Procedural Teaching

Yesterday afternoon I was in the catheterization lab with the interventional cardiologists and fellows.  It was an exciting experience in which we visualized the coronary circulation of patients who had a number of different reasons for referral.  These included: NSTEMI, troponin elevations, or positive stress testing.  It was neat to be able to review the decision-making that went into delineating which patients needed stenting versus those who were more fit for medical management.  The attending I was working with would perform the catheterization for diagnosis and if angioplasty was needed, another interventionalist would join us to complete the procedure.

For example, one of the cases was a patient who presented because of a syncopal episode in the context of a past history of coronary artery disease.  He did have a troponin elevation but also when admitted he was noted to have a significant drop in hemoglobin from his last hospitalization and an upper endoscopy showed ulceration.  After his coronary catheterization, although one of his smaller arteries did show disease, the judgement call was that his troponitis was likely due to demand from gastrointestinal bleeding rather than acute coronary syndrome.  We could have intervened yesterday, but the safer option given that we would have to keep him anticoagulated was to treat his gastrointestinal bleeding (which likely explains his vasovagal episode and troponitis) and then he would return for intervention at a later date.  This was an important teaching point.  My staff highlighted to me that when in a sub-specialty that is procedural, it is important to know as a clinician whether or not to intervene.  In cardiology, this relies on a number of factors including: the vessel that is affected, the clinical context of the patient, anticoagulation, and other risks and benefits.

It made me reflect on the concept of how we teach procedures overall in Internal Medicine.   I was watching the cases on the fluoroscopy camera and my attending was explaining to me his steps and thought process.  Even before the afternoon started, he reviewed the anatomy and procedural technique with me including how to set-up, anesthetize, gain access, and the risks and benefits of using radial versus femoral arteries for access.  This was incredibly useful so that I could follow along during the procedures.

In terms of bedside procedures, I have had the opportunity to perform a few during my core rotation and electives under the supervision of my residents and attending physicians.  Before doing any procedures, I have reviewed the NEJM Videos in Clinical Medicine (http://www.nejm.org/multimedia/medical-videos) which guide trainees through the equipment needed, how to set up, and how to actually perform the procedure.  Afterwards, it has been very helpful when I have debriefed with my residents to review positive aspects and items to improve for next time.

An article by Fincher in 2000 highlighted that competency in performing procedures is a salient aspect of internal medicine training and that it has to be delineated what procedures internists are expected to perform.  Another topic that has been brought up is how to ensure that senior trainees feel comfortable before supervising more junior trainees.  (Mourad et al., 2010) Mourad’s study surveyed 7 teaching institutions in the Medical Education Research Network (MERN) of California.  They found that three-fourths of residents reported feeling comfortable (reaching a comfort threshold) with paracenteses, lumbar punctures, and femoral CVC’s after 3 to 4 times of having performed them, thoracentesis after 5 to 6 times, and IJ and subclavian CVC’s after 7 to 9 times.  The number of procedures performed was strongly associated with meeting the comfort threshold. (Mourad et al., 2010)

Over the years, the way in which schools have addressed this is by implementing procedural teaching in Academic Half-Days and making use of simulation centres.  (Sacks et al., 2017) It has been said that objectivity can be important when determining whether trainees are competent in a specific procedure. (Tariq et al., 2015) The biggest change moving forward is that as we move into a competency-based era, every resident will have to be deemed competent in a set of procedures before formally completing the program.  These benchmarks help to ensure that residents’ academic advisors are following their progress in procedural skills and this evaluation serves as an impetus for the resident to learn the skills.

Exciting times ahead!

SH

Resources:

Fincher, R. E. (2000).  Procedural Competence of Internal Medicine Residents. J Gen Intern Med, 15(6): 432 – 433.

Mourad, M. et al. (2010). Supervising the Supervisors – Procedural Training and Supervision in Internal Medicine Residency. Journal of Internal Medicine, 25(4): 351 – 356.

Tariq, M. et al. (2015). Optimum number of procedures required to achieve procedural skills competency in internal medicine residents. BMC Medical Education, 15: 179. DOI 10.1186/s12909-015-0457-4

Sacks CA, Alba GA, Miloslavsky EM. The Evolution of Procedural Competency in Internal Medicine Training. JAMA Intern Med. 2017;177(12):1713–1714. doi:10.1001/jamainternmed.2017.5014