The effect of simulation‐based mastery learning on thoracentesis referral patterns

Abstract

Internal medicine (IM) residents and hospitalist physicians commonly perform thoracenteses. National data show that thoracenteses are also frequently referred to other services such as interventional radiology (IR), increasing healthcare costs. Simulation-based mastery learning (SBML) is an effective method to boost physicians' procedural skills and self-confidence. This study aimed to (1) assess the effect of SBML on IM residents' simulated thoracentesis skills and (2) compare thoracentesis referral patterns, selfconfidence, and reasons for referral between traditionally trained residents (non-SBML-trained), SBML-trained residents, and hospitalist physicians. A random sample of 112 IM residents at an academic medical center completed thoracentesis SBML from December 2012 to May 2015. We surveyed physicians caring for hospitalized patients with thoracenteses during the same time period and compared referral patterns, self-confidence, and reasons for referral. SBML-trained resident thoracentesis skills improved from a median of 57.6% (interquartile range [IQR] 43.3-76.9) at pretest to 96.2% (IQR 96.2-100.0) at post-test (P < 0.001). Surveys demonstrated that traditionally trained residents were more likely to refer to IR and cited lower confidence as reasons. SBML-trained residents were more likely to perform bedside thoracenteses. Hospitalist physicians were most likely to refer to pulmonary medicine and cited lack of time to perform the procedure as the main reason. SBMLtrained residents were most confident about their thoracentesis skills, despite hospitalist physicians having more experience. This study identifies confidence and time as reasons physicians refer thoracenteses rather than perform them at the bedside. Thoracentesis SBML boosts skills and promotes bedside procedures that are safe and less expensive than referrals. Internal medicine (IM) residents and hospitalist physicians commonly conduct bedside thoracenteses for both diagnostic and therapeutic purposes. 1 The American Board of Internal Medicine only requires that certification candidates understand the indications, complications, and management of thoracenteses. 2 A disconnect between clinical practice patterns and board requirements may increase patient risk because poorly trained physicians are more likely to cause complications. 3 National practice patterns show that many thoracenteses are referred to interventional radiology (IR). 4 However, research links performance of bedside procedures to reduced hospital length of stay and lower costs, without increasing risk of complications. 1,5,6 Simulation-based education offers a controlled environment where trainees improve procedural knowledge and skills without patient harm. 7 Simulationbased mastery learning (SBML) is a rigorous form of competency-based education that improves clinical skills and reduces iatrogenic complications and healthcare costs. 5,6,8 SBML also is an effective method to boost thoracentesis skills among IM residents. 9 However, there are no data to show that thoracentesi...

Residents' Procedural Experience Does Not Ensure Competence: A Research Synthesis

“…We performed a research synthesis of 7 studies performed by Northwestern University investigators, allowing us access to all data. [11][12][13][14][15]17,23 The Northwestern University Institutional Review Board approved all 7 studies. TABLE 1 summarizes the 7 studies.…”

“…These data included simulated procedures from multiple cohorts of internal medicine, emergency medicine, anesthesiology, and neurology resident physicians who performed central venous catheter (CVC) insertion, lumbar puncture (LP), paracentesis, and thoracentesis procedures. [11][12][13][14][15]17,23 Resident physicians from 4 academic tertiary medical centers and 1 academic community hospital in Chicago performed these procedures. We compared objective evaluations of residents' baseline simulated performance (before any educational intervention) measured by residents' ability to achieve the MPS (competency standard) to self-reported experience (number of procedures performed) and postgraduate year (PGY) of training.…”

Development of an intelligent surgical training system for Thoracentesis

“…The survey highlights junior doctors' deficiency in knowledge and cognitive procedural skills in performing Thoracentesis. Simulation-based training [14] and phantom model-based training [15] on Thoracentesis has found enhancing skills of the surgeons; however, the training systems were more focused on manual dexterity and lacked the aspects of context-awareness, intra-operative real-time guidance. Thus, there is indeed a need to create an intelligent training system.…”

Can lessons from systems‐based mastery learning for thoracentesis be translated to hospitalists?

“…7 They studied how their program influenced simulated skills, procedural self-confidence, frequency of real-world performance, and rate and reasons for referral to consultants. The authors compared the latter outcomes to traditionally trained residents and hospitalists, finding that SBML improved skills, self-confidence, and the relative frequency of general internist-performed procedures.…”

“…In this issue of the Journal of Hospital Medicine, Barsuk and colleagues present a prospective, singlecenter study assessing the impact of simulation-based mastery learning (SBML) on thoracentesis among a randomly selected group of IM residents. 7 They studied how their program influenced simulated skills, procedural self-confidence, frequency of real-world performance, and rate and reasons for referral to consultants. The authors compared the latter outcomes to traditionally trained residents and hospitalists, finding that SBML improved skills, self-confidence, and the relative frequency of general internist-performed procedures.…”