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.