Sunday, June 10, 2012

See one, do one, teach one...if there's time?

The Gist:   EM physician's perception of ED crowding may affect the number of procedures performed by trainees.  Procedures are an important part of the medical education process, especially in Emergency Medicine, but the mantra "see one, do one, teach one" may not be adequate/practical in the current clinical paradigm.  One can capitalize on the experience by understanding individual learning style, simulating procedures, and preparing for success using the resources of the medical education community.

The paper:  Does ED crowding decrease the number of procedures a physician in training performs?  A prospective observational study. Atzema et al.  This isn't a must-read paper but it does raise some interesting questions.

The study:
  • Prospective, observational study in a Level I ED with 45,000 visits/year
  • Data passively collected.  
    • Attendings (n=38) and medical student/resident trainees (n=113) recorded the procedures performed (n=804), attempted, or offered.
    • Attendings recorded procedures, that could have been done in the ED, that were deferred to consultants 
  • ED crowding was measured by two measures (1) ED attending perceived crowding (which apparently is fairly valid) and (2) ED Length of Stay (LOS)
The results:
  • Primary Outcome not met. No statistically significant difference in number of procedures performed with a mean of 1.0 (35% of shifts) on crowded shifts and 1.25 on non-crowded shifts.
  • More procedures in the "minor" area of the ED, especially during the day shift.
  • More procedures were given away to consultants in shifts perceived as crowded by ED attendings (10.5% vs 3.4%, P = .02)
  • Most common procedures included sutures, splint/casting, fracture reductions, arterial blood gases, nerve blocks, intubations, arthrocenteses , and lumbar punctures
  • Medical students performed more procedures, per documented shift, than residents
Why should I care about this paper?  This paper has many limitations including a small, single ED with passive data collection for less than one year.  However, I think it has some things to teach us about learning procedures..
  • Capitalize on procedures by getting familiar with them beforehand.  Many medical schools offer some instruction, but may be insufficient or remote.  
  • It's beneficial for trainees to be familiar with their own learning style.  Thrive in one-on one situations?
    • You're not alone.  This study from the BMJ demonstrated that fourth year medical students matched with one attending across shifts performed more procedures than those who had a variety of attendings. 
    • In the Atzema paper, 17.8% of shifts had more than one trainee.  This percentage is likely higher at larger teaching hospitals and could decrease the number of procedures available to a single student (although the trade-off may be larger volume), but I don't have any data to back this up other than my n=1 anecdotes. 
  • Simulation is assuming an increasingly important role and various methods have been included into the education process including simulated patients, computerized simulators, cadavers, animal simulators (ex: cricothyroidotomy training on sheep/pig tracheas), and inexpensive build-your-own simulators. 
    • In my limited experience I can vouch for the role of simulation in establishing a basic level of preparation, yet nothing comes close to the real-life scenario in which one must perform a procedure on a patient for the first time.   Perhaps the mantra, coined in Canadian Journal of Emergency MedicineSimulation training for emergency medicine residents:  time to move forward, "see one, simulate many, do one competently, teach everyone" is the real future of learning procedures.  
Atzema CLStefan RASaskin RMichlik GAustin PC.  Does ED crowding decrease the number of procedures a physician in training performs?  A prospective observational study.Am J Emerg Med. 2012 May 31

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