Medicine Residents Lack Vital Knowledge on Mechanical Ventilation
Abstract & Commentary
Source: Cox CE, et al. Effectiveness of medical resident education in mechanical ventilation. Am J Respir Crit Care Med. 2003;167:32-38.
In the United States, physicians trained in internal medicine provide a substantial portion of the care of critically ill patients. Physicians trained in internal medicine direct 63% of ICUs, and national surveys report that 59% of general internists use mechanical ventilation in their practice. To evaluate how successful internal medicine residency programs have been in providing education about the management of patients who require mechanical ventilation, Cox and colleagues administered a validated 19-item test to a nationwide sample of 347 senior internal medicine residents in 26 residency programs. The programs were chosen to reflect a diverse sample in terms of geographic region, program size, urban, suburban, or rural setting, and university vs community hospital affiliation.
Of the 347 senior residents asked to participate, 75% responded. The mean test score was 74% ? 14% correct (range, 37-100%). Of respondents, 10% answered less than half of all questions correctly and one-third answered fewer than 70% correctly. Important items representing evidence-based standard of critical care answered incorrectly included: use of appropriate tidal volume (6 mL/kg) in ARDS (48% incorrect), identifying a patient ready for a weaning trial (38% incorrect), and recognizing indications for noninvasive ventilation in a patient with chronic obstructive pulmonary disease (27% incorrect). Most respondents accurately identified pneumothorax (86% correct) and increased auto-PEEP (93% correct). Better scores were associated with several factors: "closed" vs "open" ICUs (P = 0.005); having more than 15 senior residents in the residency program (P = 0.003); having more than 5 pulmonary and critical care attending physicians on staff (P = 0.005); and graduation from a US vs an international medical school (P < 0.0001). Only 46% of the respondents reported being satisfied with their mechanical ventilation training. Conversely, most (92%) program directors thought their residents had adequate knowledge about mechanical ventilation by graduation.
Comment by Leslie A. Hoffman, PhD, RN
The major finding of this study was that internal medicine residents are not receiving adequate knowledge to provide effective care for mechanically ventilated patients. Important deficiencies were found in several areas where research findings have convincingly shown the ability to lower mortality and reduce health care costs (eg, use of a lung-protective ventilatory strategy for patients with ARDS and prompt recognition of patients ready for a weaning trial). Among the 48% of respondents who answered the ARDS question incorrectly, 85% indicated that they would use a tidal volume nearly double the recommended 6 mL/kg of ideal body weight. Although 93% identified clinical findings suggestive of severe hypotension related to auto-PEEP, 35% were unable to choose a ventilator setting that would decrease it.
The research team was rigorous in designing the test, a case-based, multiple-choice examination written in the style of the American Board of Internal Medicine certification test. To establish validity, the test was administered in a proctored setting at 5 randomly selected university-affiliated training sites. A total of 132 participants returned tests, including 103 internal medicine residents, 19 pulmonary and critical care fellows, and 10 attending physicians. The percentage of correct answers ranged from 67 ? 17% for first-year residents to 95% ? 6% for attending physicians. Test scores increased significantly with each year of training (P < 0.0001). There were also significant differences in scores between each year of training (P < 0.001) but not between fellows and attending physicians (P = 0.35).
These study findings provide convincing evidence that knowledge regarding basic mechanical ventilator management needs to be improved. Given current constraints on time and resources, it is unlikely that this goal can be accomplished unless training becomes more structured and creative. Cox et al suggest several approaches for accomplishing this goal, including the use of evidence-based learning objectives, monitoring educational outcomes using competency-based assessment, and providing a brief, early "hands on" course in mechanical ventilation management.
In addition, medical training programs should consider incorporating training using high-fidelity human simulators (HFHS), given their ability to simulate a wide variety of typical and emergent scenarios likely to be encountered in the critical care setting. The University of Pittsburgh School of Nursing has incorporated HFHS training in the nurse anesthesia program for 4 years with excellent results and recently expanded HFHS training to include all undergraduate nursing students. In the HFHS lab, students are presented with a learning situation controlled by an operator who resides behind a 1-way mirror. They learn to act quickly to reverse emergent cardiopulmonary events and see consequences of their effective (or ineffective) actions. Through "debriefing" sessions, faculty members review the videotaped scenarios with the student and critique decision making and its consequences. Educators are under pressure to do more with less. Given this expectation and findings of this study, it is imperative to improve clinician education using the most advanced educational tools.
Dr. Hoffman is Professor Medical-Surgical Nursing Chair, Department of Acute/Tertiary Care University of Pittsburgh, School of Nursing.
In the United States, physicians trained in internal medicine provide a substantial portion of the care of critically ill patients.Subscribe Now for Access
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