Coaching inexperienced clinicians before a high stakes medical procedure: “Repetitio est mater studiorum”
Alan Jay Schwartz, MD, MSEd, Justin L Lockman, MD, MSEd, Aditee P Ambardekar, MD, MSEd
Original Article
Flynn SG, Park RS, Jena AB, Staffa SJ, Kim SY, Clarke JD, Pham IV, Lukovits KE, Huang SX, Sideridis GD, Bernier RS, Fiadjoe JE, Weinstock PH, Peyton JM, Stein ML, Kovatsis PG. Coaching inexperienced clinicians before a high stakes medical procedure: randomized clinical trial. BMJ. 2024 Dec 16;387:e080924. doi: 10.1136/bmj-2024-080924. PMID: 39681397.
We are sure you have heard the admonitions, “Absence Makes the Heart Forget”, “Out of Sight, Out of Mind” and “Repetition is the mother of learning” (“Repetitio est mater studiorum”). We are also sure your parents often chided you to “practice” the piano, or throwing a baseball, or a similar activity so you could master it. How many middle schoolers have heard the “6 P’s”: “Proper Prior Preparation Prevents Poor Performance.” Just-in time training takes many forms!
The recent article by Flynn and colleagues1 is a good reminder that “practice, practice, practice” is not just for schoolchildren. Reinforcing clinical and psychomotor skills with repetition employing a just-in-time methodology can enhance clinical safety and efficiency.
Flynn and colleagues studied a high stakes skill, endotracheal intubation of babies less than or equal to 12 months of age, performed by relatively inexperienced trainees during their pediatric anesthesiology clinical education rotation. The trainees included pediatric anesthesiology residents and fellows, and student registered nurse anesthetists. The trainees were all directly supervised by attending anesthesiologists (equivalent to consultant anesthetists in the UK and other regions of the world).
“Two groups were studied. 515 intubations were performed (283 control, 232 treatment).
The control group (83 trainees) had unstructured intraoperative instruction in intubation by attending pediatric anesthesiologists.
The treatment group (70 trainees) received just-in-time coaching sessions before each clinical intubation encounter on an infant manikin within one hour of patient intubation. They completed two successful manikin intubations or 10 minutes of training before their patient encounter. Supplemental teaching added three coaching insights dealing with potential intubation challenges.
Intubation success was the primary outcome.
First attempt success for tracheal intubation was higher in the treatment group than in the control group 91.4% v 81.6%.
When video laryngoscopy was used, first attempt success was 91.9% in the treatment group versus 81.9% in the control group.
When direct laryngoscopy was used, first attempt success was 86.4% in the treatment group versus 80.7% in the control group.
The overall complication rate was 2.75% (7/255) in the treatment group and 4.71% (16/340) in the control group.
A competency acceleration analysis—designed to measure whether just-in-time training expedited trainee skill acquisition—showed a significant difference between groups in first attempt success rates by intubation rounds two and three, favoring the intervention. For example, in round two, by which the treatment group had received their second just-in-time training, their first attempt success rate was 90.9% versus 73.9% in the control group. By round three, after three just-in-time training sessions, the treatment group’s first attempt success rate was 95.8% versus 77.6% for the control group.
The improvement in first attempt success by 10 percentage points is clinically meaningful, considering the harms associated with multiple tracheal intubation attempts and the many trainee intubations performed yearly. Just-in-time training was associated with significant process improvements in quality of care, including decreased time to intubation, improved views of the larynx while intubating (which leads to easier breathing tube insertion), fewer advancement maneuvers in placing the breathing tube, and fewer technical difficulties.”1
The investigation by Flynn and colleagues is supported by other studies showing that simulation in general, and just-in-time training in particular, can lead to more effective, more efficient and safer patient care.2-4 These works support Anders Ericsson’s decades long study of deliberate practice—intentional repetition of a skill with active guidance and feedback to promote improvement.5 An editorial accompanying Flynn and colleagues’ study summarizes key concepts:
“Regardless of any broader applications, considering the intervention outside of a clinical trial, this form of point-of-care CPD [continuing professional development] has the potential to be widely adopted if it accelerates competency in inexperienced individuals with little added burden on existing resources and, as a bonus, protects the mental health of its users [we suspect both trainees and their faculty]. Furthermore, this form of coaching might not only help us from doing harm but could also prevent us from doing time.”6
How do you use just-in-time training? What do you consider its benefits? Do you perceive negative aspects of this type of clinical skill training? Have you had any special education to become an effective just-in-time teacher? Send your thoughts to Myron at myasterster@gmail.com and he will share them in a forthcoming Friday reader response.
References
1. Flynn SG, Park RS, Jena AB, Staffa SJ, Kim SY, Clarke JD, Pham IV, Lukovits KE, Huang SX, Sideridis GD, Bernier RS, Fiadjoe JE, Weinstock PH, Peyton JM, Stein ML, Kovatsis PG. Coaching inexperienced clinicians before a high stakes medical procedure: randomized clinical trial. BMJ. 2024 Dec 16;387:e080924. doi: 10.1136/bmj-2024-080924. PMID: 39681397.
2. Cheng A, Overly F, Kessler D, Nadkarni VM, Lin Y, Doan Q, Duff JP, Tofil NM, Bhanji F, Adler M, Charnovich A, Hunt EA, Brown LL; International Network for Simulation-based Pediatric Innovation, Research, Education (INSPIRE) CPR Investigators. Perception of CPR quality: Influence of CPR feedback, Just-in-Time CPR training and provider role. Resuscitation. 2015 Feb;87:44-50. doi: 10.1016/j.resuscitation.2014.11.015. Epub 2014 Nov 26. PMID: 25433294.
3. Gizicki E, Assaad MA, Massé É, Bélanger S, Olivier F, Moussa A. Just-In-Time Neonatal Endotracheal Intubation Simulation Training: A Randomized Controlled Trial. J Pediatr. 2023 Oct;261:113576. doi: 10.1016/j.jpeds.2023.113576. Epub 2023 Jun 21. PMID: 37353151.
4. Ayub SM. "See one, do one, teach one": Balancing patient care and surgical training in an emergency trauma department. J Glob Health. 2022 Jul 6;12:03051. doi: 10.7189/jogh.12.03051. PMID: 35787589
5. Ericsson KA. Deliberate Practice and Acquisition of Expert Performance: A General Overview. Acad Emerg Med. 2008; 15(11): 988-994 doi:10.1111/j.1553-2712.2008.00227.x. PMID: 18778378
6. Naylor JM. Just-in-time training could be just what the doctor ordered. BMJ. 2024 Dec 16;387:q2747. doi: 10.1136/bmj.q2747. PMID: 39681388.