Procedural skills and experience are poor
Whilst most of the CC and EM residents had performed procedures, alarmingly, five PGY3 (20%) IM residents and three PGY4 (17.6%) IM residents had not performed any procedures whatsoever (Additional file 2: Appendix 2: Table 8). Of the senior IM residents, only one PGY3 and three PGY4 IM residents had performed thoracentesis; a core skill for internists. As the IM and EM residents were surveyed towards the end of the academic year, the PGY4 residents had almost completed their residency training. Our observations are, therefore, representative of fellows’ technical skills at the start of their fellowships.
In 2018, Watson and colleagues [12] reported that 91, 84, and 86% of Canadian IM trainees had performed ultrasound-guided paracentesis, thoracentesis, and CVC, respectively. In the present study, significantly fewer Saudi IM residents had performed these procedures under ultrasound guidance (paracentesis 12%, thoracentesis 5%, CVC 37%; P < 0.00001). Even if all procedures performed with and without ultrasound guidance are included; fewer of our IM residents had performed procedures (paracentesis 62%, thoracentesis 12%, CVC 44%; P < 0.00001).
International guidelines consistently recommend the performance of procedures under ultrasound guidance. Thus, this paucity of procedural skills is likely to be a global phenomenon affecting all centres where physicians are not trained in procedural ultrasound. The skill gaps should be considered to determine whether the finite resources available for medical education should be used to rectify this.
Skill gaps and missed opportunities for procedural skills training
Unless a physician is proficient in the generic sterile technique required to perform ultrasound-guided procedures, they cannot perform any ultrasound-guided procedure safely. Thus, the nursing staff at our institution are empowered to stop a physician performing a procedure if sterility is compromised.
The sample’s self-reported proficiency in this skill suggests the presence of a large procedural skill gap in the IM residency training programme, but its absence in CC and EM. This is probably because all CC residents and most EM residents had received postgraduate training in ultrasound-guided procedures, whilst very few internists had been trained.
The performance of ultrasound-guided procedures by IM residents without any formal postgraduate training raises governance issues and patient safety concerns. These issues must be addressed by a training programme and formal processes for supervision, governance and accreditation.
Experience in procedures with and without ultrasound
Tables 4, 5, 6 show the sample’s self-reported procedural experience. All CC residents and most EM residents (n = 28) had performed ultrasound-guided procedures. Ultrasound-guided procedures are safer than landmark techniques [8,9,10,11]. However, significantly more IM residents (n = 66) had performed procedures without ultrasound guidance than with it (n = 44) and none are accredited in POCUS. In contrast, significantly fewer CC (n = 10) and EM (n = 18) residents had performed procedures using landmark techniques.
This observation suggests that training in ultrasound-guided procedures decreases the use of landmark techniques. So, instructing residents in the use of procedural ultrasound may increase patient safety. Furthermore, whilst almost all of the CC and EM residents had performed procedures, nearly 25% of IM residents had not performed any procedures. So, training in ultrasound guidance may increase the bedside performance of procedures.
Volume of procedural experience and the experience gap
At our institution, procedural competence is not solely defined by successful performance of a minimum number of procedures under supervision. It must be determined through simulation, direct observation, and other relevant criteria outlined by the curriculum of each specialty and the residency programme directors. However, many North American residency programmes still use the historical threshold of 5 procedures to define competency [25].
Although this threshold is not used to define competence at our institution, we do believe that it provides a useful marker of residents’ exposure to procedural skills (i.e. volume of experience). As mastery of any skill requires experience, the threshold of five procedures can be used to define an experience gap.
All CC residents and most EM residents had performed over five ultrasound-guided CVC (Table 5). That only two IM residents had achieved this suggests the presence of a large experience gap in the IM residency programme in this skill. Furthermore, few residents, in any specialty, had performed over five drainage procedures with or without ultrasound (Tables 5 and 6). These observations provide evidence of large experience gaps in the performance of drainage procedures within all three residency programmes.
Our data demonstrate that training in ultrasound-guided procedures in Saudi Arabia has been variable. Whilst the residents are interested in learning this skill, IM has clearly lagged behind CC and EM. To advance, the physicians, medical educators and the regulatory bodies for medical education must fully commit to training in ultrasound-guided procedures. All stakeholders must be engaged for this endeavour to be successful. To unambiguously signal the importance of competencies in ultrasound-guided procedures, it is important that the relevant regulatory bodies make an executive decision to incorporate this into undergraduate training and reinforce its importance during postgraduate training.
Our data demonstrate that untrained residents are performing procedures with and without ultrasound guidance. Learners may erroneously believe that studies describing better outcomes with ultrasound guidance in the hands of trained operators are applicable to untrained learners [26]. However, as these skills are operator dependent [17, 18, 26], inadequate training in procedural ultrasound may increase complications [17, 18, 26].
So, healthcare systems cannot ignore the potential dangers from untrained users [18, 26]. Thus, to improve patient outcomes, there is an urgent need for qualified educators to develop a curriculum and provide appropriate training in ultrasound-guided procedures.
Development of a curriculum and training programme for ultrasound-guided procedures
Ideally, the curriculum should include mandatory theoretical and practical training beginning with part-task trainers (i.e. simulation) [16]. If this training begins in medical school, specialty-specific training in residency and fellowship programmes could refine pre-existing skills before allowing trainees to perform procedures in patients [27]. To ensure patient safety close supervision of practice will be required.
Mastery learning is a model of competency-based training, which ensures learners achieve a learning objective before progressing to the next stage of training [28]. Given, the potential risks to patients, this is probably the most appropriate approach for procedural skills training. The Thoracentesis Assessment Tool is an example of a validated tool which can be used in a mastery learning model for procedural skills [28].
Whilst recommendations, competencies and curricula for training in ultrasound-guided procedures are available [16, 17] these must be adapted for each setting. So, every medical school and specialty must task a panel of experts with the relevant competencies to develop local curricula for ultrasound-guided procedures with clearly defined competencies and objectives.
During this process some basic principles must be followed [26]:
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1. The curricula must be easily teachable and reliably learnable [26]. Skills must also be assessed to ensure competency and allow progression through each stage of the mastery learning process.
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2. The use of procedural ultrasound must have clear indications (e.g. to achieve a defined goal, such as performing thoracentesis for pleural effusion).
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3. Scopes of practice and institutional privileges must be defined [26]. Physicians must be made fully aware of their limitations [26]. When performing ultrasound-guided procedures, it is important to recognize when assistance from an expert (e.g. interventional radiologist) must be obtained.
The next challenge is implementation of the curriculum.
Implementation of a curriculum and training programme for ultrasound-guided procedures
To facilitate this, each institution delivering the training requires champions for POCUS and ultrasound-guided procedures [26]. These individuals must ensure that regular didactic sessions are provided, appropriate equipment is available, and most importantly, hands-on training is offered [26].
To deliver this, faculty with sufficient theoretical, clinical, and practical knowledge and skills must be engaged [26]. The faculty must be fully trained, institutionally credentialed and ideally accredited [26]. These individuals must commit to training and assessing learners. Unfortunately, our data revealed that opportunities to perform procedures were missed because supervisors were not available. This observation is consistent with previous data highlighting that few general internists are able to teach procedural skills [29] and that many programmes lack trained faculty [30].
Institutional support for faculty training and the infrastructure for ongoing quality assurance processes with a secure system for archiving images must be prioritized [30]. This will require the support of the radiology department and fully certified interventional radiologists.
Curriculum implementation clearly requires substantial resources and organizational engagement. To facilitate this and ensure that important aspects are not forgotten quality metrics for medical education must be used [31]. The execution of this process in Saudi Arabia may also be guided by the previous experience of the implementation of training in ultrasound-guided procedures in other countries. Indeed, our IM residents’ perceptions of the applicability of procedural skills (Table 3, Fig. 1) were similar to those reported by IM residents training in Canada [12]. So, international standardization of basic training for ultrasound-guided procedures may be possible.