Mastery Learning of Comprehensive Transesophageal Echocardiography Using Simulation Technology

Introduction and background: Academic hospitals have fellowship trainees (cardiology fellows, cardiac anesthesia fellows and ICU fellows) performing TEE’s. The American College of Cardiology (ACC) recommends that cardiology fellows achieve competency in Trans thoracic Echo (TTE) and TEE.(4, 5) This is measured based on the number of procedures performed rather than rigorous skill assessment. For example, the ACC Task Force on Training in Cardiovascular Medicine updated in 2015 recommends a minimum of 25 intubations and 50 supervised diagnostic TEE studies for cardiology fellows to become competent (level 1 training). (4) Certification to perform the procedure independently (level 3 training) requires a total of twelve months of echo training along with performance of 100 TEE’s, 150 TTE’s and interpretation of at least 300 TTE’s.(4) Competence in TEE implies an understanding of the risks and benefits of the procedure, and the basics of how to perform the procedure thoroughly and safely. Performing a comprehensive and timely examination is a very important skill. Specifically, in many cardiac emergencies, the ability to perform and interpret a comprehensive TEE exam in a timely manner directly affects patient outcomes with clinical decisions about the need for additional testing Vs emergent medical or surgical intervention that would be made based on the TEE findings. The invasive nature of TEE makes adequate training and skills necessary to decrease the risk of oropharyngeal trauma during the procedure extremely important and keep patient discomfort to the least possible. Based on our experience in the echo lab, patient discomfort ,need for additional conscious sedation, and risk of oropharyngeal trauma is slightly greater when these studies are performed by 1st year fellows when compared to those with more experience, even though all procedures are supervised by an attending cardiologist. Much of the training to perform these procedures is based on independent reading about the procedure and observing more senior personnel perform the procedure with progressively increased involvement by the trainee. This has been historically referred to as the “see one, do one, teach one approach.” Because this approach is not standardized, it often results in repetition or exclusion of concepts and skills, and uneven skill acquisition (7) Furthermore, learning in this environment, including practicing on patients and potentially causing harm raises trainee anxiety and impedes the learning process. This is particularly concerning in invasive procedures such as a TEE, which can result in potential harm or where a novice operator can miss a life-threatening, but treatable diagnosis due to the lack of ability to perform a comprehensive exam. Due to these factors, TEE is an excellent target for simulation-based education in a safe environment in which patient harm cannot occur. As there is very little prior published literature on simulation-based education for TEE skills(1), we will develop and study a curriculum in which cardiology and cardiac anesthesiology fellows are trained on a TEE simulator using the principles of deliberate practice (DP) and mastery learning (ML).(2, 3) DP involves repetitive practice of a focused clinical skill under close supervision of a coach or teacher who provides individualized directed feedback. ML, a strict form of competency-based education, requires the achievement of pre-defined educational outcomes while time is allowed to vary. i.e., all learners are required to meet or exceed a minimum passin