME subcompetencies related to procedural competency.61 Program directors should audit average case logs by class on an annual basis. These efforts may assist clinical competency committees when making decisions about resident promotion or graduation, or in determining the need to alter the clinical rotation curriculum to improve procedural training.

We strongly believe that institutions must develop an educational mission that clearly identifies the priorities of its learners. At most institutions, the highest priority will continue to be physician procedural training, as physicians work independently in the clinical environment and must be trained to function without backup. In some geographic locations, however, APPs may be essential to the needs of the community at large and therefore be made the institutional priority. We cannot ignore the needs of APPs, and we must work with their program leadership to ensure consistent, high-quality learning experiences for their trainees.

As health systems expand throughout the country, so do the opportunities to provide novel educational environments. “Nonteaching” hospitals that partner with large academic medical centers might offer a solution to program directors seeking to move trainees into settings where there is not constant competition for clinical experiences. For example, it might be advantageous to host a physician residency program at a primary training institution within a health system, and a PA residency program at a partner community hospital without physician trainees. Many administrative obstacles will need to be addressed to create such partnerships, including financial and malpractice agreements, faculty development, and site directorship. Deliberate curriculum design with various institutional stakeholders is necessary to innovate these sorts of solutions within the paradigm of enlarging health systems. Physicians new to supervisory roles will require faculty development to teach, as well as to learn to monitor for their own skill decay. Educational leaders at both the institutional and individual department level may consider faculty development programs targeted at high-risk, low-frequency invasive bedside procedures to prevent skill decay.

While some health care systems may have an abundance of procedures, with the cultural norm to share procedures without competition, others may have a less harmonious environment. When there is a small number of opportunities, competition is inevitable unless faculty have agreed to a process for distribution of procedures based on learner needs. Educators and administrators have a duty to identify adequate training environments that allow each learner to acquire procedural competency. Such a call to action requires that the GME community deconstruct our educational silos and work together across disciplines with a joint responsibility for all learners at our institutions, not just those in our individual training programs. Hospitals must continually monitor for competition among learners. Hospital and GME committees with program director representation can serve to alert hospital leaders about competition, but this may not be adequate as each program director or specialty representative may have her or his own interests in mind. Trainees should be encouraged to report instances of competition to their program directors and the local GME committee, so that central monitoring can aid in improving the clinical learning environment. Institutional solutions that prevent competition through program agreements are far preferable to conflicts between trainees at the bedside.

We recommend that institutions create a standing committee charged with reducing competition for procedural training and innovating solutions for learners that align with institutional priorities (see List 1). This committee could assist with prioritization of learners when needed, generally with a focus on the learners closest to independent practice receiving priority. Such a committee would ensure adequate representation and understanding of all stakeholders (undergraduate medical education, GME, CME, APPs); identify all clinical environments in which procedural training occurs and maximize those existing resources; innovate new opportunities for procedural training within expanding health systems, such as simulation centers or cadaveric training paired with novel procedure-oriented clinical rotations31; and delineate and disseminate an accepted prioritization of learners based on the institutional mission.

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List 1Goals of an Institutional Oversight Committee for Procedural Training

  1. Identify all learners at the institution and ensure adequate committee member representation for each learner type (e.g., UME, GME, CME, APPs)
  2. Prioritize the learning needs of trainees from various disciplines and experience levels
  3. Set expectations for procedure distribution among learners based on institutional priorities
  4. Design clinical rotations that have ample opportunities for procedural training
  5. Assign learners to clinical experiences based on frequency of procedures at the institution
  6. Audit case logs and procedure logs to identify high-yield clinical rotations
    Pool institutional procedure numbers and compare against learner needs
  7. Integrate learners from several disciplines on clinical rotations that have a high volume of procedures
  8. Offer faculty development in teaching procedures to supervising faculty members
  9. Encourage trainees to report instances of competition or conflict around procedural training to GMEC
  10. Expand procedural training to new partner institutions as health systems enlarge
  11. Ensure availability of resources required for procedural training away from the bedside (e.g., simulation centers, task trainers)

Abbreviations: UME indicates undergraduate medical education; GME, graduate medical education; CME, continuing medical education; APP, advanced practice providers; GMEC, graduate medical education committee.

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Concluding Remarks

As illustrated, there is significant evidence that the pool of procedural experiences is shrinking, the number of individuals requiring these experiences is growing, and the potential for competition among learners is rising. We strongly believe that the priority for procedural training is the practitioner with the highest level of future independent procedural practice. In general, this is likely to be the resident physician; however, there are definitely circumstances when other provider groups may have priority. It is within the individual institution’s purview to determine educational priorities. We recommend that a committee composed of key stakeholders be developed to adjudicate access to procedures for circumstances in which learner groups may come into conflict or have competing demands for limited educational resources.

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