Moving Toward Competency-Based Training.

Abstract

To the Editor It was with great interest that we read the article, “Preclinical Proficiency-Based Model of Ultrasound Training.1” The authors demonstrated that first-year clinical anesthesiology residents were able to achieve a proficiency index similar to graduating anesthesiology residents through a structured competency-based perioperative ultrasound program.1 We applaud their efforts to implement this comprehensive ultrasound curriculum and more importantly, move toward residency training that emphasizes skill acquisition instead of completing an arbitrary number of procedures. Similarly, we have found that level of training does not necessarily ensure procedural competence. Our curriculum in ultrasound-guided intravenous catheter insertion in pediatric patients showed that only 21% of attendings, fellows, or residents were able to meet a minimum passing score on a pretest checklist.2 Fortunately, all of our participants were able to meet this standard after participation in the curriculum and also reported improved self-confidence with this skill. Fatima et al’s1 study echoes previous literature that has shown that procedural experience does not ensure competence in trainees. Barsuk et al3 compared residents’ baseline simulated performance for a variety of procedures including central venous catheter insertion, lumbar puncture, paracentesis, and thoracentesis with their self-reported procedure experience. They found that only 10% of residents met a preset minimum passing standard for the procedures assessed, with low passing rates for even the most senior trainees. Unfortunately, this subpar skills performance can also be seen among practicing attending physicians. In examining attending physicians’ simulated performance of central venous catheters, Barsuk et al4 found that only 17.9% met the minimum passing standard for internal jugular central venous catheter insertion and only 23.4% met the standard for subclavian central venous catheter insertion. In fact, the attending physicians performed significantly worse than the residents who underwent training in a simulation-based mastery learning curriculum. These findings are especially concerning because these attending physicians are often the ones responsible for teaching these skills to trainees. The potential end result is the passing down of technical errors from one generation of physicians to the next. To stop this cycle and improve care for our patients, competency-based training is necessary. Simulation-based mastery learning is an effective way to teach procedures through an intense form of deliberate practice. The benefit of using this type of training is that learners must obtain a high level of performance before attempting a procedure on an actual patient. First, learners engage in a pretest, typically using a simulator and checklist. Afterward, learners participate in didactics on the indications, contraindications, risks, benefits, and technical aspects of a procedure. Then, participants engage in deliberate practice with coaching. On a separate date, learners return to complete a posttest using a simulator and must reach a minimum passing score to successfully finish the curriculum. The learners who cannot meet the minimum passing score engage in deliberate practice until the score can be obtained. Competency-based clinical training is the future. The benefit to simulation-based mastery learning is that participants can have a high level of proficiency before clinical exposure. This has the potential to increase patient safety, lower the incidence of complications, and eventually lower hospital costs.3 In conclusion, simulation-based mastery learning is an effective method to ensure high standards and achieve procedural proficiency without any risk to patients. Jillian A. DiBiase, DOHeather A. Ballard, MDDepartment of Pediatric AnesthesiologyAnn & Robert H. Lurie Children’s Hospital of ChicagoNorthwestern UniversityFeinberg School of MedicineChicago, Illinois[email protected]