How general pediatricians learn procedures: implications for training and practice

Figures & data

Table 1. The current procedures recommended by the ACGME for pediatric residency programs

Emergent Procedures	Urgent Procedures	Office-Based Procedures
Bag-Valve Mask Ventilation Neonatal Endotracheal Intubation Umbilical Catheter Placement	Lumbar Puncture Simple Laceration Repair Incision & Drainage of Abscess Reduction of a Dislocation Temporary Splinting of a Fracture	Giving Immunizations Bladder Catheterization Peripheral Intravenous Catheter Placement Venipuncture Removal of a Foreign Body

Figure 1. Sawyer’s learn, see, practice, prove, do, maintain pedagogical framework for procedural skill training in medicine

Reference: Sawyer T, White M, Zaveri P, Chang T, Ades A, French H Learn, see, practice, prove, do, maintain: an evidence-based pedagogical framework for procedural skill training in medicine. Acad Med. 2015 Aug;90(8):1025–33.

Table 2. Demographic and practice profile with frequencies (counts) and percentages of the 51 general pediatricians who participated in interviews about how they learned procedures. †Type of current practice is reported as the number of general pediatricians who work in each type of practice and the average percentage of time they allocate to that practice type

Demographic characteristic		N (%)
Female		33 (64.7)
Number of Years in Practice as GPeds	< 5	12 (23.5)
	5–10	10 (19.6)
	11–20	18 (35.3)
	21–30	8 (15.7)
	>30	3 (5.9)
Pursued Subspecialty Training		6 (11.8)
Work Full Time		41 (80.4)
Other providers (MD, DO, NP, PA) in GPed’s practice		46 (90.2)
Location of Residency Training*	Northeast	6 (11.7)
	Southern	4 (7.8)
	Central	36 (70.5)
	Western	5 (9.8)
Location of Current Practice*	Northeast	4 (7.8)
	Southern	3 (5.9)
	Central	42 (82.4)
	Western	2 (3.9)
Setting of Current Practice	Urban	14 (27.4)
	Suburban	20 (39.2)
	Rural	17 (33.3)
		N (Average %of Time)
Type of Current Practice†	Office/private practice	41 (80.5)
	Hospital Medical Center	10 (35.5)
	Emergency Department	7 (37.9)
	Newborn Nursery	14 (27.9)
	Labor and Delivery	4 (19.5)
	Urgent Care	3 (13.3)
	Federally Qualified Health Ctr	1 (100)
	Other Setting	13 (43.7)
	- Research	1 (38.5)
	- Informatics	1 (90.0)
	- Administration/Education	11

*Association of American Medical Colleges Regional Categories, December 2020

Abbreviations: MD = Doctor of Medicine; DO = Doctor of Osteopathic Medicine; NP = Nurse Practitioner; PA Physician Assistant

Abbreviations: MD = Doctor of Medicine; DO = Doctor of Osteopathic Medicine; NP = Nurse Practitioner; PA Physician Assistant

Table 3. Number (N) and percentage (%) of GPeds with little to no experience performing the procedure during residency training along with representative quotes that provide explanation for their lack of experience

Procedure	Number N () Participants Commenting Little to No Experience	Representative Quote
Bag Mask Ventilation	7 (13.7)	‘Bag valve mask ventilation was mostly through simulation … the only time that I was exposed to doing bag valve mask ventilation was in the NICU during resuscitation and not super frequently.’ ‘I can’t say that I remember a time when I actually bagged a[n] older kid.’
Neonatal Endotracheal Intubation	5 (9.8)	‘I can’t say that I’ve ever successfully done this on a real person. I put like a couple LMAs, but I never actually intubated a live person.’ ‘I did intubate some babies in the NICU [but] I never had more than one attempt.’
Umbilical Catheter Placement	3 (5.9)	‘I was kind of a witness to one. I don’t think overall this is something that we do repeatedly.’ ‘I learned this as well in a skill lab during my residency training and probably had like three attempts throughout my residency career to do the umbilical catheter placement.’
Lumbar Puncture	3 (5.9)	‘I don’t know that I have a lot of vivid memories of [learning] these.’ ‘I probably did only two lumbar punctures.’
Simple Laceration Repair	12 (23.5)	“I honestly don’t feel like I ever really learned that, which I should have but I really never did … ‘In residency, the only time we got to do that was in the emergency room and even then, we didn’t get to do it very often because they had so many suture techs working.’
I & D of abscess	10 (19.6)	‘Honestly, I don’t think I ever did that because the suture techs always did that.’ ‘Not a lot, not as many as I wanted to just because it’s always like hit or miss with your emergency department shifts, but I felt like that’s something I could do in my office. But I don’t really feel comfortable with it.’
Reduction of a Simple Dislocation	51 (100)	‘Reduction … that is probably the one I’m least comfortable with because I really didn’t do a ton of that at all. I’ve never even done a nursemaid’s yet.’ ‘I did like two or three nursemaid’s. I never fixed a dislocated joint or anything like that. I definitely wasn’t trained on any of that.’
Temporary Splinting of a Fracture	18 (35.3)	‘I can tell you I never actually did a temporary splint of a fracture.’ ‘I think I was supposed to learn this in the ED, but don’t think I did, and I have no idea how to do it. I didn’t learn anything or definitely did not get enough formal practice.’
Giving Immunizations	24 (47.1)	‘I don’t think I was ever trained on giving immunizations. I mean no one said “Here’s the thing. Go ahead and give it.” I mean I knew what to do, but I don’t think I was every trained.’ ‘I never gave a shot as a resident, never.’
Bladder Catheterization	12 (23.5)	‘I did not and still do not have a lot of experience cathing [sp].’ ‘I would assess the need and order it, but I never placed a bladder catheterization.’
Peripheral Intravenous Catheter Placement	23 (45.1)	‘I remember attempting some IVs as a resident. I don’t recall if I was ever successful at doing one.’ ‘IV placements? I wish we would have gotten more of because we didn’t get a whole lot of practice with that.’
Venipuncture	17 (33.3)	‘I actually probably did more of those as a med student rather than a resident. As a resident, we really didn’t do venipunctures.’ ‘I did arterial punctures. This is just venipuncture? I think I did maybe a couple.’
Removal of a Foreign Body	13 (25.5)	“I don’t recall ever doing unless it was something like in the ear canal which I thought I could get it out by forceps or something like that. Nasal canal that I could get to. So, a couple times. And definitely not frequently. ‘Yeah. I honestly don’t remember ever having the opportunity to remove a foreign body from anything.’

Abbreviations: LMA = Laryngeal Mask Airways; NICU = Neonatal Intensive Care Unit; NRP = Neonatal Resuscitation Program; PALS = Pediatric Advanced Life Support; PICU = Pediatric Intensive Care.

Table 4. Ratings of preparedness to perform procedures (now and at residency graduation) from 39 general pediatricians

Procedure (n)	Setting	Mean	Std. Dev.	t	df	p	es*
Bag Mask Ventilation (39)	Residency	2.90	0.31	0.63	38	0.53	0.124
	Practice	2.85	0.49
Neonatal Endotracheal Intubation (39)	Residency	2.33	0.62	2.84	38	0.007	0.537
	Practice	1.95	0.79
Umbilical Catheter Placement (38)	Residency	2.34	0.75	5.72	37	<0.001	0.983
	Practice	1.61	0.76
Lumbar Puncture (39)	Residency	2.87	0.34	5.18	38	<0.001	0.927
	Practice	2.31	0.73
Simple Laceration Repair (39)	Residency	2.62	0.59	3.41	38	0.002	0.593
	Practice	2.21	0.77
Incision & Drainage of Abscess (38)	Residency	2.45	0.69	−0.77	37	0.45	−0.118
	Practice	2.53	0.65
Reduction of Dislocation (34)	Residency	1.82	0.80	−0.50	33	0.62	−0.103
	Practice	1.91	0.90
Temporary Splinting (39)	Residency	2.03	0.74	−0.50	38	0.62	−0.100
	Practice	2.10	0.79
Giving Immunizations (38)	Residency	2.24	0.75	−1.36	37	0.18	−0.221
	Practice	2.39	0.68
Bladder Catheterization (39)	Residency	2.51	0.64	1.56	38	0.13	0.259
	Practice	2.33	0.74
Peripheral Intravenous Catheter Placement (39)	Residency	2.10	0.72	2.82	38	0.008	0.468
	Practice	1.77	0.71
Venipuncture (39)	Residency	2.21	0.62	1.30	38	0.20	0.186
	Practice	2.08	0.74
Remove Foreign Body (39)	Residency	2.44	0.60	−2.16	38	0.04	−0.408
	Practice	2.67	0.53

Preparedness scale: 1 = unprepared, 2 = somewhat prepared, 3 = well prepared. Comparisons over time were performed with dependent (paired) t-tests.

*es = Cohen’s D for dependent t-tests [<.1 = no effect; .2-.4 = small effect; .5-.7 = intermediate effect; >.8 = large effect]

Table 5. GPeds did not learn procedures through methods consistent with a mastery learning model: The number (N) and percentage (%) of 51 GPeds who reported that they did not experience components of mastery learning when learning procedures. Representative quotes provide explanation for their lack of experience

Sawyer’s Model Component	Description of Component	Theme	N (%)	Quotations
Learn (Cognitive Phase)	Learn about the procedure via readings, videos, and online training. Cognitive tests may be included	GPeds Did Not Learn or Teach Back Procedures Prior to ‘Doing’	25 (49.0)	‘I don’t ever recall being given dedicated lectures to procedures.’ ‘I don’t recall having any textbooks or online resources. I think we did a verbal review with the attending or fellowbefore performing the procedure.’
See (Cognitive Phase)	Demonstration of the skill to a learner with both nonverbal and verbal instruction. Learners are asked to ‘teach back’ to solidify concepts.	GPeds Did Not Learn or Teach Back Procedures Prior to ‘Doing’	25 (49.0)	‘Because of the kind of randomness of when it was your turn to do a procedure, it was often in the moment. It’s like, here it is, jump into the pool and so I didn’t know many resources for education, especially like the Just-in-Time kind of education.’ ‘I was never asked to describe how to do a procedure before doing it on a real person.’
Practice (Psychomotor Phase)	Formative assessment, which usually entails in-vitro or simulated settings. This phase incorporates deliberate practice.	GPeds Did Not Engage in Deliberate Practice	18 (35.2)	‘Residency was a big contrast to my nursing training where you would have lectures, labs, and practice before doing a procedure. In nursing, there were multiple dummy trials before you can do it in real life. But as a resident, attendings would say, “You just need to do this”. And if you said “I don’t even know how,” Tthey would say: “Well look it up and do it.”’ ‘No, we did not have any practice or simulation labs. Sometimes at night in the ER we would get out splinting material and splint each other just for practice but it was nothing formal and was not supervised.’
Prove (Psychomotor Phase)	Summative assessment that demonstrate competency and eventually mastery learning. These assessments are typically done in in-vitro or simulated settings.	GPeds Did Not Prove Competence in Training	22 (43.1)	‘Sure, we were expected to keep a procedure log but no one ever did. So, at the very end, people just fabricated up scenarios.’ ‘You had to log your procedures and you had a minimum quota of logging. But it didn’t even say they had to be observed. You literally could make them up if you wanted to, but I’m obviously not comfortable doing that. But there was definitely not somebody who watched you do it or signed off on you.’
Do (Psychomotor Phase)	Performance of skill on a human being with direct observation, performance-based assessment and feedback.	GPeds Did Not Participate in Graduated Supervision	51 (100)	‘Well, mostly you saw somebody do one, and then you did one under supervision. Sometimes you didn’t even see somebody do one first. It was just like, an attending is telling you and making marks of where it goes and [then doing] the procedure.’ ‘It really was like watching a couple and then doing a couple with the senior resident.’
Maintain	Skill is maintained not only through clinical practice but also supplemented through simulation, procedures logs, individual quality improvement and/or maintenance of certification.	GPeds Do Not Desire Formal Skill Maintenance	29 (56.9)	“Because the scope of practice of different pediatricians is so different, the requirements which you need to be good at are different and you may not be in a setting where you really need to be great at IV placement or laceration repairs. So, I don’t think there is a real need to continue to maintain those skills because medicine is getting pretty compartmentalized. ‘My initial thought is no, [procedural maintenance] should not be required for [MOC] as we already have enough stuff to keep track of, and it’s too burdensome.’

Table

Bag-Valve Mask Ventilation Neonatal Endotracheal Intubation Umbilical Catheter Placement

Lumbar Puncture Simple Laceration Repair Incision & Drainage of Abscess Reduction of a Dislocation Temporary Splinting of a Fracture

Giving Immunizations Bladder Catheterization Peripheral Intravenous Catheter Placement Venipuncture Removal of a Foreign Body