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QA in regional anesthesia training
Regional Anesthesia 22(3):209-211, 1997
Editorial QA in Regional Anesthesia Training Quantity or Quality? I believe we may safely affirm, that the inexperienced and presumptuous band of medical tyros let loose upon the world, destroys more of human life in one year, than all of the Robinhoods, Cartouches, and Macheaths do in a century. It is in this part of medicine that I wish to see a reform. Thomas Jefferson to Dr. Caspar Wistar, 21 June, 1807 In this issue of Regional Anesthesia, Bouzaziz et al. describe the educational experience in regional anesthesia of residents in training in France, specifically highlighting the a m o u n t of exposure to peripheral nerve block (1). W h e n one examines this article in conjunction with other publications relating to the teaching of regional anesthetic techniques, several impressions emerge. First, as the authors correctly explain, most previous studies on the teaching of regional anesthetic techniques have focused on central neuraxial block (2,3). The current article importantly fills a gap in our knowledge regarding the teaching of peripheral nerve block. As one could gfiess, the numbers of peripheral n e r v e blocks performed during training are far less than the n u m b e r of spinal and epidural anesthetics being conducted. This does not appear to vary regardless of w h e r e in the world regional anesthesia is being taught, nor does it appear to be changing with time (4-6). Variability b e t w e e n training programs in the teaching of regional anesthetic techniques exists, not only in the United States but also in o t h e r countries. Regional anesthesia continues to grow in popularity. Patients and surgeons are increasingly requesting regional anesthesia for surgical procedures. Yet one problem remains: too few anesthesiologists are expert in or enthusiastic about providing and :teaching regional anesthetic techniques. Indeed, some graduating residents are being exposed to little or n o region~il anesthesia (6). In the report by Bouaziz et al., the n u m b e r of peripheral nerve blocks, and presumably the n u m ber of spinal and epidural anesthetics, varies substantially b e t w e e n different French residency training programs. W h y this variability? And is it important? Bouaziz et al. suggest that this variability in training "reflects that these techniques are better mastered by the teachers and c o n s e q u e n t l y t h e most taught." Basically teachers are uncomfortable teaching that which they have not mastered themselves. This is particularly unfortunate, since even residents with the most exposure during residency will not have e n o u g h experience to master most peripheral nerve blocks. All clinicians must remain students if they wish to use peripheral nerve block, even after obtaining certification as "consultant," "teacher," or "clinician." As with m a n y other m a n u a l techniques in anesthesia (eg, line placement), the learning of regional anesthesia does not stop at the end of the formal training period. Is this variability in training, important? Clearly, regional anesthesia cannot, and should not, be used in every patient. Likewise, general anesthesia cannot, Accepted for publication January 3, 1997.
209
210
Regional Anesthesia 22 No. 3 May-June 1997
and should not, be used in every patient. Some of the responses to the hypothetical patient scenarios in the Bouaziz et al. article are concerning--for instance, while the choice of intravenous regional anesthesia for an asthmatic patient with an elbow fracture may not be totally inappropriate, the rationale for making that choice (because no other regional anesthetic technique was known) is disturbing. These responses underscore the importance of diversification in anesthesia training and in contemplating the spectrum of anesthetic options for each individual patient. Third, while we have some data about the numbers of blocks that are being performed during training, we have considerably less knowledge about the number of each block required to attain proficiency. The post-training evaluation processes used in this country do well to assess a candidate's cognitive knowledge (American Board of Anesthesiology [ABA] written examination) and communicative skills and adaptability (ABA oral examination). During these evaluation processes, the quality of a resident's knowledge and proficiency in these areas are inherently assessed. However, evaluation of a candidate's aptitude at procedural skills remains delinquent. In the United States, the Residency Review Committee for Anesthesiology of the American Medical Association has recently (1996) modified the educational requirements of anesthesiology residency training programs. It is now suggested that trainees performed a minimum number of regional anesthetics (50 epidural, 50 subarachnoid, and 40 peripheral nerve block anesthetics), pain blocks (25 procedures), and other invasive procedures during their training period (7). The comparable anesthesiology educational governing bo~ly in France is apparently instituting similar provisions. While these amendments to residency program requirements should be applauded, they must also be viewed with caution. Quantity may not be quality. While "QA" is often used as an abbreviation for "quality assurance" or "quality assessment," in the context of training in regional anesthesia, it can currently only be used to represent quantity assurance. No true measures of quality are defined or required. We have focused on the variability of teaching and exposure to regional anesthesia, but we must also consider the variability in learning. Clearly, some residents can capture the essentials of performing a particular regional anesthetic block with virtually no instruction, and with as few as 10-15 "practice" attempts. Quantity assurance in these residents would seem inappropriate, since they may achieve a level of competence (quality) prior to reaching the designated numerical endpoint.'At the opposite extreme, other residents may never acquire the knowledge, savvy, and/or skills to perform the same block, regardless of h o w much guidance and time they are given to practice. Similarly, deeming these trainees qualified because they simply attempt a predefined number of blocks seems inappropriate. Many useful training devices (computer programs, simulators, mannequins, and models) have been developed to aid in the teaching of regional anesthetic techniques. Yet each of these training devices suffer one common shortfall being one step removed from an encounter with an actual h u m a n patient. These learning aids are helpful and may shorten a trainee's learning curve, but they are not sufficient. Hands-on experience, especially with regional anesthesia, will always be necessary. In a like manner, transesophageal echocardiography may be partially learned by viewing videotapes and by observing procedures in the echocardiography laboratory, but its performance during a cardiac anesthetic will eventually be necessary. Regardless of any suggested numerical guidelines, the end product of individual competency is more important than the numerical milestones along the way (8). But can we assess quality? Several objective methods that help with this task have been described. Performance testing, such as direct observation and scoring
Editorial
9
of the discrete and critical steps of a n epidural and s u b a r a c h n o i d block, has b e e n s h o w n to provide reliable m e a s u r e s of m o t o r skills (3,9). Proficiency in these tests i m p o r t a n t l y encompasses not only the basic technical skills of p e r f o r m i n g regional anesthetic blocks, but also k n o w l e d g e of the possible side effects and complications a n d the essentials of their m a n a g e m e n t . A resident's successful c o m p l e t i o n of such testing indicates a certain degree of quality and suggests the s u b s e q u e n t c o n t i n u e d safe p e r f o r m a n c e of these regional anesthetic techniques. Recently, Kestin (10) has reported h o w c u s u m (cumulative sum) analysis, a t e c h n i q u e used widely for quality assurance in industry, can be adapted to track technical skills in anesthesiology. Initially, "acceptable" and "unacceptable" levels of successful block are defined, w h i c h m a y v a r y b y locale. While conducting c u s u m analysis, o u t c o m e s of a t t e m p t e d regional anesthetic techniques are continually recorded. Deficient trends in p e r f o r m a n c e can be detected and hopefully r e m e d i e d as the technique is first being learned. Equally important, c u s u m analysis can d e m o n s t r a t e a continuing level of proficiency after c o m p l e t i o n of resid e n c y training. Owing to the time and effort required, assessment of e v e r y resident for each particular block m a y not always be possible, but s o m e effort at certifying quality is essential. If o u r ultimate objective, the e n h a n c e m e n t of patient care, is to be realized, w e as teachers a n d learners of regional anesthesia m u s t ensure a minim u m in quantity. We also m u s t ensure a m i n i m u m in quality.
Dan Kopacz, M.D. Department of Anesthesiology Virghlia Mason Medical Center Seattle, Washhlgton
References 1. Bouaziz H, Mercier FJ, Narchi P, Poupard M, Auroy Y, Benhamou D. A survey of regional anesthetic practice among French residents at time of certification. Reg Anesth 1997: 22: 218-222. 2. Kopacz DJ, Neal JM, Pollock JE. The regional anesthesia "learning curve," What is the minimum number of epidural and spinal blocks to reach consistency? Reg Anesth 1996: 21: 182-190. 3. Sivarajan M, Lane PE, Miller EV, Liu E Herr G, Willenkin R, Winter E Hardy CA, Mulroy ME Performance evaluation: Continuous lumbar epidural anesthesia skill test. Anesth Analg 1981: 60: 543-547. 4. Tetzlaff JE, Smith ME Experience with specific regional techniques in current American anesthesia residency training. Reg Anesth 1996: 21: $89. 5. Duncan P, Cohen M, Yip R. Is success in anaesthesia practice affecting resident education? Can J Anaesth 1992: 39: A121. 6. Kopacz DJ, Bridenbaugh LD. Are anesthesia residency programs failing regional anesthesia. The past, present and future. Reg Anesth 1993: 18: 84-87. 7. American Medical Association: Program requirements for residency education in anesthesiology, in: Graduate medical education directory 1996. Chicago, American Medical Association, 1996: 34-37. 8. Cahalan MK, Foster E. Training in transesophageal echocardiography: In the lab or on the job? Anesth Analg 1995: 81: 217-218. 9. Sivarajan M, Miller E, Hardy C, Her G, Liu E Willenkin R, Cullen B. Objective evaluation of clinical performance and correlation with knowledge. Anesth Analg 1984: 63: 603-607. 10. Kestin IG. A statistical approach to measuring the competence of anaesthetic trainees at practical procedures. Br J Anaesth 1995: 75: 805-809.
Kopacz
211
Editorial QA in Regional Anesthesia Training Quantity or Quality? I believe we may safely affirm, that the inexperienced and presumptuous band of medical tyros let loose upon the world, destroys more of human life in one year, than all of the Robinhoods, Cartouches, and Macheaths do in a century. It is in this part of medicine that I wish to see a reform. Thomas Jefferson to Dr. Caspar Wistar, 21 June, 1807 In this issue of Regional Anesthesia, Bouzaziz et al. describe the educational experience in regional anesthesia of residents in training in France, specifically highlighting the a m o u n t of exposure to peripheral nerve block (1). W h e n one examines this article in conjunction with other publications relating to the teaching of regional anesthetic techniques, several impressions emerge. First, as the authors correctly explain, most previous studies on the teaching of regional anesthetic techniques have focused on central neuraxial block (2,3). The current article importantly fills a gap in our knowledge regarding the teaching of peripheral nerve block. As one could gfiess, the numbers of peripheral n e r v e blocks performed during training are far less than the n u m b e r of spinal and epidural anesthetics being conducted. This does not appear to vary regardless of w h e r e in the world regional anesthesia is being taught, nor does it appear to be changing with time (4-6). Variability b e t w e e n training programs in the teaching of regional anesthetic techniques exists, not only in the United States but also in o t h e r countries. Regional anesthesia continues to grow in popularity. Patients and surgeons are increasingly requesting regional anesthesia for surgical procedures. Yet one problem remains: too few anesthesiologists are expert in or enthusiastic about providing and :teaching regional anesthetic techniques. Indeed, some graduating residents are being exposed to little or n o region~il anesthesia (6). In the report by Bouaziz et al., the n u m b e r of peripheral nerve blocks, and presumably the n u m ber of spinal and epidural anesthetics, varies substantially b e t w e e n different French residency training programs. W h y this variability? And is it important? Bouaziz et al. suggest that this variability in training "reflects that these techniques are better mastered by the teachers and c o n s e q u e n t l y t h e most taught." Basically teachers are uncomfortable teaching that which they have not mastered themselves. This is particularly unfortunate, since even residents with the most exposure during residency will not have e n o u g h experience to master most peripheral nerve blocks. All clinicians must remain students if they wish to use peripheral nerve block, even after obtaining certification as "consultant," "teacher," or "clinician." As with m a n y other m a n u a l techniques in anesthesia (eg, line placement), the learning of regional anesthesia does not stop at the end of the formal training period. Is this variability in training, important? Clearly, regional anesthesia cannot, and should not, be used in every patient. Likewise, general anesthesia cannot, Accepted for publication January 3, 1997.
209
210
Regional Anesthesia 22 No. 3 May-June 1997
and should not, be used in every patient. Some of the responses to the hypothetical patient scenarios in the Bouaziz et al. article are concerning--for instance, while the choice of intravenous regional anesthesia for an asthmatic patient with an elbow fracture may not be totally inappropriate, the rationale for making that choice (because no other regional anesthetic technique was known) is disturbing. These responses underscore the importance of diversification in anesthesia training and in contemplating the spectrum of anesthetic options for each individual patient. Third, while we have some data about the numbers of blocks that are being performed during training, we have considerably less knowledge about the number of each block required to attain proficiency. The post-training evaluation processes used in this country do well to assess a candidate's cognitive knowledge (American Board of Anesthesiology [ABA] written examination) and communicative skills and adaptability (ABA oral examination). During these evaluation processes, the quality of a resident's knowledge and proficiency in these areas are inherently assessed. However, evaluation of a candidate's aptitude at procedural skills remains delinquent. In the United States, the Residency Review Committee for Anesthesiology of the American Medical Association has recently (1996) modified the educational requirements of anesthesiology residency training programs. It is now suggested that trainees performed a minimum number of regional anesthetics (50 epidural, 50 subarachnoid, and 40 peripheral nerve block anesthetics), pain blocks (25 procedures), and other invasive procedures during their training period (7). The comparable anesthesiology educational governing bo~ly in France is apparently instituting similar provisions. While these amendments to residency program requirements should be applauded, they must also be viewed with caution. Quantity may not be quality. While "QA" is often used as an abbreviation for "quality assurance" or "quality assessment," in the context of training in regional anesthesia, it can currently only be used to represent quantity assurance. No true measures of quality are defined or required. We have focused on the variability of teaching and exposure to regional anesthesia, but we must also consider the variability in learning. Clearly, some residents can capture the essentials of performing a particular regional anesthetic block with virtually no instruction, and with as few as 10-15 "practice" attempts. Quantity assurance in these residents would seem inappropriate, since they may achieve a level of competence (quality) prior to reaching the designated numerical endpoint.'At the opposite extreme, other residents may never acquire the knowledge, savvy, and/or skills to perform the same block, regardless of h o w much guidance and time they are given to practice. Similarly, deeming these trainees qualified because they simply attempt a predefined number of blocks seems inappropriate. Many useful training devices (computer programs, simulators, mannequins, and models) have been developed to aid in the teaching of regional anesthetic techniques. Yet each of these training devices suffer one common shortfall being one step removed from an encounter with an actual h u m a n patient. These learning aids are helpful and may shorten a trainee's learning curve, but they are not sufficient. Hands-on experience, especially with regional anesthesia, will always be necessary. In a like manner, transesophageal echocardiography may be partially learned by viewing videotapes and by observing procedures in the echocardiography laboratory, but its performance during a cardiac anesthetic will eventually be necessary. Regardless of any suggested numerical guidelines, the end product of individual competency is more important than the numerical milestones along the way (8). But can we assess quality? Several objective methods that help with this task have been described. Performance testing, such as direct observation and scoring
Editorial
9
of the discrete and critical steps of a n epidural and s u b a r a c h n o i d block, has b e e n s h o w n to provide reliable m e a s u r e s of m o t o r skills (3,9). Proficiency in these tests i m p o r t a n t l y encompasses not only the basic technical skills of p e r f o r m i n g regional anesthetic blocks, but also k n o w l e d g e of the possible side effects and complications a n d the essentials of their m a n a g e m e n t . A resident's successful c o m p l e t i o n of such testing indicates a certain degree of quality and suggests the s u b s e q u e n t c o n t i n u e d safe p e r f o r m a n c e of these regional anesthetic techniques. Recently, Kestin (10) has reported h o w c u s u m (cumulative sum) analysis, a t e c h n i q u e used widely for quality assurance in industry, can be adapted to track technical skills in anesthesiology. Initially, "acceptable" and "unacceptable" levels of successful block are defined, w h i c h m a y v a r y b y locale. While conducting c u s u m analysis, o u t c o m e s of a t t e m p t e d regional anesthetic techniques are continually recorded. Deficient trends in p e r f o r m a n c e can be detected and hopefully r e m e d i e d as the technique is first being learned. Equally important, c u s u m analysis can d e m o n s t r a t e a continuing level of proficiency after c o m p l e t i o n of resid e n c y training. Owing to the time and effort required, assessment of e v e r y resident for each particular block m a y not always be possible, but s o m e effort at certifying quality is essential. If o u r ultimate objective, the e n h a n c e m e n t of patient care, is to be realized, w e as teachers a n d learners of regional anesthesia m u s t ensure a minim u m in quantity. We also m u s t ensure a m i n i m u m in quality.
Dan Kopacz, M.D. Department of Anesthesiology Virghlia Mason Medical Center Seattle, Washhlgton
References 1. Bouaziz H, Mercier FJ, Narchi P, Poupard M, Auroy Y, Benhamou D. A survey of regional anesthetic practice among French residents at time of certification. Reg Anesth 1997: 22: 218-222. 2. Kopacz DJ, Neal JM, Pollock JE. The regional anesthesia "learning curve," What is the minimum number of epidural and spinal blocks to reach consistency? Reg Anesth 1996: 21: 182-190. 3. Sivarajan M, Lane PE, Miller EV, Liu E Herr G, Willenkin R, Winter E Hardy CA, Mulroy ME Performance evaluation: Continuous lumbar epidural anesthesia skill test. Anesth Analg 1981: 60: 543-547. 4. Tetzlaff JE, Smith ME Experience with specific regional techniques in current American anesthesia residency training. Reg Anesth 1996: 21: $89. 5. Duncan P, Cohen M, Yip R. Is success in anaesthesia practice affecting resident education? Can J Anaesth 1992: 39: A121. 6. Kopacz DJ, Bridenbaugh LD. Are anesthesia residency programs failing regional anesthesia. The past, present and future. Reg Anesth 1993: 18: 84-87. 7. American Medical Association: Program requirements for residency education in anesthesiology, in: Graduate medical education directory 1996. Chicago, American Medical Association, 1996: 34-37. 8. Cahalan MK, Foster E. Training in transesophageal echocardiography: In the lab or on the job? Anesth Analg 1995: 81: 217-218. 9. Sivarajan M, Miller E, Hardy C, Her G, Liu E Willenkin R, Cullen B. Objective evaluation of clinical performance and correlation with knowledge. Anesth Analg 1984: 63: 603-607. 10. Kestin IG. A statistical approach to measuring the competence of anaesthetic trainees at practical procedures. Br J Anaesth 1995: 75: 805-809.
Kopacz
211