Discussion
The see one, do one, teach one paradigm has been a key tenant in
surgical education, allowing more autonomy of the trainee with each step10,11. However, public reporting and increased
scrutiny of outcomes and surgical practices have hindered this training
model, reducing senior resident experience over the past decade12–14. While the majority of technical learning for
residents occurs directly by faculty in the operating room, this occurs
to a lesser extent for bedside procedures. Moreover, the residents in
this study reported that 48% were taught a beside procedure by a senior
resident instead of an attending or senior independent practitioner is
not uncommon finding 4,15,16. However, bedside
procedures are far more routine procedures that cardiothoracic residents
are expected to perform safely and independently. Unsurprisingly, the
average Likert score for standardization of bedside procedures was 3.5.
Unlike some other surgical subspecialists, the bedside procedures
performed by cardiothoracic residents have an elevated risk for
morbidity and mortality thus making the need for appropriate teaching
and standardization even more pointed. This represents the impetus
behind this study, to standardize and credential all cardiothoracic
residents on the routine high risk beside procedures they will
encounter, increasing their confidence in the procedure and ultimately
improve patient safety. Also, residents had no reference point for what
the agreed upon way was to do any beside procedure. Now the course
materials including video, power point presentation and the departmental
policy in text are all available online.
With increasing scruitiny on surgical outcomes comes a focus on the
standardization of teaching and evaluation practices. However, recent
literature has shown a concerning lack of standardization in training4–6. In an order to address standardization and
increase frequency of training, simulations are utilized to facilitate
trainee practice in a no risk environment 17–23. For
bedside procedures, groups have shown a benefit of simulation training
prior to patient procedures 17–20. For thoracentesis,
Barsuk et al. showed in a randomized trial that standardized
simulation-based learning decreased complication rates17. This study echoes this finding, while not
assessing complication rates, by showing an increase in the
standardization of performing a thoracentesis after the credentialing
course. In fact, we demonstrated an increase of standardization across
all the high-risk bedside procedures included in this credentialing
program. Standardization is crucial in areas of surgery where
supervision is lacking. Through a credentialing course, standardization
and competency can be enforced, ensuring a common skillset for bedside
procedures.
Along with increases in standardization came increases in trainee
confidence to safely perform these high-risk bedside procedures.
Interestingly, we found a dependence of this increase on the initial
confidence of the residents. The most commonly performed and most
comfortable procedure for the residents was a nasogastric tube/duo tube
insertion. Likewise, the least commonly performed and least endorsed
procedure was an endotracheal tube intubation. There was no change in
resident confidence for performing an NG/duo tube insertion while the
greatest improvement in confidence was for endotracheal intubation. This
suggests that institutional training and exposure patterns need to be
considered to better asses which of these bedside procedures warrant
more rigorous standardization and frequent exposure to ensure trainee
competency. In fact, a recent meta-analysis showed that junior residents
in cardiac surgery benefitted most from simulation-based skill
training, implying that the less
exposure and experience a resident has with a particular skill set, the
more effective and prudent a simulation-based training session will be20.
An important part of this work is the fact that this curriculum was
created and executed in a multidisciplinary fashion. This allowed for
the development of the online curriculum in as board and widely
applicable a manner as possible. Also, the CVC and endotracheal
intubation hands on sessions were proctored by CRNPs, CRNAs and critical
care physicians demonstrating the importance of the residents learning
procedures from the most skill. Also, this course has the potential
given how it was structured to be repeated specifically for APPs and
other learners.
While the standardization and confidence metrics were assessed
subjectively, it is important to emphasize that each resident was
assessed and approved by an attending following a predetermined set of
criteria for each bedside procedure. By doing so, we ensured a common
competency baseline for our residents. Moreover, a knowledge-based test
was taken by each resident before and after the training session, of
which a large portion showed improvement. This test was aimed at
assessing knowledge surrounding indications, complications, and
maneuvers key in each procedure. Along with initial assessments on
simulations as well as attending’s assessment of competency, knowledge
based tests are a key component of suggested credentialing
paradigms24.
This work demonstrates that a bedside procedural credentialing course is
effective at raising resident knowledge, increase confidence and
standardizing performance of procedures in a cardiothoracic surgery
training program.