Retention of Pediatric Procedural Skills Wanes in Months After Simulation-Based Training

By Will Boggs MD

October 31, 2019

NEW YORK (Reuters Health) - Pediatric procedural skills developed during simulation-based training of adult emergency physicians wane by six months and disappear by four years after training, according to results from an observational study.

Simulation-based education has been shown to enhance performance of numerous procedures - neonatal resuscitation, pediatric advanced life support, and so on - but few studies have examined the retention of these skills in the months or years after training.

Dr. Daniel Aiham Ghazali of the University Hospital of Bichat and Beaujon and the University of Paris-Diderot and colleagues assessed essential but rarely used technical skills in pediatric emergencies among emergency physicians who had received relevant simulation-based training at different time points prior to the assessment.

The cross-sectional study included 23 participants trained less than half a year before the assessment (G1), 20 trained between half a year and two years before (G2), 22 trained between two and four years before (G3), 23 trained at least four years before (G4), and 19 controls who had not yet taken the Pediatrics Emergency Procedures (PEP) course.

Performance dropped significantly over time (P<0.0001). The highest assessment scores were achieved in G1 (85/100). G2 and G3 both achieved scores of 70, a 17.4% performance reduction.

G4 scored only 35, which was identical to the scores measured in the control group, the researchers report in BMC Medical Education, online September 9.

Despite these differences in performance scores, the groups did not differ significantly in their perceptions of self-confidence, pre-simulation stress, feelings of dissatisfaction, or realism of the scenario. The level of perceived stress during the simulation was higher in G1 than in the other groups.

"Based on performance evaluation using a valid and reproducible scale, this study tends to objectively demonstrate the need for re-training every 2 years and if not, to retake the course before 4 years after training to maintain acceptable performance," the researchers conclude. "That said, it is not always easy to determine the level of performance for skills and knowledge that would be acceptable, in order to reach and maintain a high level of competence ensuring patient safety."

"Future research should focus on the same outcomes in a prospective cohort study, and should analyze the process of re-training and reactivation of memory by repeated training in order to determine what would be the optimal repetition interval between simulation sessions most likely to blunt memory decline over time," they add.

Dr. Pamela Andreatta of the Uniformed Services University of the Health Sciences, in Bethesda, Maryland, who earlier demonstrated significant decreases in retention scores 18 and 52 weeks after simulation-based training in neonatal intubation, said, "These outcomes align with strong theoretical foundations and empirically evaluated outcomes from other high-acuity performance areas, including in other medical-, surgical-, and health-professions contexts."

"The problem for the health professions has been the lack of substantive ways to develop, practice, and maintain abilities outside of patient-care environments," she told Reuters Health by email. "As a consequence, the default assumption is that clinicians develop and maintain their abilities as part of professional practice and experience. But this study, and others, document that this is not an accurate assumption."

"We need to be able to use simulation to conduct routine practice, as well as performance assessment, so that we can document where the ability gaps are and focus training, refreshment, or remediation activities to assure that all clinicians are able to perform competently at any time in any context," said Dr. Andreatta, who was not involved in the new study.

"I think that the culture of medicine focuses more on confidence building and less on performance competence, especially documented competence," she said. "This is a historic artifact of the old-school apprenticeship model that most modern medical training programs are built on. But the apprenticeship model is no longer feasible, and rarely do any physicians in training receive focused, deliberate one-on-one attention from a mentor on a routine basis. So they don't necessarily learn whether or not they are performing to the best of their abilities, or even to a standard of performance competency because there largely are none in medicine."

Dr. Ghazali did not respond to a request for comments.


BMC Med Educ 2019.


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