Counterbalancing clinical supervision and independent practice: case studies in learning thoracic epidural catheter insertion

Johnson, Timmi

doi:10.1093/bja/aeq233

Cited by 6 publications

(6 citation statements)

References 16 publications

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“…29,30 In the thoracic spine (above T11), the caudal angulation of spinous processes explains failure with the traditional midline approach. 1,29 Furthermore, the interlaminar spaces of the midthoracic region are notoriously narrow and partially covered by the slanted spinous processes originating from the upper vertebra.…”

Section: Nonspecific Nature Of Lor Techniquementioning

confidence: 99%

“…Unfortunately, in recent years, opportunities to practice and learn TEA seem to be decreasing. 30 Complex reasons include perceived risks associated with the latter, subjective technical end point, inexperienced supervisor, decreased caseload, and reliance on alternate blocks. Some anesthesiologists may avoid TEA because of the pervasive myth that thoracic epidural blocks lead to an increased incidence of complications.…”

Section: Are We Failing Our Trainees?mentioning

confidence: 99%

“…Thus, anesthesiologists may hesitate to teach thoracic epidural blocks, as resident failure can escape immediate detection (and correction). 30 The supervisor's inexperience further complexifies the issue. 30 In a 2010 qualitative study, Johnson 30 surveyed 10 consultant anesthesiologists and found that some still felt the need for continued practice with TEA, thus creating direct competition with the trainees they were supervising.…”

Section: Are We Failing Our Trainees?mentioning

confidence: 99%

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Primary Failure of Thoracic Epidural Analgesia in Training Centers

Tran

Zundert

Aliste

et al. 2016

Regional Anesthesia and Pain Medicine

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In teaching centers, primary failure of thoracic epidural analgesia can be due to multiple etiologies. In addition to the difficult anatomy of the thoracic spine, the conventional end point-loss-of-resistance-lacks specificity. Furthermore, insufficient training compounds the problem: learning curves are nonexistent, pedagogical requirements are often inadequate, supervisors may be inexperienced, and exposure during residency is decreasing. Any viable solution needs to be multifaceted. Learning curves should be explored to determine the minimal number of blocks required for proficiency. The problem of decreasing caseload can be tackled with epidural simulators to supplement in vivo learning. From a technical standpoint, fluoroscopy and ultrasonography could be used to navigate the complex anatomy of the thoracic spine. Finally, correct identification of the thoracic epidural space should be confirmed with objective, real-time modalities such as neurostimulation and waveform analysis.

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Section: Nonspecific Nature Of Lor Techniquementioning

confidence: 99%

Section: Are We Failing Our Trainees?mentioning

confidence: 99%

Section: Are We Failing Our Trainees?mentioning

confidence: 99%

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Primary Failure of Thoracic Epidural Analgesia in Training Centers

Tran

Zundert

Aliste

et al. 2016

Regional Anesthesia and Pain Medicine

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“…16,33,34 Despite patient safety concerns of housestaff independence, there are data to suggest that autonomous decisions made by housestaff during the learning process do not have a negative impact on patient care. 23,35,36 Moving forward, it is imperative for attending physicians to promote autonomous decisions by housestaff, with proper support and supervision.…”

Section: Discussionmentioning

confidence: 99%

Perceptions of 24/7 In-Hospital Intensivist Coverage on Pediatric Housestaff Education

et al. 2014

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WHAT'S KNOWN ON THIS SUBJECT: Increasing numbers of hospitals are instituting 24/7 in-hospital pediatric intensivist coverage. Data regarding patient outcomes are mixed and the impact on housestaff education remains unknown. WHAT THIS STUDY ADDS:This study quantifies the perceived impact of in-hospital attending coverage on pediatric resident and critical care fellow education and also investigates the growing concern that increasing supervision may contribute to housestaff being less well prepared for independent clinical practice. abstract BACKGROUND: In recent years, the focus on patient safety and housestaff supervision has led to a steady increase in institutions providing 24/7 in-hospital (also known as in-house, henceforth referred to as IH) coverage by pediatric intensivists. Effects of this increased attending physician presence on education of pediatric housestaff have not been studied. We hypothesized that IH coverage would decrease perceived autonomy of housestaff and negatively affect their preparedness to be independent attending physicians on completion of training. METHODS:A secure, anonymous, Web-based survey was sent to pediatric intensivists in the United States and Canada, and pediatric critical care fellows and pediatric residents at academic centers across the United States. Questions focused on perceptions of IH coverage and housestaff educational experience. RESULTS:We report 1323 responses from 147 institutions (center response rate 74%). Although 96% of respondents stated that the PICU provides "a good educational experience," only 50% of pediatric intensivists and 67% of housestaff feel that housestaff are prepared for independent practice after training in an IH model. Compared with those training in home-call models, respondents currently working in IH models have more favorable perceptions of the effects of IH coverage on housestaff autonomy (P , .0001), supervision (P , .0001), and preparation for independent practice (P , .0001).CONCLUSIONS: Pediatric intensivists and housestaff express concern regarding the preparation of housestaff training in a 24/7 IH attending model. An important priority for institutions using or considering a 24/7 IH attending coverage model is the balance between adequate housestaff supervision and autonomy. Dr Rehder conceptualized and designed the study, supervised data collection, completed data analysis, and drafted the initial manuscript; Dr Cheifetz conceptualized and designed the study and critically reviewed the manuscript; Dr Willson assisted with study design and critically reviewed the manuscript; Dr Turner assisted with conceptualization and study design, participated in data analysis, and critically reviewed and revised the manuscript; and all authors approved the final manuscript as submitted.www.pediatrics.org/cgi/doi/10.1542/peds. 2013-1990 doi:10.1542/peds.2013-1990 Accepted for publication Sep 19, 2013 In academic medical centers, increasing emphasis is being placed on housestaff supervision and attending physician presence. [1][...

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“…How much of this practice should be supervised directly, and how much should be carried out independently are important questions. While close supervision may offer opportunities for bedside teaching and possibly improved block success and safety, it can limit independence and negatively impact confidence and proficiency when fellows transition to autonomous practice 17,18. In a series of studies examining motor learning, individuals who were given feedback after every trial of performing simple tasks learned faster than individuals who were given summary feedback after a series of trials 19–21.…”

Section: Discussionmentioning

confidence: 99%

Survey of international regional anesthesia fellowship directors

Lansdown

McHardy

Patel³

et al. 2013

LRA

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BackgroundThe scope of regional anesthesia fellowship programs has not been analyzed but may provide insights that could improve fellowship training and standards.MethodsRegional anesthesia fellowship directors across the world were asked to complete a comprehensive survey that detailed the range of educational and practical experience and attitudes as well as assessment procedures offered in their programs.ResultsThe survey response rate was 66% (45/68). Overall, the range of activities and the time and resources committed to education during fellowships is encouraging. A wide range of nerve block experience is reported with most programs also offering acute pain management, research, and teaching opportunities. Only two-thirds of fellowships provide formal feedback. This feedback is typically a formative assessment.ConclusionThis is the first survey of regional anesthesia fellowship directors, and it illustrates the international scope and continuing expansion of education and training in the field. The results should be of interest to program directors seeking to benchmark and improve their educational programs and to faculty involved in further curriculum development.

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Counterbalancing clinical supervision and independent practice: case studies in learning thoracic epidural catheter insertion

Abstract: There are many obstacles to trainees' participation in thoracic epidural catheter insertion, and learning assistance is not matched to need. A more explicit understanding of stages of learning is required to benefit the learning of this and other advanced clinical skills.

Cited by 6 publications

References 16 publications

Primary Failure of Thoracic Epidural Analgesia in Training Centers

Primary Failure of Thoracic Epidural Analgesia in Training Centers

Perceptions of 24/7 In-Hospital Intensivist Coverage on Pediatric Housestaff Education

Survey of international regional anesthesia fellowship directors

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