The man in the red jacket had arrived in the emergency department complaining about a sore throat and hoarseness, and it soon became apparent that his throat swelling was about to suffocate him. Anne (not her real name), the emergency medicine senior resident, came to me with an anxious look on her face that was in marked contradistinction to her usual confident ebullience.
“I’m really worried about this guy,” she said. “I think he’s about to obstruct.” As I glanced over at the man, who was sitting up and leaning forward with drool coming from his mouth, I was also worried. “He’s so swollen,” she continued. “I don’t know if I’m going to be able to intubate him. He can barely open his mouth. I think we need to prepare for a cricothyrotomy and I’ve never done one.” As her attending on the case, I knew it might fall to me to perform this rare but lifesaving procedure of cutting through the neck to insert a tube into the trachea. Anne had performed the procedure only in the simulation lab. I had done it only five times in my career, most recently more than five years ago. I sent for the on-call surgical resident and surgical attending for help, but they were in the operating room and would not be available for half an hour. Before I could make any other calls, the man in the red jacket collapsed, fell back on the stretcher unconscious, and stopped breathing. A nurse began to do CPR while Anne looked into the man’s throat with her laryngoscope to see if she could intubate him.
“All I can see is swollen tissue,” she yelled. “There’s not enough room. Should I try a blind intubation?”
“Yes,” I said. “Try while we prep for the cric.”
Another nurse washed the front of the man’s neck with antiseptic solution and opened the cric tray with its gleaming set of metal tools. It seemed that the tray had changed since the last time I had used it. There were different types of forceps, spreaders, and scissors. Anne was having no success with the blind intubation, and the respiratory therapist who was attempting to ventilate the man with a bag valve mask was having trouble pushing air past the obstruction in the man’s throat. I took a quick look with the laryngoscope to verify Anne’s impressions and agreed that we needed to do the cricothyrotomy, as it seemed to be the man’s only hope. Anne moved over to the other side of his neck to assist me. I showed Anne where to cut, and she made the first incision through the edematous throat tissues. The patient was bouncing up and down from the CPR, and we asked that the nurses stop for a moment as I tried to dissect the tissue with a forceps and cut deeper with the scalpel to where the cricothyroid membrane should have been, but everything was so swollen that I could not be sure what I was feeling. Finally, I poked through the cricothyroid membrane and a rush of air came out. We place a small endotracheal tube into the trachea and the patient’s oxygenation quickly improved and his heart began to pump again. By this point the surgery resident had arrived from the operating room and assisted us in completing the procedure.
I think of this case often because it was a moment of life and death for the patient and terror for the health care team, where procedural skills made the difference. Here was a patient who arrived well enough to speak to the nurse in the triage room and then had a rapid deterioration. His survival depended on our ability to perform a procedure that we did only rarely and had to carry out under the most difficult of circumstances. And yet this is what people expect from doctors and the medical care system: to provide the lifesaving procedures that can make a difference. How are we training our residents to perform such procedures safely and competently? How do we maintain the proficiency of our practicing clinicians to supervise and assist the residents as they learn while ensuring that they provide safe, high-quality care? Ultimately, how do we teach our future physicians to find the right balance between doing no harm and doing good by knowing when a procedure is needed and then performing it effectively?
Assessment of Procedural Competence
In this issue, Fahim et al1 present a systematic and scoping review of assessment methods for procedural competence of surgical residents in the operating room. They found some confusion about whether competence should be defined as “the minimum skill required to safely and independently practice or as a complete mastery of the procedure.” They noted the importance of recognizing the resident’s learning curve for a procedure, the typical number of procedures needed to achieve competence, and the timing of assessments at different points along the curve. Stanford et al2 have summarized the efforts to identify competence for performing a colonoscopy and the variability in the number of colonoscopies needed for trainees to achieve competence, noting that the number of colonoscopies alone does not necessarily guarantee a trainee’s proficiency. They recommend potential advances in the use of feedback as a training tool.
But for faculty to monitor procedural progress of a resident and provide feedback, they must have access to accurate information. Unfortunately, Patel et al,3 in their qualitative study of surgical residents published in this issue, report that it was common for residents to influence faculty assessments of their competence by creating an image that they knew more than they did, sometimes even fabricating information rather than admitting a lack of knowledge or skill. One resident explained, “I’ve done it, and I’ve seen people do it where you feel like it’s so important that you know the answer to something that you might guess or make it up.” When residents feel pressured to create an impression of competence that does not coincide with how they feel about their competence, how accurate can faculty assessments of their competence be, and how effective can their supervision and feedback be? What could we do to improve the training culture so that there would be a more honest reckoning between residents and faculty supervisors about residents’ competence, including their procedural competence?
In a culture that creates the temptation for residents to hide their uncertainty and provide false answers to questions, it should not be surprising that later in their careers some physicians would lack confidence and feel like imposters, which was the finding of the study in this issue by Ladonna et al.4 The imposter syndrome causes physicians to doubt themselves and their competence even when they are well trained. One physician explained it this way:
Many of my colleagues and I often talk about the imposter syndrome, and [I] feel like someone’s really going to find out that I have absolutely no idea what I’m doing. I still think someone is going to send me a letter saying, “Actually, it was a mistake. You weren’t supposed to get into medical school, therefore, we’re taking it all away.” And yet you go on and you pass all your exams with flying colors, but it’s this “Who am I, and am I really capable of doing this?”
In contrast, residents at the bottom of the performance curve may be more likely to overestimate their competence.5 A learning environment that creates fear among trainees about disclosing their lack of confidence or experience is not only unsafe for patients. It can, as just shown, also lead to psychological distress in physicians.
Not only are learning environments and assessment methods in need of improvement, but rapid developments in technology are constantly changing the procedures that students and residents need to master, the indications for the procedures, and the care for patients during and after a procedure. A comprehensive approach to improving procedural training and maintenance requires an analysis of the current and anticipated procedures in health care, the types of health professionals who will need to do those procedures, and the environments needed to support learning and performance of the procedures. An analysis of procedural training would also be incomplete without incorporating patients’ perspectives and the influence of financial incentives upon the performance of procedures.
Procedures That Students and Residents Need to Learn
I begin my discussion of these issues by considering which procedures students and residents need to learn. The training approach will differ if the goal is initial exposure to a skill versus achievement of competence in that skill. A trainee may not be performing many procedures independently, so an initial exposure to the skills and equipment may often be sufficient education. Wu et al6 surveyed fourth-year students from seven medical schools concerning performance of 22 procedural and interpretive skills and found that students had limited experience with cardioversion, thoracentesis, cardiopulmonary resuscitation, blood culture, PPD placement, and paracentesis. More recently, Dehmer et al7 also demonstrated that students from one medical school had very limited experience with performance of basic procedures. However, this may be acceptable if students are not expected to perform the procedures independently at the start of residency. The training for competence in performing the procedure could occur later during residency or fellowship.
Gisondi et al8 in this issue note the changing technology that has reduced or altered the indications for procedures that were commonly done in the hospital. For example, advances in CT scanning have reduced the need for lumbar puncture in suspected subarachnoid hemorrhage, and new treatments of respiratory failure have reduced the need for intubation. Gisondi et al also noted the increasing competition for procedural experience from physician assistants, nurse practitioners, and paramedics.
Wigton and Alguire9 have documented the reductions over 20 years in procedures that internists used to perform, further exacerbating the shortages of procedural learning opportunities for students. In this environment of decreasing procedural activity, Vaisman and Cram10 raise concerns about the procedural competence of faculty who supervise students and residents but may not have maintained their own competence. Gisondi et al noted that procedural skills will decay without maintenance of competence.
It will be important at each level of the continuum of medical education to evaluate the set of procedures students and residents need to be able to perform and at what level of proficiency, and to frequently update that set as practices change. Gisondi et al recommend that priority for procedural experience be given to those providers most likely to be performing the procedures independently. Priority also should be given to those faculty who need to maintain their own procedural abilities to be able to supervise learners effectively.
Achieving Procedural Competence
For those procedures deemed to be necessary, the learning process should be organized to provide safe and consistent learning and assessment. Barsuk et al11 in this issue describe a study of the use of simulation-based mastery learning to train internal medicine residents to reduce complications from the performance of thoracentesis. The authors found that those residents who took the mastery learning simulation training experienced fewer complications than did the residents without the training. Duncan et al12 provide an additional model for thoracentesis procedural competence for faculty, using a quality improvement methodology with initial collection and analysis of performance data, physician training to include ultrasound instruction, clinical observation, minimum numbers of procedures, standardization of equipment and performance parameters, and ongoing data collection to maintain performance standards. Taken together, these approaches provide useful guidelines for the acquisition of procedural competence.
Some physicians become known for their procedural competence (“When it’s time for a hernia operation, Dr. X is the one to do it”). The effects on a physician of performing a successful procedure are often immediate and gratifying, as in the case presented earlier in this editorial. However, we physicians must be constantly vigilant to spotting the danger of our egos. Desire for the approval and recognition of colleagues or students, and pride in a reputation for competence, can cloud our judgment. In each situation, we must be ready to ask ourselves whether we are the best ones to perform a procedure or whether there might be a safer, better alternative for the patient—including, in some cases, no procedure at all.
In addition, physicians must remember that frequently, procedural competence is not solely a function of the individual performing the procedure. In many cases, there are other members of the team who will facilitate the procedure by setting up the equipment, sedating the patient, and monitoring the procedure as it progresses. Pronovost et al13 have demonstrated that procedural excellence in the insertion of a central line is a function of the team of physicians, nurses, and other health professionals who work together and improve the processes associated with the procedure. Simulation can provide some of the training needed for the development of individual expertise, as noted above by Barsuk et al; however, Henriksen et al14 in this issue encourage moving research in simulation beyond studies that demonstrate individual learning of procedures to a broader investigation of how to use simulation to improve processes and team function and prevent deterioration of skills.
The Role of the Practice Environment
While individual procedural competence is important, there is ample evidence that the practice environment in which a procedure occurs is also important in fostering successful procedures; outcomes for complex procedures are better in those regional centers with the most experience in performing the procedure.15 This relationship has been shown with numerous complex surgical procedures such as esophagectomy, pancreatectomy, and bariatric surgery and is probably due to the experience not only of the surgeon but also of the nursing and technical support teams. It seems clear to me that trainees who are in these types of practice environments have better opportunities for learning necessary procedures.
There are also likely effects from adopting the newest and best approaches for procedures. Teaching hospitals have been shown to have lower operative mortality for complex surgical procedures,16 and in this issue Yeo et al17 demonstrate that academic health centers (AHCs) adopt surgical innovations more quickly than other hospitals do. This diffusion of innovation occurring at AHCs undoubtedly helps to spread the innovation when the trainees leave the institution and go out into the community.
The Role of Patients
Patients cannot be left out when considering factors that foster procedural learning and competence. Since the procedures are performed on patients, they have a critical role in participating in the decisions to undergo the procedures.18 Patients’ values and priorities should be included in assessing the benefits and risks of the various procedural options. Patients and their families need to understand the nature of the procedure; the risks, benefits, and alternatives; and how to communicate with their health care team during and after the procedure. Patients need to know who will be performing the procedure, and if a learner is involved, they need to understand the role of the learner and provide consent. Optimally, a family member or other designated decision maker should be available to provide further input as needed during the procedure.
The Effects of Payment Incentives
The potential motivating effects of the fee-for-service payment system upon the performance of procedures must also be recognized.19 Performance of unnecessary procedures has been the subject of the Choosing Wisely program, originated by the American Board of Internal Medicine Foundation; other specialties have joined internists in identifying tests and procedures in their specialties that may not be necessary.20 Residents and students have also reduced unnecessary procedures and tests that were being done routinely on hospitalized patients.21 Procedures have had a high compensation level in a fee-for-service system compared with evaluation and management services, which has encouraged increased volumes of procedures, sometimes without adequate evidence that the procedures were needed.22 Recent legislative changes in the payment incentives for Medicare patients have encouraged alternative payments to the fee-for-service system, including bundled payments.23 In a bundled payment system, all elements of the procedure are paid for together, including surgical, anesthesia, nursing, and facility fees at a set total fee; this approach encourages collaboration and reduction of costs for procedures. The move toward alternative payment systems may change the financial incentives related to performance of procedures.
The development of a comprehensive approach to procedural training and performance will require the collection, analysis, and availability of data on performance of procedures, both those carried out by individuals and by teams. The access to procedural performance data in government databases such as Hospital Compare24 is still, regrettably, at an early stage in health care compared with access to performance data of many types in other sectors of society. It occurred to me that more than 60 years ago, I had daily access to the batting averages of every player on my home team, the Boston Red Sox. It was all published in the daily newspaper, the Boston Globe, along with all the statistics of each baseball game, and I would check the data every day. In 1958, I could compare Red Sox star players with those playing for their arch enemy, the Yankees—Ted Williams or Jackie Jensen to Mickey Mantle—and compare Red Sox pitching to Yankee pitching. Shouldn’t we be able to have that same depth of information available about the performance of our doctors and hospitals and clinics now six decades later in 2018?
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