Comment on: D.M. Yousem and S.K. Gujar Are C1–2 Punctures for Routine Cervical Myelography below the Standard of Care? AJNR Am J Neuroradiol first published on April 15, 2009 as doi: 10.3174/ajnr.A1594

In an original research article published April 15, 2009, Yousem and Gujar set out to determine the current neruradiologic practices and opinions on the performance of C1-2 punctures for routine cervical myelography. The impetus behind this investigation was a medicolegal case where the plaintiffs attorney argued that the performance of a C1-2 puncture for cervical myelography was below the standard of care.

The authors used a survey instrument sent to neuroradiology program directors. Eleven questions were used and designed to gain an understanding of whether C1-2 punctures are performed, under what conditions they are performed, how often they are performed and whether the fellows or residents were trained to perform these procedures. 12 of 85 respondents or 14.1 % reported that their program performed less than one C1-2 puncture per year for cervical myelography, 66 of 84 or 78.6% averaged between one and twentyfive C1-2 punctures per year and 40 or 47.6% of respondents said that they averaged between one and five C1-2 punctures per year. C1-2 puncture to obtain CSF was performed by 52 of 83 programs or 62.7%. 83 of 84 respondents or 98.8% of respondents stated that there was a person trained to perform C1-2 punctures and 59 of 81 or 72.8% of programs train their fellows and/or residents to perform C1-2 punctures. Only 4 of 80 or 5% of respondents felt that performing a C1-2 puncture as the primary approach for cervical myelography in a patient with a contraindication for MR imaging was below the standard of care.

Based on the survey, we have no way to determine the frequency of the performance of C1-2 punctures per individual. In addition, myelography in the United States is performed by many physicians and other radiologists, neurologists, and neurosurgeons perform myelography and this research does not address this. The number of myelograms performed (as with other interventional procedures) has declined because of improved non-invasive imaging techniques. The real question to address, then, is whether the “standard of care” (Do others in the local physician community or throughout the country perform the procedure?) is an appropriate measure? Does performing one C1-2 puncture per year, every other year, (chose a number) or having been trained during residency qualify an individual for the performance of this procedure?

The authors make reference to the use of simulation for those that perform below a certain number of C1-2 punctures per year. What is the number? Even if an individual performs 50 per year, does that mean this individual is competent? While the authors ask a valid and interesting question, the heart of the issue is procedural competency. As a medical community, we must move toward improved documentation of procedural competency. Our traditional system of medical education has outlived its usefulness1. Consider that today we still pursue the same medical education model that worked so well when the most advanced technology in America was the Model T¹.

The effect of the dwindling availability of highly experienced physicians will become apparent first in those countries where the most severe restrictions on patient contact hours have been enforced, in Europe before America, and in those systems that have rewarded efficient care by holding hospital stays as short¹. We must decide now how to train the next generation of specialists so that a gap in expertise does not produce an unintended and unfortunate consequence of modern medical education: increased medical errors and decreased patient safety¹.

Medical simulation can be segmented into 5 categories as proposed by David Gaba.² It is important to understand these different simulation methods because each has a unique characteristic and play different roles in education. As outlined by Rosen³, verbal simulation is simply role playing. Standardized patients (SP’s) are actors used to educate and evaluate history taking and physical examination skills, communication, and professionalism. Part-task trainers may be simple anatomical models of body parts in their normal state or representing disease. The more complex modern surgical task trainers are also included in this category. Computer patients are interactive and may be software-based or part of an Internet-based virtual world. These patients serve the same functions as SPs in many areas at a reduced cost. The most comprehensive form of simulation is the electronic patient. Electronic patients can be either mannequin or VR-based, and replication of the clinical environment is integral. This method can be the most costly and might be the best along with part-task simulation for learning spinal punctures.

Bradley⁴ has pointed out that the cost of equipment, personnel, and programs only recently have been overcome by the expansion of large collaborative simulation centers. These partnerships support the projection of increases in multidisciplinary, interprofessional, and multimodal simulation training. Rosen points out that despite obstacles of implementing medical simulation: surgical specialties are moving rapidly forward with incorporating simulation into competency requirements during residency and licensure; The American College of Surgeons has begun to offer a process of certification for multidisciplinary simulation centers; and in November 2007, the American Society of Anesthesiologists posted applications to offer a similar credential on its Web site.

Another obstacle that exists and antedate’s medical simulation is the lack of medical faculty who are well trained evaluators. As pointed out by Patel et al.⁵ many instructors in medicine are not trained to be evaluators, and this may limit the reproducibility, reliability, and objectivity of their assessment of the trainee’s proficiency. This will have to be addressed as we move forward in these forms of medical education. Potential roles of simulation include aptitude testing, early skills acquisition, advanced skills training, career long training, board examination, credentialing, pre-procedural rehearsal, procedural prototyping, and replacements for animal laboratories.1

In a systematic review of 109 published studies Issenberg⁶ looked at whether medical simulation facilitates learning and found that although the overall quality of the research was considered weak, the best available evidence did show a benefit for simulation when the following conditions are met: (a) educational feedback is provided, (b) learners are given the opportunity for repetitive practice, (c) tasks range in difficulty, and (d) the exercises based on the simulation are integrated into the curriculum. When criteria of functionality such as these are met, and in particular if the simulation and its content are appropriate, simulators could seemingly provide training and assessment of IR skills. The level of fidelity (accuracy) could then be chosen to suit the training objectives of the curriculum. Training would become learner-centered, performed at the learner’s pace and remotely from patients, with a new opportunity to learn safely from mistakes. There is a need for some proof of the effectiveness, or validity, of simulated training tasks or test items and of any complete procedures and their assessment methodologies. For training purposes alone, however, it is necessary to validate only that part of the simulation being used for training.

There are a multitude of reasons why simulation may be the best method for the determination of procedural competency, and whether more stringent documentation of procedural competency will be a key question in some medical legal cases, rather than whether the standard of care was practiced and whether the individual “trained” (in the more traditional sense) to perform the procedure. Medical simulation enables students and providers to learn, practice, and repeat procedures as often as necessary in order to correct mistakes and fine tune their skills without compromising the safety of real patients. Fidelity and validity issues still justify the skeptic’s delay in implementation7, but these issues will eventually be overcome.

References:

1. Dawson S. Procedural Simulation: A Primer. J Vasc Interv Radiol 2006; 17:205–213.
2. Cooper JB, Taqueti VR. A brief history of the development of mannequin simulators for clinical education and training. Qual Saf Health Care 2004;13:11-8.
3. Rosen KR. The history of medical simulation. Journal of Critical Care 2008; 23: 157–166.
4. Bradley P. The history of simulation in medical education and possible future directions. Med Educ 2006;40:254-62.
5. Patel AA, Glaiberman C , Gould DA. Anesthesiology Clin 2007; 25: 349–359.
6. Issenberg SB, McGaghie WC, Petrusa ER, et al. Features and uses of high fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach 2005; 27:10 –28.
7. Day RS. Challenges of biological realism and validation in simulation-based medical education. Artif Intell Med 2006; 38:47-66.