For decades the mantra for procedural education in medicine has been “see one-do one-teach one”. Those of us who learned bedside procedures and point-of-care ultrasound by this model understand that this approach does not optimize safe and competent performance. At Hospital Procedures Consultants, we have been teaching bedside procedures and point-of-care ultrasound (POCUS) for over a decade using simulation-based training and live ultrasound models. Here, I will review recent evidence supporting this approach to procedural education over more traditional methodologies, and build the case that no one’s first POCUS exam or bedside procedure should be on a live patient.
POCUS has long been taught at the bedside. Given that this is a noninvasive procedure, an argument could be made that this is an adequate methodology for ultrasound training. However, there is a growing body of literature arguing for a more structured approach to POCUS education. In 2015, Beaulieu et al. published an article in the Critical Ultrasound Journal in which they compared training for senior residents using traditional methods to training for junior residents using web-based e-learning followed by hands-on training. These authors found that junior resident outperformed their senior counterparts on practical tests for both vascular access (94% vs 68%) and even more for pleural assessment (92% vs 9%)1 In 2016, Amini et al. published in Advances in Medical Education and Practices looking at the efficacy of a multimodal teaching strategy that included asynchronous learning, a didactic lecture, case based learning and hands-on stations for emergency medicine residents. This group was able to demonstrate a marked improvement in hands on skills as well as improvement on diagnostic and management surveys conducted during PGY1-PGY3. 2 More recently, Casey et al. evaluated the efficacy of a combined didactic and hands-on approach to teach Extended Focused Sonography in Trauma (E-FAST) to NP and PA students. POCUS training is not commonly integrated into NP/PA curricula. The authors found that all students had marked improvement on a five-point Likert scale self-confidence, knowledge, efficacy, probe choice, probe orientation, depth and gain. 3
The support for simulation-based training for invasive bedside procedures is even stronger. In 2012, Barsuk et al. used a paracentesis simulator to train medicine residents during a three-hour session. Pretest score average was 33% and posttest score average was 92.7% with all residents achieving a minimum passing score on posttest. 4 In 2021, Hale et al demonstrated that simulation-based mastery learning increased hospitalist minimum passing scores on paracentesis and lumbar puncture checklists form 16% (LP) and 32% (para) to 100% of participants with a passing score on both procedures. 5 This study demonstrated that some hospitalists may be performing these procedures without the ability to demonstrate adequate skills and that simulation-based training can remedy this problem with 100% efficacy. There have also been studies examining complication rates between different proceduralists who underwent different approaches to training. In 2018, Barsuk et al. compared complications rates in patients in whom thoracentesis was performed by medicine residents trained by simulation-based mastery learning, residents traditionally trained and attending pulmonary medicine or IR physicians. Patients who had thoracentesis performed by residents trained in simulation-based mastery learning had fewer clinically meaningful iatrogenic pneumomothoraces and hemothoraces when compared to patients treated by traditionally trained residents AND those referred to pulmonary or IR for the procedure (p=0.008). 6
At Hospital Procedures Consultants, we are committed to teaching our students how to perform POCUS and invasive bedside procedures using the safest and most effective methods available. Didactic learning is important. We offer over 19 online modules where clinicians can review indications, contraindications, techniques and complications from the comfort of their own home or during a slow shift at work. Our live courses are designed for simulation-based mastery. Simulators have evolved tremendously over the last few decades. In the early days we found ourselves choosing between a poor representation of the human body or an animal model with associated ethical and hygienic concerns. Former students who report back to us now, often comment on how close the feel of the simulators is to that of human tissue. For POCUS training, there is great value in scanning live models to learn about probe position and handling, settings and how the probe interacts with the human body. In addition to this training, we now use an ultrasound simulator, Heart Works, that allows students to learn probe position and view optimization while also changing the “patient’s” cardiac pathology with the click of a mouse. See one-do one-teach one method is outdated and dangerous. As technology evolves, and the evidence for new technology grows, we must continue to rethink the way we train and retrain ourselves to perform the dangerous work of our profession.
REFERENCES
- Beaulieu et al. Bedside ultrasound training using web-based e-learning and simulation early in the curriculum of residents. Critical Ultrasound Journal (2015) 7:1
- Amini et al. Point-of-care echocardiography in simulation based education and assessment. Advances in Medical Education and Practices. 2016:7 325-328.
- Casey et al. Evaluating knowledge, confidence and self-efficacy of NPs and PAs in the emergency department: extended-focused assessment using sonography in trauma. Journal of American Association of Nurse Practitioners. July 2022. Vol 34. No 7.
- Barsuk et al. Simulation-based education with mastery learning improves paracentesis skills. Journal of Graduate Medical Education. Mar;4(1):23-7.
- Hale et al. Cohort study of hospitalists’ procedural skills: baseline competence and durability after simulation-based training. 2021;11: e 045600.
- Barsuk et al. Simulation-based mastery learning for thoracentesis skills improves patient outcomes: a randomized trial. Academic Medicine. Vol 93. No 5. May 2018.