Competency Assessment in Regional Anesthesia: Quantity Today, Quality Tomorrow
The definition of a minimum number of regional procedures, accompanied by a move away from emphasis on numbers, may seem paradoxical, but this supports the dual goal of ensuring sufficient quantity of experience while also emphasizing quality of competency assessment. In this issue of Regional Anesthesia and Pain Medicine, Neal et al1 utilize national and program-level case log data from the ACGME to account for the number of regional anesthesia procedures (including neuraxial) and pain consultations performed by the 2015 class of anesthesiology residency graduates. Comparison with previous surveys (1990 and 2000) suggests that the proportion of anesthetics done under regional is unchanged, but the distribution has altered in favor of peripheral nerve blocks over neuraxial techniques.2 They note that a key factor underpinning this shift could be development and adoption of ultrasound and continuous catheter techniques. Perhaps the most important aspect of this article is the finding that even trainees from residency programs in the bottom decile of programs by block volume meet the ACGME minimum procedure requirements for spinal, epidural, and peripheral nerve blocks. Although the authors point out a change in counting methodology based on changes in the ACGME case log system, this finding is good news. Continuing the restaurant analogy, Neal et al show us the kitchen is stocked and ready to serve.
Strikingly, although virtually all programs now meet ACGME-defined thresholds, the differences between high and low procedural volume residencies can be an order of magnitude or more.1 But this raises the question of whether quantity alone is sufficient as a metric. Somewhat counterintuitively, a program with a numerical glut of blocks may not expose trainees to complex, advanced procedures, challenging patients, or catheter techniques. In addition, production pressure may degrade educational opportunities or lead to carelessness and formation of bad practices, especially if the high numbers of block experiences are not paired with high-quality competency assessment and constructive feedback.