Procedural Training in Pediatric Hospital Medicine: One Size Fits None

What procedural skills do pediatric hospitalists perform, and do they feel competent performing them? These are the questions posed by Kuchipudi et al in this issue of Hospital Pediatrics.¹  Specifically, they surveyed hospitalists practicing in diverse settings about the number of times in the last year they performed the 11 minor procedures recommended by the American Board of Pediatrics (ABP) and their self-assessed competence in those skills. Not surprisingly, they found hospitalists who performed a given procedure more frequently also had higher self-assessed competence. Although most hospitalists had performed bag-valve-mask (BVM) ventilation and lumbar puncture (LP), more than one-half of respondents never performed any of the 9 remaining procedures on their list. This highlights the significant variability in procedures performed by hospitalists and a possible misalignment between the recommended procedure list and the actual scope of practice.

Part of this disconnect is likely due to the fact that the majority of the 2 million pediatric hospitalizations in the United States are dispersed across >3000 general hospitals with great heterogeneity in patient populations, as well as resources and support services. Hospitalists participating in this study had responsibilities in ICUs, emergency departments, and newborn nurseries, which, presumably, would impact their procedural scope of practice. Of note, most respondents had not completed pediatric hospital medicine fellowship training. On the other hand, 78% of pediatric fellowship-trained hospitalists go on to practice at university or children’s hospital sites,²  in which many of the recommended minor procedures are routinely performed by nursing, respiratory therapy, vascular access teams, phlebotomy, or pediatric emergency medicine physicians. It has been suggested that procedural training during residency and fellowship should take into account the trainee’s future practice site and anticipated procedural skills needed, but challenges remain.

It is interesting to note that pediatricians were once expected to be able to perform a wide variety of procedures. More than 40 years ago, the ABP established requirements for general pediatric training programs to verify that graduates could perform technical diagnostic and therapeutic procedures. Although the ABP provided a list of 101 technical procedures, they did not state which skills were required and left it to the discretion of training programs. The list of procedures included skills such as ventilator operation, intracardiac injections, paracentesis, and external cardiac massage.³  Then, 20 years ago, the Accreditation Council on Graduate Medical Education (ACGME) introduced requirements for competence for pediatric residents in 13 procedures that remain in effect today. However, the specific methods for the assessment of competency are left up to individual residency programs. Pediatric residents in different programs undoubtedly have varied opportunities to gain supervised procedural experience based on the types of patients seen, competition with other trainees, and the presence of specialized procedural teams, such as vascular access teams and interventional radiologists. If evolving ACGME requirements eliminate some of the procedures currently required in pediatric residency training, this will further impact graduates’ preparedness for jobs that require competency in these procedures.

Another key challenge in procedural training is that a clear definition of “procedural competency” does not exist. Currently, most programs use procedural logs, which serve as an indirect measure of competence.⁴  Rather unsurprisingly, practicing pediatricians report that they did not achieve procedural competence during training for the majority of those 13 procedures.⁵  To ensure competence in a training setting with unpredictable opportunities for performing procedures, some have suggested that teaching to competence should be done through a pedagogical framework such as mastery learning models, which incorporate deliberate practice⁶  in which skills are performed under the direct observation of an instructor with immediate formative feedback until they have achieved a level of performance expected of a master. This is in contrast to the common “see one, do one” model, which only requires the demonstration of rudimentary skills. Studying the outcomes of this time-intensive and deliberate approach may be helpful in developing effective procedural training curricula for pediatric residents. In a recent study among practicing adult hospitalists, most were deemed not competent to perform an LP. After a simulation-based mastery training program, all were deemed competent; unfortunately, 7 months later, only 40% were deemed competent, suggesting that those skills decay quickly.⁷  There is evidence for low-dose, high-frequency cardiac resuscitation training in maintaining and improving competence in the psychomotor skills associated with cardiopulmonary resuscitation,⁸  an approach which may be considered for maintaining competency in low-frequency procedures that a practicing hospitalist is expected to perform at their institution.

Fellowship training is one way for residency graduates to increase their procedural skills. In a survey of recent pediatric emergency medicine fellowship graduates, intubation and intraosseous placement were among those they rated as “comfortable,”⁹  and learning which strategies impact comfort and competence may be vital to planning for effective procedural skill training during a pediatric hospital medicine (PHM) fellowship. In their PHM fellowship requirements, the ACGME states “Fellows must demonstrate the necessary procedural skills, and develop an understanding of the indications, risks, and limitations, including, but not limited to…” followed by a list of 11 procedures of which 5 (BVM, bladder catheterization, LP, intubation, and peripheral intravenous catheter placement) are currently required during residency training. Trainees completing a PHM fellowship will have opportunities to continue to develop the procedural skills they gained during residency training. However, their post-residency procedural competency could change as opportunities for some procedures decrease¹⁰  and residency requirements evolve. This may not only impact the scope of fellowship procedural training needs but also poses a challenge for residency graduates pursuing PHM without fellowship training. Yet, many PHM fellowship programs are based in tertiary care centers in which many of the recommended procedures are routinely performed by nursing, respiratory therapy, vascular access teams, phlebotomy, or pediatric emergency medicine physicians, and therefore, time dedicated to working with these other care team members may be the only way for PHM fellows to gain additional experience.

Given that the ACGME only requires 24 months of PHM fellowship training, which is shorter than all other ABP-accredited fellowships, the need to allocate that time wisely is paramount. How should pediatric procedures be prioritized? It seems like a leap of faith to solely base the prioritization of procedural training on each individual trainee’s anticipated future career plans because these plans are likely to change over time. Prioritizing the most frequently performed procedures in pediatric hospital medicine and those with the greatest life-saving potential may be a good initial strategy. BVM ventilation seems like an easy choice because it is both frequently performed and potentially lifesaving, but further prioritization of the other minor procedures may be more challenging. Even when procedural training is implemented in training programs, questions remain on how program directors or hospitalist leaders should define or determine competence, and further study is needed in this area.

Even if PHM training programs guarantee procedural competence in the 11 required procedures and residency programs confirm the procedural competence of graduates entering PHM directly, the maintenance of competence requires a certain frequency of performing procedures post-training. Simulation training is likely to be effective if the opportunity for procedures is limited in the clinical setting; however, it is likely to require repeat exposures to maintain competence. Might individual hospitals be tasked with some post-fellowship training responsibilities relevant to the clinical needs of their setting? In some instances, hospitals may have access to simulation or use an apprenticeship model to ensure the procedural competence of new staff. However, if these resources are not available locally, partnerships between academic training programs and hospitals in their vicinity could be leveraged to support training and maintenance of procedural skill competence.

PHM is still a young discipline faced with unique challenges, and procedural competence requires training and ongoing practice. Which procedures are prioritized might be subject to change as program requirements and the clinical practice of pediatric hospitalists evolve. Our PHM community has a vested interest in the procedural training of residents, PHM fellows, and practicing hospitalists, ensuring that the right people are trained in the right procedures at the right time.