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2011; 33: 116–123
A blended approach to invasive bedsideprocedural instruction
JOSHUA LENCHUS, S. BARRY ISSENBERG, DANIEL MURPHY, RUTH EVERETT-THOMAS,LAURA ERBEN, KRISTOPHER ARHEART & DAVID J. BIRNBACH
University of Miami, USA
Abstract
Objective: This study assessed the impact of a blended, standardized curriculum for invasive bedside procedural training on
medical knowledge and technical skills for Internal Medicine residents.
Methods: The investigators developed a curriculum in procedural instruction and performance for Internal Medicine house staff,
and implemented the program at a tertiary care academic medical center with a primary affiliation with a US medical school.
The investigators chose procedures recommended for technical competence by the American Board of Internal Medicine:
lumbar puncture, thoracentesis, paracentesis, central venous catheter insertion, and knee arthrocentesis. The program included:
(1) assessment of baseline medical knowledge and technical proficiency on mannequins, (2) video instruction of procedure,
(3) faculty-led discussion of critical concepts, (4) faculty demonstration of the procedure on mannequin, (5) individual practice
on simulators, (6) post-intervention knowledge evaluation, and (7) post-intervention skills evaluation. The performance achieved
during the initial skills evaluation on a mannequin was compared to the performance achieved on the first patient subsequent
to the instructional portion.
Results: All participants with complete data demonstrated a statistically significant pre-intervention to post-intervention
improvement (p5 0.05) in comprehensive medical knowledge and procedural skills.
Conclusion: A blended, standardized curriculum in invasive bedside procedural instruction can significantly improve
performance in participants’ medical knowledge and technical skills.
Introduction
The landmark Institute of Medicine report, To Err is Human,
raised the awareness and importance of patient safety
(Institute of Medicine 1999). From that point on, medical
errors were no longer considered as rare and benign events, as
we were shown that a large number of patients annually suffer
preventable harm and death. Invasive bedside medical proce-
dures are associated with greater risks for serious errors and
complications, leading to an increase in length of stay and
higher associated health care cost (Reynolds et al. 2006).
Standardized procedural training has the potential to
address the shortcomings of the traditional ‘‘see one, do one,
teach one’’ approach. The apprenticeship model (learners
imitating actions of skilled mentors) is inefficient because
learners are exposed to numerous procedures performed by
few faculty, thus competence is proved with subjective
evaluations (Walter 2006). As most faculty do not undergo
standardized training to teach procedures, learners receive
variable experience in their performance on patients (Boots
et al. 2009). Additionally, all learners do not progress at the
same rate, and their ultimate performance can depend on their
own confidence and competence levels.
In academic medical centers, trainees (taught through
the apprenticeship model) traditionally perform the majority of
bedside procedures. Recently, several Internal Medicine
residency programs have abandoned this approach in favor
of a more structured instructional one (Smith et al. 2004;
Lenhard et al. 2008). One recently published study evaluated
comfort level and self-perceived knowledge improvement
after formal teaching sessions that included didactic lectures,
video instruction, faculty demonstration, and observed prac-
tice (Lenhard et al. 2008). Another group reported instruction
of trainees using procedure-specific, web-based, multimedia
programs. These were reviewed, and an online quiz
completed, prior to performing the procedure on a patient
Practice points
. Standardized procedural training using a blended
approach for instruction has the potential to address
the shortcomings of the traditional apprenticeship
method.
. The use of task trainers in procedural instruction allows
for deliberate practice prior to patient contact.
. Experience with ultrasound improves technical
proficiency.
. Bedside checklists are a proven tool to ensure patient
safe practices.
. Direct supervision, combined with team training,
solidifies the educational experience.
Correspondence: J. Lenchus, University of Miami – Jackson Hospital Center for Patient Safety, 1611 NW 12 Avenue, Institute building, 4th floor,
Miami, FL 33136, USA. Tel: 1 305 585 1454; fax: 1 305 585 1475; email: [email protected]
116 ISSN 0142–159X print/ISSN 1466–187X online/11/020116–8 � 2011 Informa UK Ltd.
DOI: 10.3109/0142159X.2010.509412
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(Smith et al. 2004). These papers contributed to the foundation
of a new paradigm in procedural instruction. Simulation-based
educational initiatives have increased in the recent years.
Indeed, ‘‘the [American Board of Internal Medicine] ABIM
strongly recommends that procedural training be conducted
initially through simulations’’ (ABIM 2009) as it provides a safe
environment for trainees to learn, practice, and hone skills
without patient risk (Ziv et al. 2005). We sought to build upon
the work of these investigators, and others (Wayne et al. 2008),
in crafting a simulation-based, blended curriculum to teach
multiple invasive bedside procedures. This would be accom-
plished by trainees on a dedicated rotation, supervised by a
faculty member. We hypothesized that the implementation
of a standardized curriculum in invasive bedside procedural
training would significantly improve medical knowledge and
technical skills.
Methods
Course content
The course content development team was composed of the
Internal Medicine residency program director, an associate
program director, and the director of the institution’s patient
safety center. The team chose procedures recently recom-
mended for technical competence by the ABIM. These
included: (1) lumbar puncture, (2) thoracentesis, (3) paracent-
esis, (4) central venous catheter insertion, and (5) knee
arthrocentesis.
Course equipment
For this program, we used task trainers (mannequins) for each
procedure. The effectiveness of using such simulation devices
has been previously described (Issenberg et al. 2005; Hutton
et al. 2008). To assist the development team with the selection
of task trainers, feedback was solicited from the electronic
message boards of the Society for Simulation in Healthcare
(http://www.ssih.org/public/) and the Association of Program
Directors in Internal Medicine (http://www.im.org/About/
AllianceSites/APDIM/Pages/Default.aspx), and vendors were
invited for hands-on demonstrations. We obtained two task
trainers for each procedure so that a back-up was available
should technical issues arise. We had an initial budget of
$60,000 (USD) from the patient safety center and the Internal
Medicine residency program. Table 1 lists the task trainer
models purchased and utilized for this project.
Recent papers have demonstrated that ultrasound guidance
during procedures reduces complications and yields higher
technical success rates (McGee & Gould 2003; Nazeer et al.
2005). We also purchased a dedicated ultrasound machine
(GE LogiqE; Milwaukee, WI) for procedural instruction along
with the linear (12L) and curved (4C) probes for vascular
access and paracentesis and thoracentesis procedures,
respectively.
Course faculty
Our objective was to recruit a cadre of faculty from disciplines
that routinely and frequently perform the selected procedures
(e.g., critical care, anesthesiology, emergency medicine, gas-
troenterology, neurology, radiology). We e-mailed faculty
from these disciplines who were previously rated highly for
their ability to teach residents and invited them to participate.
Instructor training
Instructor candidates underwent a three-part process:
(1) participate in a ‘‘show-and-tell’’ session during which the
curriculum was outlined, the evaluation tools were discussed,
and they had the opportunity to practice their technique on the
mannequin, all in an interactive manner; (2) they observed a
teaching session led by the course director; and (3) the course
director observed them leading a session. If a key point was
omitted during the session, the course director interjected.
Constructive verbal feedback provided to instructors was
based on Kolb’s model of experiential learning as faculty were
encouraged to self-reflect on previous experience and current
performance to guide their teaching of procedural skills (Kolb
1984). Thus, we created a multidisciplinary team of instructors
to teach a standardized method of procedural performance
(e.g., neurologists for lumbar puncture, radiologists for
thoracentesis, emergency medicine for central venous catheter
insertion).
Study setting and participants
The study was conducted at an urban, tertiary care academic
medical center with a primary affiliation with a US medical
school. Second- and third-year Internal Medicine residents,
Table 1. List of task trainers (mannequins) purchased per invasive bedside procedure for use at the institution’s patient safety center duringInternal Medicine resident training, July 2007 to June 2009.
Procedure Task trainer (mannequin)
Lumbar puncture Spinal injection simulator, item AB 1030, Armstrong Medical Industries, Inc. (Lincolnshire, IL)
Thoracentesis Ultrasound guided thoracentesis, item BPTT1000-1, Blue PhantomTM (Kirkland, WA)
Paracentesis Thoracentesis and paracentesis, item 1513-36, Sawbones Worldwide, a division of Pacific Research
Laboratories, Inc. (Vashon Island, WA)
Central venous catheter insertion Central venous access hands-on training model, item BPH600f, Blue PhantomTM (Kirkland, WA)
Vascular access training The Blue PhantomTM original two vessel and branched four vessel ultrasound phantom for vascular access, item
BPO100-b and BPBV110, respectively, Blue PhantomTM (Kirkland, WA)
Knee arthrocentesis Large left knee injection model, item 1517-1, Sawbones Worldwide, a division of Pacific Research Laboratories,
Inc. (Vashon Island, WA)
Notes: Specific item numbers and vendor information are included. Current purchase prices can be obtained from the companies’ websites.
Invasive bedside procedural training
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a convenience sample population whose schedule was more
flexible than first-year residents, were eligible and participated
from July 2007 through June 2009. After volunteering, a max-
imum of four residents were assigned to this 4-week elective
rotation. The instructional sessions occurred at the patient
safety center, and they were scheduled in the morning so
that the residents could attend their continuity clinics in the
afternoon.
The project was approved by the institution’s Human
Subjects Research Office (Institutional Review Board).
Participants read and signed a consent form that permitted
us to use their information for quality improvement and
academic purposes, including publication.
Course description
A master resident schedule was created in advance of the
academic year, so that the procedural training course director
was in contact with the chief medical resident to ascertain the
number and names of participants assigned. The curriculum
was divided into specific components and each procedure
encompassed the same items.
(1) Introduction (5 min) – the course director provided
a brief overview of the course; logistics, roles and
responsibilities, and expectations were covered.
(2) Written pre-test (10 min) – participants completed a
baseline medical knowledge assessment in the form of
a written quiz. Questions were a mixture of true/false
and single answer multiple choice. Although the total
number of questions varied by procedure, the maxi-
mum possible score ranged from 10 to 14. Participants
did not receive feedback on their performance.
(3) Skills check (15–20 min, depending on procedure) –
participants reported the number of prior procedures
and this was entered on a log sheet. Those who had
performed the indicated procedures on live patients
prior to their arrival had their technical skills evaluated
by using a procedural checklist (Figure 1). Those
without prior experience in the performance of the
procedure did not undergo the initial skills assessment,
and therefore their data were not included in the final
checklist analysis. Each participant rotated through a
task trainer (mannequin) station specific for that
procedure. He/she was asked to complete the proce-
dure on the model, beginning with reviewing the
patient’s chart through the completion and documen-
tation phase of the procedure. No feedback was
provided during the evaluation. However, immediately
after their attempts, participants reviewed the missed or
incomplete items with the instructor.
(4) Video instruction (8–16 min depending on procedure) –
following the pre-intervention knowledge and skills
assessments, the entire group watched the procedural
videos from The New England Journal of Medicine
website (NEJM 2009) and was encouraged to ask
questions or make comments at the conclusion.
(5) Faculty-led discussions of the key topics (informed
consent, aseptic technique, ‘‘time-out’’ process)
(15 min) – faculty discussed the concept, importance,
and key components of the informed decision-making
process. We created a consent card, a laminated index
card with procedure-specific complications (Figure 2),
that could be used to facilitate the process of commu-
nication with the patient. To achieve uniformity, we
created standardized informed consent forms that list
the procedure, its explanation in layman’s terms, and
some potential complications. Faculty also provided an
overview of aseptic technique with special attention
given to hand washing and donning personal protec-
tive equipment and clothing. Finally, an overview of the
‘‘time out’’ concept, its importance, and relevance to
the performance of invasive bedside procedures was
presented. Specifically, we focused on identification of
the three core aspects: correct patient, correct proce-
dure, and correct site. This process has been well
adopted in the operating room and is gaining accep-
tance on the hospital wards (The Joint Commission on
Accreditation of Healthcare Organizations 2009).
(6) Orientation on ultrasound guidance (30 min) – faculty
instructed the participants on the use of real-time
ultrasound guidance for insertion of central venous
catheters and static ultrasound imaging to facilitate the
performance of paracentesis and thoracentesis.
Trainees practiced their skills on the vascular access
trainer blocks (Table 1).
(7) Faculty demonstration (approximately 30 min depend-
ing on procedure) – in the simulation laboratory, the
instructor performed the procedure, going through
the specific steps on the checklist, emphasizing those
that were missed by trainees. During this session,
the group had the opportunity to interact with the
instructor, ask questions, and receive specific
feedback.
(8) Individual practice (about 15 min depending on proce-
dure) – participants had the opportunity to familiarize
themselves with the equipment and to practice on the
task trainer. They were able to practice repetitively until
they felt comfortable with both the equipment and
procedure.
(9) Procedural documentation (5 min) – participants were
instructed on the importance of obtaining the necessary
information as required by The Joint Commission on
Accreditation of Healthcare Organizations standards,
the federal Conditions of Participation, and other
regulatory agencies. We have created standardized,
fill-in-the-blank, procedure notes (Figure 3) for appro-
priate comprehensive documentation to be completed
by the operator before including in the patients’
medical records.
(10) Post-test (10 min) – participants completed a
written test, identical to the pre-test, to demonstrate
intervention-based improvement of knowledge. This
test was administered immediately after the practice
component, without delay or other outside influence.
Faculty reviewed the answers with the participants in
an interactive manner.
(11) Instructor evaluation (5 min) – learners completed an
anonymous, written, faculty, and course evaluation.
J. Lenchus et al.
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(12) Clinical performance (variable) – subsequent to train-
ing, participants formed the nucleus of a dedicated
procedure service. Here, the participants operated
under the direct supervision of an attending physician;
the checklist used during the simulation-based instruc-
tion was also employed in the clinical area.
Outcome measures
Our tests and checklists were vetted through a multidisciplin-
ary group of faculty experts who provided evidence for their
construct validity. All items were weighted equally, as they
all were considered integral to the successful completion of the
procedure.
Knowledge exam. Each participant completed a pre- and
post-intervention written test to evaluate medical knowledge
base related to each procedure. Questions were comprised
of true–false and single answer multiple choice items, each
of which was equally weighted. The pre-test was accom-
plished without subsequent immediate feedback. After the
CENTRAL VENOUS CATHETERIZATIONTHE 26 STEPS PERFORMANCE CHECKLIST
Name Date
Training program Procedure/site
Training year Attending
Task (Chronological Order)
IncompletelyPerformed
Completely Performed
Notes(Complete if not done at all or
incompletely performed) 1) Review patients’ chart, labs, and imaging (as relevant) 2) Obtain informed consent 3) Position patient 4) Localize/mark needle insertion site – IJ or SC preferred 5) Wash hands 6) Don necessary protective clothing 7) Prepare site using chlorhexidine 8) Drape site using maximal barrier precautions 9) "Time out": verify patient, procedure and insertion site are correct 10) Verify no allergy to anesthetic
Pre
- P
roce
dure
11) Inject anesthetic
12) Insert needle 13) Obtain venous access (perform a. OR b. below)
a. Disconnect the syringe; use the introducer to advance the curved end of the guide wire through the needle
b. Pass the guide wire through the perforated end of the syringe plunger
14) Holding the guide wire, withdraw the needle with or without the syringe 15) Make a small superficial skin incision at the entry of the wire, and pass the dilator(s) over the guide wire 16) Withdraw the dilator(s) and feed the catheter over the guide wire while firmly holding the wire 17) Remove the guide wire 18) Check for blood return in all ports. Flush the ports. Place caps on the hubs.
Pro
cedu
re
19) Secure the catheter in place
20) Clean the area and apply Biopatch® and sterile dressing 21) Throw away sharps 22) Discard protective clothing 23) Wash hands 24) Obtain chest x-ray if IJ or SC site accessed 25) Document procedure
Pos
t -
Pro
cedu
re
26) Aseptic technique maintained
Number of attempts at procedure: _______
Assessment of Performance: Confidence (1: not at all; 3: average; 5: completely) Self-assessment of confidence: _______1 – 5 Faculty assessment of confidence: _______1 – 5
Competence (1: not at all, need several more; 3: average, need 1 – 2 more; 5: no further supervision needed) Self-assessment of competence: _______ 1 – 5 Faculty assessment of competence: _______1 – 5 Adapted from Graham AS, Ozment C, Tegtmeyer K, Lai S, Braner DAV. N Engl J Med 2007;356(21):e21, May 24, 2007.
*Intellectual property of Joshua D. Lenchus, DO, RPh, FACP. Not to be reproduced without permission.
Figure 1. Central venous catheterization performance assessment checklist developed by the institution’s patient safety center.
Invasive bedside procedural training
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instructional intervention, participants completed the post-test
and the answers were reviewed in an interactive manner.
Skills exam. The procedure checklists (Figure 1) were
divided into three sections, (a) pre-procedural – encompassing
11 items, all of which should be completed regardless
of procedure, such as chart review and wash hands, (b) pro-
cedural – a variable number of steps necessary for the
successful completion of the specific procedure, and (c) post-
procedural – a list of 6 items that should be performed at the
completion of every procedure, such as wash hands and
document procedure.
Performance was evaluated and scores were compiled and
used by the research coordinator in comparing participants’
method of procedural accomplishment (based on the appren-
ticeship training before our course) to their performance post-
intervention, on a live patient. Scoring was based on level of
completion. For example, a completely missed item was
assigned 0 points, a partially completed item was assigned
1 point, and a task completely performed, without prompting,
was assigned 2 points. The total number of items varied by
procedure, resulting in a maximum possible score ranging
from 42 to 52 (e.g., 21–26 items).
Study design
This was a case cohort before and after study designed to
evaluate the impact of a simulation-based course to improve
the invasive bedside procedural knowledge and skills of
Internal Medicine residents. Randomization was impractical
due to the large number of residents in our program and the
small number of instructors, equipment, space, and time to
undertake such an effort. Participants served as their own
controls as we compared their prior knowledge base and skill
set to that subsequent to participating in our instructional
course. Each participant completed the written pre-test before
undergoing a hands-on skills assessment. The pre- and post-
test scores were compared, per individual participant, to
ascertain a change in their post-intervention scores. The tests
were administered on the same day, within hours of each
other, depending on the time needed to teach the particular
procedure. Similarly, we compared the checklist score during
the instructional skills check portion (pre-intervention) to the
score achieved during their first procedural attempt on a
patient (post-intervention). The performance of the procedure
in the clinical setting was accomplished within the first week
following the instructional period.
Statistical methods. The data for the pre-tests, post-tests,
and differences (post-test minus pre-test) for the knowledge
tests and the performance checklists are presented as mean
and standard deviation. We used a paired t-test to test the
significance of the difference between post-test and pre-test
scores. Statistical significance was set at a p-value less than
0.05. We used the statistical program of SAS 9.2 (SAS Institute
Inc., Cary, NC) for all computations.
Results
Summary data for the pre-tests, post-tests, and differences in
knowledge tests and performance checklists are presented in
Table 2. The difference between pre-test and post-test scores is
significant for all scores (p5 0.05). The number of participants
who underwent training sessions varied, and there is some
crossover of participants between procedures. That is, trainee
A may have participated in any or all procedures, but only did
so once per procedure. Demographics of the knowledge test
participants are as follows: 33 male, 52 female, 63 PGY2s
(PGY, postgraduate year), and 22 PGY3s. Demographics of the
performance participants are as follows: 29 male, 47 female, 55
PGY2s, and 21 PGY3s.
Discussion
We developed a standardized method of teaching ABIM
recommended invasive bedside procedures. We demonstrated
that a simulation-based invasive bedside procedural curricu-
lum improves immediate medical knowledge base and tech-
nical proficiency. The curriculum not only addresses the ABIM
recommendations to require knowledge surrounding the
performance of these procedures, but also the technical skills.
We capitalized on prior work by using a blended approach
(Gordon et al. 2005) to develop a comprehensive curriculum
Procedure Risks
Arterial line/puncture • Arterial injury • Arterial spasm • Arterial thrombosis • Hand injury
Arthrocentesis
• Bleeding• Damage to tendons, cartilage, or
nerves • Localized trauma • Re-accumulation of fluid
Central line insertion
• Arterial puncture • Cardiac dysrhythmias • Central venous thrombosis • Hematoma • Hemothorax • Pneumothorax
Lumbar puncture
• Bleeding• Damage to nerve or spinal cord • Headache • Herniation • Persistent leakage of CSF
Paracentesis
• Abdominal wall hematoma • Circulatory dysfunction if large
volume withdrawn (>5L) • Hemorrhage • Injury to intra-abdominal organs • Persistent leakage of ascitic fluid
Thoracentesis
• Air embolism • Coughing • Hemothorax • Injury to intra-abdominal organs • Pneumothorax • Post-expansion pulmonary edema if
large volume withdrawn (>1.5L)
In addition to above, all procedures have risks of pain and infection.
Figure 2. Consent card including procedure-specific associ-
ated potential risks as items of discussion during the informed
consent process.
Source: Adapted from NEJM (2009) clinical videos.
J. Lenchus et al.
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of multiple procedures: (a) simulation-based instruction,
(b) the use of a checklist to document performance and
assess competence, (c) instruction and relevant use of ultra-
sound, and (d) direct observation by an attending supervisor
(Barsuk et al. 2009). Subsequent to the training phase,
residents participated on a dedicated team, performing proce-
dures on live patients, under attending supervision. This last
step of the training process allows for deliberate practice,
which involves the provision of immediate feedback, time
for problem solving and evaluation, and opportunities for
repeated performance to refine behavior (Ericsson 2008). The
improvement noted on post-intervention checklist scores on
actual patients supports the translation of simulation-based
teaching into the clinical setting. While the team aspect is not
necessary to implement the instructional component, it pro-
vided an opportunity to evaluate the skills of the resident on
the wards, with the identical checklist used during the training
portion. These elements, taken together, can improve proce-
dural instruction and performance through measurements of
medical knowledge and technical skill. Further, they are
critical components of a procedure-based curriculum.
Limitations
First, this was not a randomized controlled trial as we were
limited by space and resources. Second, we did not have the
participants practice on the simulator until they achieved
objective mastery of the procedure. We did, however, have
them practice until they reported that they were comfortable
with their performance. Thus, while the course facilitated
immediate self-perceived skills acquisition, future study will
include the measure of skill competence on task trainers
Date and Time:
Indication:
Chart Check: Pertinent patient information was reviewed including, but not limited to, indication for the procedure, coagulation profile and prior history of central venous catheter placements. _____ (physician’s initials)
Allergies: Allergies were reviewed prior to the start of the procedure. _____ (physician’s initials)
Time out: Time out was performed at bedside prior to the beginning of the procedure, confirming ID of the patient, procedure to be done, and correct site. _____ (physician’s initials)
Anesthesia:
Primary Team:
Consulting Team (if applicable):
Procedure Description: The need for such procedure was ascertained after checking the chart including, but not limited to, reviewing pertinent labs and radiographic studies.
The risks, benefits, and alternatives of the procedure were discussed in detail with ___________________ and consent was obtained. The consent can be found under the administrative section of the chart.
Potential access sites were/were not examined with ultrasound (u/s) and an acceptable patent and compressible vein was selected. If u/s was used, permanent documentation of the selected site was recorded. After identification, the skin was prepared with ______________________, and draped in a sterile fashion. After the sterile field had been established, the u/s probe was covered with a sterile sleeve, if it was used. Infiltration of the subcutaneous tissues with local anesthesia (above) was then accomplished. Aquasonic gel was applied and real-time u/s was/was not performed, monitoring the advancement of the access needle into the lumen of the ___________________. If u/s was used, this position was also recorded. Once blood was freely aspirated, a flexible guide wire was inserted through the needle and the needle was removed. A small skin incision was made and a dilator was slowly introduced over the guide wire. The dilator was removed and a ______cm ______French ________ lumen catheter was inserted. After it had been inserted, blood was aspirated through each port and flushed clear with normal saline. The catheter was secured with sutures/staples at ______ cm. The insertion site was cleaned and a sterile occlusive dressing was applied. A chest x-ray was/was not ordered.
The patient’s nurse and primary team (if applicable) were notified.
Complications:
Performing physician (sign):
Attending physician (sign):
As the supervising physician, I certify that I was present for the key portion of this procedure.____ (Attending’s initials)
Figure 3. Central venous catheter insertion procedure note created by the institution’s patient safety center for appropriate
documentation to be included in the medical record.
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immediately and longitudinally after training. Finally, we have
piloted this program only at our institution to date, a 1500þ
bed, urban, tertiary care academic medical center, and thus the
results cannot necessarily be generalized to other training
programs. The month-long rotation may not be practical for
community-based teaching facilities, but we believe that the
instructional phase is modular and flexible enough to be
incorporated at any training site.
Conclusion
Standardized curricula that provide guided learning, an avail-
able range of training tools, and opportunities for deliberate
practice and feedback in a protected environment offer
several advantages to the traditional apprenticeship model
that is based on the teaching approach of individual faculty
members. This latter system is problematic as learners
progress at different rates and the number of procedures
accomplished does not guarantee proficiency (Cation &
Durning 2003).
We have created a formal, standardized, simulation-based
procedural curriculum and have piloted it at a large, urban,
tertiary care academic medical center. Our participants dem-
onstrated a statistically significant improvement in their post-
intervention medical knowledge and technical skills. We
believe such a curriculum can serve as a model for others
who wish to provide a successful and uniform procedural
curriculum to their trainees.
Declaration of interest: The authors report no conflicts of
interest. The authors alone are responsible for the content and
writing of this article.
Notes on contributors
JOSHUA D. LENCHUS, DO, RPh, FACP is an associate director, University
of Miami – Jackson Memorial Hospital Center for Patient Safety, and
associate program director, JMH Internal Medicine Residency Program.
S. BARRY ISSENBERG, MD, FACP is an assistant director of the Michael
S. Gordon Center for Research in Medical Education and professor of
medicine and assistant dean, research in medical education, UM Miller
School of Medicine.
DANIEL MURPHY, MD, MBA was a resident in the JMH Internal Medicine
Program.
RUTH EVERETT-THOMAS, RN, MSN is a nurse research coordinator,
UM – JMH Center for Patient Safety.
LAURA ERBEN, MD, MPA was a resident in the JMH Internal Medicine
Program.
KRISTOPHER L. ARHEART, EdD is an associate professor, Department
of Epidemiology and Public Health, UM Miller School of Medicine.
DAVID J. BIRNBACH, MD, MPH is a director of the UM – JMH Center for
Patient Safety, professor of anesthesiology and public health, and associate
dean, patient safety and quality, UM Miller School of Medicine.
References
American Board of Internal Medicine, ABIM. 2009. Internal medicine
policies website. Available from: http://www.abim.org/certification/
policies/imss/im.aspx#procedures. Accessed 2009 May 8.
Tab
le2
.C
om
paris
on
ofp
erf
orm
ance
on
writ
ten
test
sand
checkl
ists
forse
cond
-and
third
-yearIn
tern
alM
ed
icin
ere
sid
ents
perp
roced
ure
as
com
ponents
ofin
vasi
veb
ed
sid
ep
roced
ura
ltra
inin
gatth
ecente
rfo
rp
atie
nt
safe
ty,
July
2007
toJu
ne
2009.
Lum
bar
punctu
reThora
cente
sis
Para
cente
sis
Centr
alve
nous
cath
ete
rin
sert
ion
Knee
art
hro
cente
sis
Know
led
ge
test
(n¼
85)
Perf
orm
ance
checkl
ist
(n¼
56)
Know
led
ge
test
(n¼
78)
Perf
orm
ance
checkl
ist
(n¼
53)
Know
led
ge
test
(n¼
82)
Perf
orm
ance
checkl
ist
(n¼
67)
Know
led
ge
test
(n¼
83)
Perf
orm
ance
checkl
ist
(n¼
74)
Know
led
ge
test
(n¼
77)
Maxi
mum
score
11
52
13
50
14
48
10
52
10
Pre
-test
5.8
6�
1.6
140.5
4�
6.6
19.6
3�
1.6
438.6
2�
8.3
49.7
2�
2.0
036.7
2�
6.2
96.4
0�
1.8
545.5
5�
5.6
97.3
5�
1.1
7
Post
-test
9.1
6�
1.2
448.5
0�
2.0
912.0
4�
0.9
548.8
3�
3.6
112.6
2�
1.1
745.4
8�
1.1
58.5
9�
1.1
551.1
5�
1.6
69.1
3�
1.0
0
Diff
ere
nce
3.3
1�
1.6
57.9
6�
6.4
42.4
1�
1.6
010.2
1�
9.3
92.9
0�
1.9
78.7
6�
6.1
92.1
8�
1.7
25.5
9�
5.8
31.7
8�
1.3
1
Note
s:M
ean�
stand
ard
devi
atio
n.
Diff
ere
nce
isp
ost
-test
–pre
-test
.A
lld
iffere
nces
are
signifi
cant
(p5
0.0
5).
J. Lenchus et al.
122
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y C
ase
Wes
tern
Res
erve
Uni
vers
ity o
n 10
/30/
14Fo
r pe
rson
al u
se o
nly.
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learning of temporary hemodialysis catheter insertion by nephrology
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Boots RJ, Egerton W, McKeering H, Winter H. 2009. They just don’t get
enough! Variable intern experience in bedside procedural skills. Intern
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Cation LJ, Durning SJ. 2003. Procedure skill competence and certification
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Lenhard A, Moallem M, Marrie RA, Becker J, Garland A. 2008.
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New England Journal of Medicine, NEJM 2009. Videos in clinical medicine
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Reynolds MR, Cohen DJ, Kugelmass AD, Brown PP, Becker ER, Culler SD,
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Smith CC, Gordon CE, Feller-Kopman D, Huang G, Weingart SN, Davis RB,
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Wayne DB, Barsuk JH, O’Leary KJ, Fudala MJ, McGaghie WC. 2008.
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Invasive bedside procedural training
123
Med
Tea
ch D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y C
ase
Wes
tern
Res
erve
Uni
vers
ity o
n 10
/30/
14Fo
r pe
rson
al u
se o
nly.
