- Email: [email protected]
Competency and confidence: Procedures in the emergency department
RESIDENTS’ PERSPECTIVE
Residents’ Perspective Competency and Confidence: Procedures in the Emergency Department Albert K. Hsiao, MD Jerris R. Hedges, MD, MS Department of Emergency Medicine
Competency and Confidence: Procedures in the Emergency Department
Oregon Health Sciences University Portland, OR Dr. Hedges receives royalties as coeditor of Clinical Procedures in Emergency Medicine. Section Editor
[Hsiao AK, Hedges JR. Competency and confidence: procedures in the emergency department. Ann Emerg Med. June 2001;37:686-687.]
David H. Newman, MD University of Pittsburgh Affiliated Residency in Emergency Medicine Pittsburgh, PA Reprints not available from the authors. Address for correspondence: Albert K. Hsiao, MD, Department of Emergency Medicine, Oregon Health Sciences University, 3181 SW Sam Jackson Park Road, UHN-52, Portland, OR 97201-3098; E-mail [email protected]. Copyright © 2001 by the American College of Emergency Physicians. 0196-0644/2001/$35.00 + 0 47/1/115530 doi:10.1067/mem.2001.115530
6 8 6
INTRODUCTION One of the features that makes emergency medicine unique among specialties is the frequent performance of emergency and invasive procedures in the acute setting. Successful performance of these clinical procedures can not only benefit the patient but also enhance the practitioner’s excitement and gratification. Unfortunately, untoward and unexpected events can occur during the course of an invasive procedure. Besides the obvious effect on patient care, bringing a procedure to a successful or unsuccessful conclusion may directly effect an emergency medicine resident’s emotional state or sense of self-worth and value in the emergency department. Although it is natural to respond in this manner, the resident should understand both what is behind that emotion and how to cope with a failed procedure. A primary goal of residency is to build an experiential legacy that will define the approach to emergency situations beyond residency, be they successes or failures. We present thoughts and ideas regarding both the technical and emotional aspects of clinical procedures in the context of residency training.
COMPETENCY AND CONFIDENCE Procedures can be life-saving or life-taking, a distracting reality. As residents, we are keen to be viewed as team players, to play a role in ensuring high-quality patient care, and to facilitate the smooth running of our ED. Acknowledging that our abilities may have direct consequences on morbidity and mortality may affect how we view this role. Completion of a procedure is an important concrete action for which we can take credit and responsibility during patient care. Hence, success can be seen as a measure of competency and confidence for a resident physician. Resident attitude provides the basis on which to build and maintain procedural competency and confidence. It is important to say to oneself, as well as to project to others, the notion that “I am ready, and I can do it.” Furthermore, the faculty physician can do much to enhance the confidence and competence of the resident. The overall goal of competency and confidence development by instructors is to connect, communicate, and teach effectively and constructively. Given that residents are adult learners, the better instructors will support residents as colleagues and foster a positive and productive learning environment. Demeaning a resident in the face of a procedural challenge is a teaching opportunity lost and a detriment to the goal of his or her education. MAXIMIZING THE POTENTIAL FOR SUCCESS It is important to maximize the odds of procedural success. One must understand the pro-
ANNALS OF EMERGENCY MEDICINE
37:6 JUNE 2001
RESIDENTS’ PERSPECTIVE
cedure, its indications, and its contraindications.1 Before performing the procedure, the procedural steps should be reviewed and the technical aspects practiced. The patient and physician both should be positioned for anatomic benefit and comfort. Anticipate potential complications and take steps in advance to address these problems should they arise. Know how to premedicate and monitor the patient for systemic complications during the procedure. Ensure that materials are arranged as they will be needed and that good lighting is assured for the procedure. Address extraneous issues in the ED so that concentration can be focused fully on the procedure at hand. Although there may still be disappointment if one is technically unsuccessful after taking these steps, it will not be because of lack of preparation, perhaps the most common pitfall. SEE ONE, DO ONE, TEACH ONE Significant training advances have been made in resident procedural skills laboratories. National certification courses, such as Advanced Trauma Life Support, have contributed to the advancement and standardization of procedural techniques by including practical skills teaching in their sessions through the use of animal laboratories. Many residency programs continue to offer traditional cadaver laboratories for procedural skills training. Some centers are now using high-tech mannequins that simulate procedural scenarios to teach residents. Yet even with large-scale financial resources and advanced technology available, the most fundamental and by far the most prevalent form of procedural teaching continues to be “see one, do one, teach one.” The “one” refers to a technique or procedure with which a resident is unfamiliar. In the high-volume, high-intensity environment of the ED, this may be the best way to truly learn certain procedures. Reading the technical aspects of a procedure or performing a procedure on a cadaver or animal model, while offering some value to the beginning trainee, ultimately can not substitute for practical experience. “See one, do one, teach one” is a necessary and invaluable tool for the education of residents, and guides to this form of bedside teaching exist that will encourage more effective performance for both the teacher and the resident during each phase of this process.2,3
JUNE 2001
37:6
ANNALS OF EMERGENCY MEDICINE
THE PUNT Patients are best served by physicians who recognize their self-limitations. Although emergency medicine residents desire to be seen as procedurally invincible, they must know when to “punt,” and it is important to have a practice climate that comfortably accepts this. Some centers allow no more than 3 unsuccessful attempts before a colleague (generally someone more senior) attempts the procedure. An experienced and skilled physician may be unable to successfully complete a procedure on any given day, and a less-experienced individual may occasionally be able to successfully complete the same procedure. The factors determining success or failure can sometimes be elusive, and this idiosyncrasy of procedures should be respected and accepted. This concept is critical for residents and is well appreciated by everyday practitioners of emergency medicine both inside and outside of academic centers, where it may be necessary to call in intravenous nurses, anesthesiologists, intensivists, or surgeons to assist in difficult cases.
human reason, usually anything arising from reason alone, including abstract definitions, mathematics, or indisputable events. In our universe of the ED, the development of procedural competency and confidence requires embracing both worlds. Residents must observe, reason, and continue to assess and reevaluate to secure their role as emergency physicians after residency. Procedural success should bring pleasure, but technical failure should not be a measure of self-worth. Technical failure should generate further resolve to broaden and strengthen our problem-solving armamentarium. 1. Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 3rd ed. Philadelphia, PA: WB Saunders Co; 1997. 2. Thomas H Jr. Teaching procedural skills: beyond “see one - do one.” Acad Emerg Med. 1994;1:398-401. 3. Hedges JR. Pearls for the teaching of procedural skills at the bedside. Acad Emerg Med. 1994;1:401-404.
KEEPING PROCEDURES IN PERSPECTIVE Although procedural success is important, it is more important to keep the bigger picture in mind. When a procedure is successful, savor the satisfaction of one difficult step being well done. Let the patient, his or her family (if available), and your colleagues know of your success. Yet recognize and verbalize that the procedure is but a small step toward addressing the underlying problem or making a diagnosis. Keep in mind that a successful procedure may bring bad news (eg, lumbar puncture demonstrating infection or evidence of subarachnoid bleeding). Similarly, when a procedure does not proceed well, it need not alter what you can ultimately provide the patient. After all, the patient generally does not come to you solely to perform a procedure. The patient presents with a problem that needs resolution. Generations ago, Plato championed the idea that “the visible world”—what we see, what we hear, and what we experience—is a world of change and uncertainty. He also promoted the view that “the intelligible world” is made up of the unchanging products of
6 8 7
Residents’ Perspective Competency and Confidence: Procedures in the Emergency Department Albert K. Hsiao, MD Jerris R. Hedges, MD, MS Department of Emergency Medicine
Competency and Confidence: Procedures in the Emergency Department
Oregon Health Sciences University Portland, OR Dr. Hedges receives royalties as coeditor of Clinical Procedures in Emergency Medicine. Section Editor
[Hsiao AK, Hedges JR. Competency and confidence: procedures in the emergency department. Ann Emerg Med. June 2001;37:686-687.]
David H. Newman, MD University of Pittsburgh Affiliated Residency in Emergency Medicine Pittsburgh, PA Reprints not available from the authors. Address for correspondence: Albert K. Hsiao, MD, Department of Emergency Medicine, Oregon Health Sciences University, 3181 SW Sam Jackson Park Road, UHN-52, Portland, OR 97201-3098; E-mail [email protected]. Copyright © 2001 by the American College of Emergency Physicians. 0196-0644/2001/$35.00 + 0 47/1/115530 doi:10.1067/mem.2001.115530
6 8 6
INTRODUCTION One of the features that makes emergency medicine unique among specialties is the frequent performance of emergency and invasive procedures in the acute setting. Successful performance of these clinical procedures can not only benefit the patient but also enhance the practitioner’s excitement and gratification. Unfortunately, untoward and unexpected events can occur during the course of an invasive procedure. Besides the obvious effect on patient care, bringing a procedure to a successful or unsuccessful conclusion may directly effect an emergency medicine resident’s emotional state or sense of self-worth and value in the emergency department. Although it is natural to respond in this manner, the resident should understand both what is behind that emotion and how to cope with a failed procedure. A primary goal of residency is to build an experiential legacy that will define the approach to emergency situations beyond residency, be they successes or failures. We present thoughts and ideas regarding both the technical and emotional aspects of clinical procedures in the context of residency training.
COMPETENCY AND CONFIDENCE Procedures can be life-saving or life-taking, a distracting reality. As residents, we are keen to be viewed as team players, to play a role in ensuring high-quality patient care, and to facilitate the smooth running of our ED. Acknowledging that our abilities may have direct consequences on morbidity and mortality may affect how we view this role. Completion of a procedure is an important concrete action for which we can take credit and responsibility during patient care. Hence, success can be seen as a measure of competency and confidence for a resident physician. Resident attitude provides the basis on which to build and maintain procedural competency and confidence. It is important to say to oneself, as well as to project to others, the notion that “I am ready, and I can do it.” Furthermore, the faculty physician can do much to enhance the confidence and competence of the resident. The overall goal of competency and confidence development by instructors is to connect, communicate, and teach effectively and constructively. Given that residents are adult learners, the better instructors will support residents as colleagues and foster a positive and productive learning environment. Demeaning a resident in the face of a procedural challenge is a teaching opportunity lost and a detriment to the goal of his or her education. MAXIMIZING THE POTENTIAL FOR SUCCESS It is important to maximize the odds of procedural success. One must understand the pro-
ANNALS OF EMERGENCY MEDICINE
37:6 JUNE 2001
RESIDENTS’ PERSPECTIVE
cedure, its indications, and its contraindications.1 Before performing the procedure, the procedural steps should be reviewed and the technical aspects practiced. The patient and physician both should be positioned for anatomic benefit and comfort. Anticipate potential complications and take steps in advance to address these problems should they arise. Know how to premedicate and monitor the patient for systemic complications during the procedure. Ensure that materials are arranged as they will be needed and that good lighting is assured for the procedure. Address extraneous issues in the ED so that concentration can be focused fully on the procedure at hand. Although there may still be disappointment if one is technically unsuccessful after taking these steps, it will not be because of lack of preparation, perhaps the most common pitfall. SEE ONE, DO ONE, TEACH ONE Significant training advances have been made in resident procedural skills laboratories. National certification courses, such as Advanced Trauma Life Support, have contributed to the advancement and standardization of procedural techniques by including practical skills teaching in their sessions through the use of animal laboratories. Many residency programs continue to offer traditional cadaver laboratories for procedural skills training. Some centers are now using high-tech mannequins that simulate procedural scenarios to teach residents. Yet even with large-scale financial resources and advanced technology available, the most fundamental and by far the most prevalent form of procedural teaching continues to be “see one, do one, teach one.” The “one” refers to a technique or procedure with which a resident is unfamiliar. In the high-volume, high-intensity environment of the ED, this may be the best way to truly learn certain procedures. Reading the technical aspects of a procedure or performing a procedure on a cadaver or animal model, while offering some value to the beginning trainee, ultimately can not substitute for practical experience. “See one, do one, teach one” is a necessary and invaluable tool for the education of residents, and guides to this form of bedside teaching exist that will encourage more effective performance for both the teacher and the resident during each phase of this process.2,3
JUNE 2001
37:6
ANNALS OF EMERGENCY MEDICINE
THE PUNT Patients are best served by physicians who recognize their self-limitations. Although emergency medicine residents desire to be seen as procedurally invincible, they must know when to “punt,” and it is important to have a practice climate that comfortably accepts this. Some centers allow no more than 3 unsuccessful attempts before a colleague (generally someone more senior) attempts the procedure. An experienced and skilled physician may be unable to successfully complete a procedure on any given day, and a less-experienced individual may occasionally be able to successfully complete the same procedure. The factors determining success or failure can sometimes be elusive, and this idiosyncrasy of procedures should be respected and accepted. This concept is critical for residents and is well appreciated by everyday practitioners of emergency medicine both inside and outside of academic centers, where it may be necessary to call in intravenous nurses, anesthesiologists, intensivists, or surgeons to assist in difficult cases.
human reason, usually anything arising from reason alone, including abstract definitions, mathematics, or indisputable events. In our universe of the ED, the development of procedural competency and confidence requires embracing both worlds. Residents must observe, reason, and continue to assess and reevaluate to secure their role as emergency physicians after residency. Procedural success should bring pleasure, but technical failure should not be a measure of self-worth. Technical failure should generate further resolve to broaden and strengthen our problem-solving armamentarium. 1. Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 3rd ed. Philadelphia, PA: WB Saunders Co; 1997. 2. Thomas H Jr. Teaching procedural skills: beyond “see one - do one.” Acad Emerg Med. 1994;1:398-401. 3. Hedges JR. Pearls for the teaching of procedural skills at the bedside. Acad Emerg Med. 1994;1:401-404.
KEEPING PROCEDURES IN PERSPECTIVE Although procedural success is important, it is more important to keep the bigger picture in mind. When a procedure is successful, savor the satisfaction of one difficult step being well done. Let the patient, his or her family (if available), and your colleagues know of your success. Yet recognize and verbalize that the procedure is but a small step toward addressing the underlying problem or making a diagnosis. Keep in mind that a successful procedure may bring bad news (eg, lumbar puncture demonstrating infection or evidence of subarachnoid bleeding). Similarly, when a procedure does not proceed well, it need not alter what you can ultimately provide the patient. After all, the patient generally does not come to you solely to perform a procedure. The patient presents with a problem that needs resolution. Generations ago, Plato championed the idea that “the visible world”—what we see, what we hear, and what we experience—is a world of change and uncertainty. He also promoted the view that “the intelligible world” is made up of the unchanging products of
6 8 7