Sep. 6, 2011 Critical care physicians trained in a high-intensity clinical protocol environment for mechanical ventilation practice had similar test results on examination questions regarding mechanical ventilation management compared to physicians in a low-intensity protocol environment, according to a study in the September 7 issue of JAMA, a medical education theme issue.
Clinical protocols (precise and detailed plans for a regimen of treatment) provide management algorithms that can minimize practice variation and can often be implemented by nonphysicians. "However, protocols may distance physicians and physicians-in-training from direct patient care. Development of clinical competency requires that trainees have an active role in decision making, and protocols may attenuate their experiences. Conversely, clinical protocols may be one of many means to facilitate learning by providing a summary of best practices that can serve as a tool for knowledge dissemination," the authors write. ." ..it is unknown if unintended consequences of protocols exist, such as the potential creation of a physician workforce unable to think beyond an algorithm, and whether these consequences may outweigh the benefits to patients."
Meeta Prasad, M.D., M.S.C.E., of the University of Pennsylvania School of Medicine, Philadelphia, and colleagues examined the relationship between critical care training using clinical protocols and subsequent trainee knowledge, using mechanical ventilation management as a model system. The study linked a national survey of mechanical ventilation protocol availability in accredited U.S. pulmonary and critical care fellowship programs with knowledge about mechanical ventilation among first-time examinees of the American Board of Internal Medicine (ABIM) Critical Care Medicine Certification Examination in 2008 and 2009. Exposure to protocols was defined as high intensity if an examinee's training intensive care unit had 2 or more protocols for at least 3 years and as low intensity if 0 or 1 protocol. Knowledge was measured by examination questions specifically about mechanical ventilation management.
Of 129 pulmonary critical care training programs, 90 (70 percent) responded to the survey. Of these, 86 percent had protocols for ventilation liberation, 73 percent had protocols for sedation management, and 60 percent had protocols for lung-protective ventilation. Of the programs responding to the survey, 88 (98 percent) graduated trainees who completed the ABIM Critical Care Medicine Certification Examination in 2008, 2009, or both. Of these programs, 31 percent had 0 protocols, 22 percent had 1 protocol, 27 percent had 2 protocols, and 20 percent had 3 protocols for at least 3 years. Forty-two programs (48 percent) were classified as high intensity and 46 programs (52 percent) were classified as low intensity.
Within the study population, 503 of 553 examinees passed the examination, for an overall pass rate of 91 percent. A total of 304 examinees (55 percent) trained in high-intensity protocol programs and 249 (45 percent) in low-intensity protocol programs. After analysis, the researchers found that the mean scores on the mechanical ventilation questions were equivalent between the 2 groups.
"As the use of clinical protocols increases in prevalence in response to concerns about patient safety and practice variation, understanding the potential relationship of protocols with education in clinical settings is essential. There is a reasonable concern about the potential unintended consequences of protocols on education, because some protocols will by design remove junior clinicians from direct clinical decision making experience necessary for building their knowledge, decision making skills, and confidence. Our study suggests that this phenomenon may not occur," the authors write.
"In conclusion, as medical education evolves, with work-hours limitations, increasing compartmentalization of care, reductions in procedural requirements, and emphasis on patient safety in the educational setting, it is important to understand all the effects of the systems that are implemented to respond to these changes and principles. Our study provided empirical evidence that clinical protocols, designed to standardize and optimize patient care, may not hinder high-quality medical education in mechanical ventilation management. Further exploration in other content areas and with other measures of competence should investigate the balance between patient safety and the needs of medical trainees to ensure present and future high-quality care."
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- M. Prasad, E. S. Holmboe, R. S. Lipner, B. J. Hess, J. D. Christie, S. L. Bellamy, G. D. Rubenfeld, J. M. Kahn. Clinical Protocols and Trainee Knowledge About Mechanical Ventilation. JAMA: The Journal of the American Medical Association, 2011; 306 (9): 935 DOI: 10.1001/jama.2011.1226
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