Competency Assessment in Regional Anesthesia: Quantity Today, Quality Tomorrow

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Most life experiences and circumstances benefit from a subtle balancing of quantity and quality. Take dining, for instance. All-you-can-eat buffets are rarely seen as a high-quality, fine-dining experience, although they abound in quantity. Alternatively, even a 5-star restaurant will disappoint if the kitchen has run out of food. So it is in many areas of education, especially in regional anesthesia training today. A residency program starved of procedural opportunities will struggle to adequately train residents no matter the skill and dedication of its educators or the quality of the assessments that they provide to trainees. Conversely, programs that provide copious opportunities to perform blocks will do little to advance trainees beyond minimal competence unless quality assessment and educational feedback are provided (Fig. 1). The Accreditation Council for Graduate Medical Education (ACGME) sets minimum requirements for number of spinal, epidural, and peripheral nerve blocks residents perform, implicitly recognizing the importance of quantity of experience in skill development. Simultaneously, the ACGME Milestones project has expanded on and clarified the ACGME 6 core competencies, which involves moving away from a simple focus on procedure counts or time served toward assessing the level of supervision required or autonomy granted for completion of defined clinical tasks.
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.

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