Cork University Hospital, Cork, Ireland

What do Lionel Messi, Billie Eilish and Banksy have in common? Other than being household names, they are masters of craft. They possess the rare ability to perform complex tasks with apparent consummate ease. Like many high performing people, they have developed domain specific mastery by developing their mind, their body and their craft. Excellence is easily observed, but is less easily described. To objectively describe performance characteristics that are foundational to high performance is difficult. What are the observable characteristics of a virtuoso violinist during a performance?

To contextualise this discussion to neuraxial anaesthesia and analgesia we might ask: what does a competent or proficient anaesthesiologist do that makes them an expert? It is probably fair to state that many of us have identified a preferred colleague to provide neuraxial anaesthesia should that need arise. It is probably equally as fair to state the converse: there are certainly colleagues whose skills do not meet a notional standard. Objective descriptions of the characteristics of each of these hypothetical colleagues might provide insight into high and low performance in neuraxial anaesthesia. In the following paragraphs and accompanying lecture the foundational concepts that underpin the application of proficiency based progression training in neuraxial analgesia will be discussed.

High level procedural skills are directly associated with better patient outcome.¹ Experts perform complex tasks more completely and make fewer errors than non-experts.² Errors in procedural healthcare cause harm.^1,3 Errors and associate harm are entirely avoidable by improving technical performance. To understand why metrics based training is an important concept, the learning environment must be better understood. Trainees have fewer learning opportunities than their historical peers of 10 or 20 years ago. Work time limitations, a move toward shift work patterns and condensed specialist training programmes mean that trainees have less exposure to clinical caseload and senior clinical tuition in the workplace than prior generations. This environment inadvertently places inexperienced non-expert doctors in roles that they are poorly prepared to fulfil.

Experts consume less cognitive load when performing complex tasks than non-experts. This concept is readily seen by an expert’s ability to hold a conversation while simultaneously performing complex tasks. Non-experts conversely are often fixated on the task at hand and miss environmental queues.⁴ The attentional capacity paradigm is a conceptual framework that describes human attentional capacity as finite.⁵ Experts automate tasks and do not rely on cognitive processing other than for key sentinel moments during a procedure or process. Non-experts are at or above a notional attentional capacity ceiling which limits their ability to perform complex tasks in dynamic environments. The analogy of a laptop running too many applications and exceeding random access memory (RAM) comes to mind.

Epidural analgesia for the woman in labour is an example of a set of complex tasks in a dynamic environment. The process can be defined in clear and unambiguously terms as a set of individual tasks by observing expert performance. By observing non-expert performance, commonly performed errors can be defined. These definitions can be used to design a list of objective and observable behaviours that inform curriculum design. Those defined components that differentiate expert from non-expert performance can be used to assess performance and provide feedback. The integration of validated metrics into curriculum design has been associated with an improvement in skill based performance in a variety of both simulation based learning and clinical environments.^6,7

In relation to epidural analgesia, Srinivasan et al,⁸ described the use of a metrics based curriculum to train and assess both the technical performance and clinical efficacy of epidural analgesia. Half of the participants were trained to perform epidural analgesia on the labour ward without alteration to standard training. Half of the participants received metrics based training. Those who received metrics based training were assessed as to their proficiency in a simulation environment prior to being permitted to perform epidural analgesia on the labour ward. Only those who met the proficiency standard were permitted to proceed to place epidurals for labour analgesia. The authors identified a significant improvement in analgesic outcome in patients who were treated by anaesthesiologists in training who received metrics based training rather than those who received traditional in-service clinical training. Metrics based training improved first pass success rate and the quality of analgesia provided while a shortened needling procedure time was observed. The authors suggest that proficiency based progression training enhances the performance of non-experts.

The use of proficiency based training progresses trainees further up a notional learning curve in a simulation learning environment prior to performing complex tasks on patients. Ultimately proficiency based progression training may prove beneficial in limiting harm that occur due to avoidable errors in procedural healthcare.

References

1. Birkmeyer JD, Finks JF, O’Reilly A, et al. Surgical skill and complication rates after bariatric surgery. New England Journal of Medicine 2013; 369: 1434–42.

2. Angelo RL, Pedowitz RA, Ryu RK & Gallagher AG. The Bankart performance metrics combined with a shoulder model simulator create a precise and accurate training tool for measuring surgeon skill. Arthroscopy: The Journal of Arthroscopic & Related Surgery 2015; 31: 1639–54.

3. James JT. A new, evidence-based estimate of patient harms associated with hospital care. Journal of Patient Safety 2013;9:122–28.

4. www.theinvisiblegorilla.com accessed April 10 2022

5. Gallagher AG. Metric-based simulation training to proficiency in medical education. What it is and how to do it. Ulster Medical Journal 2012; 81: 107–13.

6. Ahlberg G, Enochsson L, Gallagher AG, et al. Proficiency-based virtual reality training significantly reduces the error rate for residents during their first 10 laparoscopic cholecystectomies. The American Journal of Surgery 2007; 193: 797–804.

7. Gallagher AG, Seymour NE, Jordan-Black JA, et al. Prospective, randomized assessment of transfer of training (ToT) and transfer effectiveness ratio (TER) of virtual reality simulation training for laparoscopic skill acquisition. Annals of Surgery 2013; 257: 1025–31.

8. Srinivasan K, Gallagher A, O’Brien N, et al. Proficiencybased progression training:an ‘end to end’ model for decreasing error applied to achievement of effective epidural analgesia during labour: a randomised control study. BMJ Open 2018;8:e020099.