The July Effect is a relatively well-known reference to the influx of new trainees entering hospital systems annually on the first of the month. Researchers have attempted to investigate the impact of the new trainees on patient outcomes with divergent conclusions. Despite the ongoing debate, educators in medicine recognized the need to prepare medical students for day 1 of residency training, by establishing core competencies to evaluate the preparedness of students. One such example of this is the American Associated of Medical Colleges (AAMC) publication, Core Entrustable Professional Activities for Entering Residency. A quick glance through the Faculty and Leaners’ Guide shows the 13 entrustable professional activities (EPAs) identified by the AAMC as basic skills every medical school graduate should possess. The one that caught my eye was EPA 12: Perform general procedures of a physician.
The procedures listed under this heading include:
- basic cardiopulmonary resuscitation
- bag and mask ventilation
- inserting an IV line
Although I agree that these are basic procedures that most medical students should have familiarity with, I find it interesting that they are considered competencies. As part of my current rotation in anesthesiology, I am required to obtain a minimum number of experiences in bag and mask ventilation as well as with inserting IVs. Opportunities for bag and mask ventilation are abundant in the operating room setting (this is assuming we are counting the bag on the anesthesia circuit), but I wonder how much experience is necessary to truly be competent at it?
I can tell you from my personal experience that I did not feel comfortable nor confident in bag and mask ventilation until my third anesthesia rotation. The basic concept is easy to grasp, but in practice, there are additional variables to consider: Is there a good seal around the mask? Is there adequate chin-lift? Are soft tissue structures causing airway obstruction? If I were a patient in need of bag and mask ventilation, I would surely want someone who has basic knowledge of how to recognize successful ventilation and troubleshoot when unsuccessful.
Now onto inserting an intravenous line. If you ask most physicians to insert an IV, I bet that they would chuckle at the thought of it. At my institution, we have phenomenal nurses with extraordinary skill in cannulating veins, so, opportunities do not present themselves often for a medical student to learn. We have to actively seek patients who are willing to be poked and prodded by a junior trainee. Often, our attempts are futile.
Case in point — I asked a nurse whether I could start an IV on a younger patient that was in the preoperative area. While I was waiting outside of the curtain, I heard her say, “There’s a medical student here that wants to get experience putting in IVs. Are you OK with that? You don’t have to say yes.” To this, the patient asked if the medical student was “going to kill him.” I laughed to myself when I heard this but then realized the sad catch-22: one component of competency is procedural, but the prerequisite to this is adequate experience, which we cannot get because to be competent, we are also expected to “contribute to a culture of safety and improvement” and learning to cannulate veins on real patients doesn’t quite align with that. Something has got to give in order to make this work.
This brings us to the advocates that say simulation training is the best way to gain experience and confidence. While I agree that there is a place for simulation training, I don’t think it is adequate to establish true competency. Competency requires a real-life interaction between a trainee and patient — those experiences are the ones that stick with us and build our clinical knowledge base.
In the end, I applaud the efforts of the organizations that have stepped up to try to address the issue of preparedness for residency training. However, I think we have a long way to go. As a fourth-year medical student less than four months away from starting residency training, I can tell you that I don’t feel ready. But then again, who does?