New Residents and
Procedures: A Tempest in a Teapot?
Michael S. Axley, M.D., Junior
Co-editor
“Residents’ Review”.
rocedures are one of the things that make anesthesiology
as a field so special — and they are an aspect
of our specialty that can be a barrier to success,
particularly early on.
Literature addresses proficiency in anesthesia procedures
as well as the use of simulators and so on. I would
like to approach the matter from the perspective of
a CA-1 resident with roughly six months’ training
in anesthesiology.
During the first few months of our training, other
first-year residents and I felt no small amount of
anxiety surrounding even common procedures —
I.V.s, arterial catheters, central lines — let
alone more complex undertakings such are epidurals
or regional blockade.
This happened despite heroic efforts by our residency
director and our chief resident to ease the strain.
Our chief resident was probably to the point where
his wife could hear him mumble in his sleep: “It’s
O.K., don’t worry about it — you’re
going to do plenty of those. It just takes time.”
Our director repeated a similar mantra: “I don’t
know of any resident who has failed to become a proficient
anesthesiologist due to a lack of ability to perform
procedures.”
And yet, it was not all that comforting. A little,
maybe, but I continued to miss lines. Why? Maybe because
I had not done enough of them. Most of us have heard
that it takes between 50 and 100 procedures of any
one type to develop proficiency. One could posit that
my anxiety regarding procedures was due to the fact
that I had not yet ascended that part of the curve
where things start to fall into place. Since this
line of thinking deals with acquiring numbers, we
might call it the “volume” hypothesis.
Enough procedures will, in the end, generate proficiency.
But there may be a few things missing from this construct.
A recent grand rounds at our institution focused on
issues surrounding the education of anesthesiology
residents. The speaker, Karen J. Souter, M.B., suggested
that research has identified different types of learners
and that some types of learning may be better suited
to anesthesiology than others.
For example she cited studies that defined differences
between surface learning, or memorization to obtain
rote knowledge, and the complex ability to respond
to changing circumstances that is obtained by thinking
through a particular objective in all of its permutations,
preferably prior to an event. Another type of thinking
was what she termed “strategic” —
cram before the test, but compare and contrast multiple
sources when there is less in the way of time pressure.
The point was it would seem that good anesthesiologists
are going to demonstrate the latter two types of thinking.
Furthermore it might be possible to usher residents
out of one type of thinking style and into another
more complex style, partly by teaching them about
it.
What better way to get residents to concentrate more
on effective thinking strategies than to apply those
same strategies to our favorite activity?
Perhaps the way education takes place around procedures
can be considered a surrogate for other types of education
for the professionalism and attention to detail that
we as residents very much want to acquire and that
our staff is eager to instill.
So why not organize training for procedures early
on? It is certainly reasonable to suggest that exposure
to sheer volume is going to ultimately result in competent
consultants. I would suggest that if we look at the
procedures in their context, that is, as an integral
component of a balanced anesthetic, we would like
to have residents experience them with the same rigor
and intellectual attention to performance that they
bring, for example, to the preoperative interview.
The difference here is that the preoperative interview,
or H&P, has been coached, in an organized fashion,
since the second year of medical school.
Am I suggesting that chairs and residency program
directors should make room in their budgets for resident
workshops dedicated to professionalism with regard
to the different regional and anesthetic procedures?
Why not? And there are side benefits as well.
For instance if surgeons clearly understand that we
place real value on the systematic education of residents
in the correct and timely procedures necessary to
perform the appropriate anesthetic, perhaps they will
be less inclined to agitate for changes that distance
residents from those procedures.
I guess this could be considered a tempest in a teapot.
I would submit, though, that the first year of anesthesiology
training is quite a tempest, and there is no need
for first-year residents to be grasping at their lines
when the boat needs someone at the helm.
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Michael
S. Axley, M.D., is a CA-1 resident at Oregon
Health and Science University, Portland, Oregon.
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