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Editorials |
1 From the Department of Radiology, University of Arizona College of Medicine, 1501 N Campbell Ave, Room 1363, Tucson, AZ 85724-5067. Received April 16, 2007; final version accepted April 25. Address correspondence to the author (e-mail: Becker{at}rsna.org).
In this issue, Gaca and colleagues (1) describe a study performed to assess the preparedness of contemporary radiology residents in the recognition and management of severe reactions to iodinated contrast material in children of differing ages and sizes. Their report provides a glimpse at how, in radiology as well as across all subspecialties of medicine, we might apply new methods to address the difficult challenge of achieving and maintaining competency in the management of low-frequency life-threatening events encountered in practice. Their report calls to mind three pillars of a major but nascent transformation occurring in medical training and practice today: patient-centered care with an emphasis on quality and safety; new training models, including standardized clinical encounters and simulations; and competency- and milestone-based education, training, and credentialing.
In the reported study, each of 19 1st- or 2nd-year radiology residents with current basic and/or advanced life support training and certification was randomly presented with two simulated life-threatening contrast reaction scenarios in mannequins simulating children of different ages and sizes: one scenario with resuscitation aids and one without them. The resuscitation aids were color-coded information sheets modified from Broselow-Luten tape (2). The latter, used widely in pediatric emergencies, provides vital sign ranges, doses and routes of administration of medications, and appropriate intravenous fluid management—all based on head-to-toe length measurements of the child. The 38 contrast material reaction scenarios, which involved approximately 400 potential interventions, were video and audio recorded from two vantage points and were facilitated by a registered nurse trained in the emergency resuscitation of children. A registered technologist was present to respond to orders from the residents. All recorded data were analyzed, and residents were scored on three essential responses: (a) calling a code team (whether they called it and, if so, how long they took to do so), (b) administering oxygen (>5 L through the appropriate-size nonrebreather mask), and (c) administering epinephrine (in the correct dose via the correct route). Residents were also scored on whether they completed the essential responses in the correct order.
Only five of 19 residents verbalized their recognition of the scenarios as contrast material reactions. Only 12 (63%) of the 19 residents called a code team in both scenarios; the same number of residents administered oxygen both times. Although epinephrine was administered in appropriate doses less than one-fourth of the time when resuscitation aids were unavailable, it was given appropriately more than half the time when the aids were available. Four residents measured the simulated patient incorrectly, with resultant improper dosing in all subsequent medication administrations. Of 19 residents and 38 scenarios, only one resident in one scenario completed all essential tasks in the correct order. The significant learning effect clearly demonstrated that the two scenarios were not truly independent events.
Several conclusions can be drawn: First, despite certain misconceptions, medical simulation is as relevant to radiology as it is to other clinical disciplines of medicine. Second, even basic life support– and advanced life support–certified physicians may not be prepared to recognize or manage life-threatening pediatric emergencies. Third, even when the residents in this study recognized the need to provide resuscitation, they often failed to provide the appropriate care in the correct sequence. Fourth, the use of resuscitation aids probably increased the likelihood of appropriate medication dosing, as it has in previous studies (3,4). Fifth, the availability of resuscitation aids does not guarantee their use, let alone their proper use. Thus, both increased awareness of and training in the use of resuscitation aids are needed. Finally, the learning from scenario 1 demonstrated by the improved performance in scenario 2 suggests that the simulation offers substantial promise as a training aid.
By far the most important conclusion that can be drawn from the article is that by using simulation to assess individual physician preparedness to manage an extremely low-frequency life-threatening event encountered in practice, Gaca and colleagues have taken a very important step into the future. The fundamental problem with such events is that their rarity almost guarantees an uneven training experience across large numbers of residents. The result is that many, if not most, residents enter practice without ever having witnessed or managed a contrast material reaction, let alone one in a child. Yet some will encounter this reaction in practice, in either a hospital or an outpatient setting, and the likelihood of the patient surviving will be directly related to the physician's preparedness to handle the emergency.
Clearly, all graduating trainees should feel confident in their ability to manage severe contrast material reactions. Yet we know that exposure to these reactions in training is erratic. Therefore, to render the training experience more homogeneous, we must standardize it. To standardize it and still incorporate rare events, we must be prepared to adopt specific simulated clinical scenarios into the training curriculum. This would mean not only assessing trainees with a simulated scenario of contrast material reaction recognition and management but also training them with it and thereby guaranteeing that each resident will reach specific milestones. Simulations of similarly rare events have been incorporated into training in other medical disciplines. One example in anesthesiology is the recognition and management of malignant hyperthermia (5).
Standardization of training is a goal that must not be confined to recognition and management of rare life-threatening events, and simulation must not be so limited either. Rather, standardization should be pursued wherever possible, and simulation should be used to fill in curricular gaps and explore other opportunities to enhance preparedness, remove risk from the patient bedside, and ensure the achievement of critical milestones.
Paul Batalden, MD, Director, Health Care Improvement Leadership Development, Dartmouth Medical School, once told David C. Leach, MD, Executive Director, Council for Graduate Medical Education (ACGME), that "clinical skills should be learned as far away from the patient as possible; it's about respect" (6). I wholeheartedly agree: It is about respect. Learning clinical skills in a low-stakes environment remote from the patient satisfies one of the three fundamental principles (primacy of patient welfare) and one of the 10 professional responsibilities (commitment to professional competence) of the physician charter on medical professionalism in the new millennium (7). The latter seminal document, drafted by the American Board of Internal Medicine Foundation, the American College of Physicians–American Society of Internal Medicine Foundation, and the European Federation of Internal Medicine, has been formally endorsed by the American Board of Radiology and the Radiological Society of North America (8). Fundamentally, the document sets forth the principles and professional commitments by which each medical professional can and should adopt and maintain a patient-centered approach.
Thus far, in our discussion of the work of Gaca and colleagues, we have addressed only a very narrow area of practice and training: patient resuscitation in the context of life-threatening reactions to contrast media. Thinking a bit more broadly, one might reasonably ask, "How much change in education and training is needed?" "What else about the way we teach medical students, train residents, and maintain competency in practice warrants improvement?" Rather than answer with my opinion, I shall defer to a quote from Jordan Cohen, MD, from his time as president of the Association of American Medical Colleges: "People have said that the graduate education system is broken, but it's actually outmoded. It was designed for an earlier era and worked well for its time. The task before us is not repair, but redesign" (6).
Indeed we are poised at the threshold of a transformation in medical education and graduate medical training so momentous as to be unparalleled since Halsted introduced our current system of residency training at the turn of the 20th century (9) and since education theorist Abraham Flexner's report to the American Medical Association Council on Medical Education led to the implementation of medical school entry criteria, the earliest standardized medical school curricula, and eventually the establishment of the Federation of State Medical Boards (10,11).
For several major reasons, we cannot continue to train residents under the Halstedian master-apprentice model; instead, we must adopt new models of training. First, since the release of the Institute of Medicine report, To Err is Human: Building a Safer Health System (12), the public could no longer be expected to accept the time-honored practice of learning with use of patients (ie, allowing trainees to make mistakes on patients as they learn). Nor should we physicians accept it. Second, current ACGME limitations on resident duty hours impose real limitations on the clinical experience each resident will obtain during training. Third—and most important for procedural specialties—noninvasive diagnostic paradigms are increasingly limiting the resident trainee's acquisition of basic skills upon which more advanced skills must be built. Fourth, under current ACGME requirements, all residencies have started down the path of competency-based education and training. The latter is a major departure from the traditional time-in-service model. The six basic physician competencies are patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice (13). Within every training curriculum, there are opportunities to develop and assess the competencies specific to a field of practice (eg, the contrast material reaction management skills that are the subject of the Gaca and colleagues report). In vascular and interventional radiology, for example, a joint international task force on medical simulation is undertaking the task of identifying opportunities for medical simulation in the training curriculum.
David Leach has proposed that simulations can help to achieve our objectives in resident education in the following ways: (a) enabling the acquisition of skills by residents in the low-stakes environment remote from the bedside, (b) providing the means for procedure and treatment rehearsals and debriefings, (c) serving as a formative tool for resident development (similar to the use of objective standardized clinical encounters for medical students), (d) helping to determine how residents respond in different contexts, (e) exposing the mastery of both rules and values through the judicious use of improvisation, (f) populating a portfolio of assessed experiences that enable residents to demonstrate their abilities, (g) permitting residents to make deliberate errors to learn about their consequences, (h) helping residents learn systems-based practice through simulations that involve multiple interdependent variables, (i) documenting how residents think rather than simply what they think, and (j) expressing respect in a concrete manner (6).
In professional life beyond training, time-limited certification and maintenance of certification comprise the new paradigm. It is now imperative that each physician wishing to maintain certification by his or her Member Board of the American Board of Medical Specialties (ABR is one) participate in that Member Board's Maintenance of Certification program. Participation includes addressing each of the six competencies. New training and assessment tools will also have a role at the practice level. Simulation may be used for procedure rehearsals, some of which may involve patient-specific data sets; for regularly scheduled practice sessions to maintain specific competencies; for credentialing and recredentialing; and as a practice improvement measure.
In summary, the future of medical student education, residency training, and maintenance of competence and clinical privileges in practice will bear little resemblance to the past. We must accept the primacy of patient welfare and embrace our commitment to professional competence. In so doing, we should be prepared for new models of education and training and for the adoption in the practice environment of simulation technologies that facilitate both individual patient management and the maintenance and assessment of specific competencies.
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Author stated no financial relationship to disclose.
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