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[00:00:00] non: You are listening to the ATS Breathe Easy podcast, brought to you by the American Thoracic Society.
[00:00:18] Eddie: Hello, hello, and welcome. You're listening to the ATS Breathe Easy Podcast with me, your host, Dr. Eddie Chan. I'm also the host of the ICUN Podcast. Each Tuesday, the ATS will welcome guests who will share the latest news in pulmonary and critical care and sleep medicine.
Whether you're a patient, a patient advocate, or healthcare professional, the ATS Breathe Easy podcast is for you. Today we're gonna be talking about the current state of procedural training and training programs. And joining me today are two really special guests, Dr. Meredith Pugh, the program director of the Pulmonary and Critical Care Fellowship Program at Vanderbilt.
And Dr. Kaele Leonard, who serves as the Associate Program director for procedural education for the Vanderbilt Internal Medicine Residency Program. Welcome, Meredith and Kaele.
[00:00:57] Meredith: Thanks for having me, Eddie. It's a pleasure to be [00:01:00] here. Yes, thanks.
[00:01:02] Eddie: let's just jump, I think, right into it. And so we're talking about procedural training.
Why are we talking about procedural training? Why is talking about procedural training important? Why does an internist or a pulmonologist, or an intensivist need to know procedures?
[00:01:17] Meredith: I think procedure training is important for a number of reasons. Now, granted, I think about it more day to day in the care of patients in the ICU and on the pulmonary floors, and then also think about it.
As the perspective of a training program, director and procedures are part of what we do in all those different arenas, and then thinking thoughtfully about how we prepare our trainees to serve their patients in different arenas and, and be capable and competent. Proceduralist is an important part of my job.
when we're talking about procedures, we're talking about. Not only the things that we most commonly think of when we talk about procedures, like putting a needle into a space for a diagnostic or therapeutic purpose, but I think in [00:02:00] today's, medical practice era, we're also talking about things like point of care ultrasound.
that may not be a procedure in the classical sense or even things like a CLS training, but there, opportunities for us to care for patients. That, require practice and training, and, and, and require specific attention in the context of training. I think the other thing is anyone who's been involved in medical care or certainly in medical training probably has a visceral sense that there has been some evolution, in the, the way that our regulatory agencies like the A-C-G-M-E and A BIM or the.
Thinking about procedural training, there's some changes and, and there's also a visceral sense of trainees coming into fellowship, for example, with slightly different procedural training and backgrounds than what was the case, you know, 10 or 20 years ago
[00:02:53] Eddie: the, you mentioned Meredith talking about there's a sense that procedural changing has changed over time.
what can [00:03:00] you describe to me this change? Where are we today?
[00:03:04] Kaele: I think I can, start us off with this one. when we think about, program requirements for different training programs, the A-C-G-M-E, has different program requirements depending on the program and wants trainees to be able to perform all medical diagnostic and surgical procedures for that area of practice.
But then specifically the A BIM. Has changed what they require from a procedure standpoint for the internal medicine resident over time where they state. All residents must do procedures, but not all residents must do all procedures. And that residents also should have the opportunity to develop competence in those procedures that will further their development in their career choice or subspecialty, fellowship that they're pursuing.
So. Historically, there were certain bedside procedures where there were number [00:04:00] requirements that you had to hit, and now that has gone away. what is required by the A BIM is to obtain informed consent, apply standard, sterile precautions and a sterile field, and be able to apply local anesthetic.
However, the new guidelines allow, individual interim medicine program directors to tailor the procedural training for their residents, for their specific residency and also for, specific residents.
[00:04:34] Meredith: So I think those changes within the internal medicine residency training structure have definitely impacted what we're seeing when trainees enter into our fellowship program and really, a variety of different approaches to this, across internal medicine training programs in the country.
But in general, there has been a shift away from a discreet number of procedures. That would indicate competency to a more [00:05:00] holistic evaluation of competency that is, different than just a, a blanket number of procedures. And, and then also different experiences across trainees, in terms of, of bedside procedures.
Like if you're as old as I am, you know, it used to be that every patient in the ICU that was on norepinephrine got a central line, you know, placed by residents in the. Program. and so entering into Fellowship in my era, you know, we had accumulated a vast experience in the placement of central lines, you know, in the current era, not only because of those changing guidelines that Kaele mentioned, but also because of increasing use of peripheral vasopressors, the, ubiquitous nature of pick teams and other procedural teams at the hospital.
All of those things together have really. Change the experience of internal medicine residents. So they may not have as much exposure to central venous catheterization, you know, by the time they enter into fellowship. And so [00:06:00] that just means we've had to think about ways to adjust our experiences of making sure that fellows get those experiences, in our program.
[00:06:09] Eddie: We, we've talked a little bit here about, being competent with procedures and, for different types of procedures and tailoring them and say, getting away from some of these, quotas, so to speak, of the number of baseline, number of procedures. Is this, is this the, is this the right thing for us for our training?
Should our medicine trainees, be quote unquote competent with bedside procedures?
[00:06:36] Kaele: I think that, it really just depends. I think that there are, certain procedures that, internists should be able to do or at least have the opportunity to do. but with the cha changing landscape of medicine and procedures, like Meredith mentioned, I don't think it is a, should be a requirement that all residents are, um.
Competent in all of those different [00:07:00] procedures, and I think it's a good thing that residencies can tailor their training and their requirements to their particular residency. So for our program for example, we, have decided to require residents to be competent or signed off for indirect supervision.
paracentesis and do off tubes. And the reason we made that decision was due to the high volume of those procedures in often times, sensitive nature of them, that we thought it was important that all residents be able to do that. and then we also require a CLS certification, to be current for all of our, residents.
For other bedside procedures such as Central line thoracentesis, lumbar puncture, we encourage, but do not require, residents to be competent or signed off on those procedures. however, we do encourage or try to tailor someone's [00:08:00] procedural experience to what their, future career goals are. When
[00:08:07] Meredith: people enter into our fellowship program, you know, the A BIM is pretty clear about what procedural competency, or I should say, what procedures are a requisite part of training within the field of pulmonary and critical care.
and so unlike internal medicine that has really moved away from specific procedures, we have no numeric. Requisite. but we, we do have procedures and as a program director, I do need to have a way of verifying that my trainees are getting adequate numbers of these procedures with supervision that are achieving a, a certain level of, of competency.
and that includes procedures like fiber optic bronchoscopy. Airway management, arterial puncture, central venous catheterization, and even the use of, of bedside ultrasound or point of care ultrasound, especially for central venous catheterization. So I think when, when you look at other subspecialties of internal [00:09:00] medicine, like oncology or rheumatology, you know, program directors in those areas probably have a very different perspective on what procedures they want their fellows coming into their program with.
I'm very grateful that, um. Others have done work in this area. So Effie SGA and colleagues published a survey that they sent to internal medicine, subspecialty program directors. and there's quite a diversity of perspectives about which procedures I am. Subspecialty program directors want their incoming fellow.
To be, have experience and competency and you know, for example, in, in the field of pulmonary and critical care medicine, which is obviously a procedure heavy field, you know, three quarters of program directors surveyed wanted their incoming trainees to have had experience in abdominal paracentesis, which sounds like they'd be fine coming from Kaele's program into fellowship.
and, uh. Almost 90% wanted their trainees to have had exposure in, in venipuncture, for [00:10:00] example. Whereas when you look at oncology, a hundred percent of surveyed program directors wanted their trainees to have had experience in lumbar puncture, which makes a lot of. A lot of sense, but, but not as much of a, of a desire to have training in central venous catheterization.
So I think just from the, the program director standpoint, you know, I'm balancing the, the need to have our trainees exposed to very specific procedures that are part of our daily life and part of A BIM certification, but then also ensuring that it's the right type of exposure where trainees can develop competence.
[00:10:35] Eddie: Yeah, it seems like it's a really difficult job for the residency programs to kind of cater to every individual subspecialty. There are a couple of points I wanna come back to, but we spent a lot of time talking about. Competence. We've talked about a holistic approach to competence. We've talked about, maybe quotas aren't the right way to do it for both bedside procedures and even more advanced speci, specialty specific procedures like bronchoscopy.
[00:11:00] What does it mean to be competent in a procedure? And in an, in an ideal world, what should someone, what kind of level should someone achieve before they're declared competent, quote unquote, for independent practice?
[00:11:13] Kaele: So I think that, that has als, that landscape has also changed over time. I think we've moved away from the CC one, do one, teach one, and with the decreasing number of, procedures overall.
I think in an ideal world, starting with a simulation, uh. Way to learn is probably, a, a great way to, sort of initially learn these procedures. I think that, you know, it allows for a safe, you know, hands-on way to kind of work through the steps before you're doing, in, in our. In the real world or on a real patient.
so there's actually a group out of VCU that, has put and implemented a [00:12:00] competency-based procedure curriculum, where they used a checklist based simulation, training where all the residents had to be. Checked off on the steps of the procedure in a simulation environment before they moved to the real world.
and then they also had a, you know, procedure committee, competency committee that looked at the feedback that people had on their procedures and numbers before they determined that somebody was competent. So that sort of starts from that simulation. Setting moves to a real world supervised setting.
before that, trainee is deemed, a competent for indirect supervision to perform the procedure without having somebody, watching them the whole time. So I think that is sort of an ideal world situation. And just commenting briefly on, to add to something I mentioned before about what. Should internal medicine residents, [00:13:00] do, I also think it's specifically important that they at least understand and know the basics of all these bedside procedures that their, patients are having.
And so implementing a curriculum where they get. Some didactic or simulation training on all these different bedside procedures that are within the scope of internal medicine, I think is helpful just for their understanding, their patient care, and, you know, potentially, affecting their future, for future career as well.
Mm-hmm.
[00:13:35] Eddie: It makes a lot of sense to kind of demystify these procedures for trainees that, I mean, not even just bedside procedures, but even to some extent, the relevant surgical procedures that otherwise are important for us to know when we're talking about talking with our patients. Mm-hmm.
[00:13:49] Meredith: And I think that's important too because when you think about even if a trainee is not gonna be performing the procedure themselves, they may be able to, explain [00:14:00] it to their patient and their family member better when they understand a little bit about the procedure.
Also, I think an important skill and part of procedural training is, is not just the steps of doing the procedure itself, but also, being able to recognize a patient who may be at higher risk from a procedure or being able to navigate and, and, um. Lower the risk of certain, aspects of the procedure.
You know, for example, a highly anxious patient, if you know what it's like to have to put someone in, a, a position to place a central venous catheter. and they have severe orthopnea and they're very anxious. You know that you should recognize that ahead of time, that that procedure may place that patient at higher risk and potentially have additional hands at the bedside or a change in procedural positioning.
and if you don't fully understand what it looks like to put a central line in, then you may not have that knowledge ahead of time. And so I think even as we're talking about procedural training, we don't want to lose sight of, [00:15:00] aspects of the procedure management informed consent process that are outside the actual.
Hands-on performing the procedure itself, that are equally important aspects of training.
[00:15:12] Eddie: Yeah, that makes, that makes a lot of sense. So we're, what we're talking about is that it, it, you don't have to actually do the procedures to have the knowledge of what the procedure is and how things, the re kind of real logistics of doing the procedure can really impact the way that you take care of patients before and after.
Because in theory, and ideally, we're taking care of these patients before and after procedure, if not during.
[00:15:35] Meredith: Yeah,
[00:15:35] Eddie: that's right. Yeah, so Kaele, should we all be moving towards this VCU model that you had talked about, where we start with the sim and then check off and then move to a, a real world kind of scenario and get checked off again?
It really seems like a, a pretty large lift. And you said that this mm-hmm. Field is evolving.
[00:15:54] Kaele: Yes, I, I definitely agree with that. It does seem like a very large lift. they, I [00:16:00] think that is an ideal scenario when you have a very supportive, program. You have the time and faculty support for that.
ultimately they published again and saw that. Their, curriculum and and committee, resulted in an increase in the volume of procedures that the, residents performed and that they supervised, which is great, but if you don't have that kind of support, it's hard to implement something like that.
And so I think there are ways to, uh. Optimize or improve a procedure curriculum, in smaller steps. so I think it's important, as I mentioned, that all of, all residents get a basic understanding of these bedside procedures. And so we are implementing a longitudinal curriculum, that's, part didactic and part simulation, hands-on training, throughout their intern year Now.
They haven't had their [00:17:00] paracentesis simulation yet, but they might have already had the opportunity to do a bedside paracentesis. And so I think if, you know, if that is the case, their supervising provider should recognize that and they're gonna do some more coaching, reviewing of the procedure steps, maybe a video prior to that experience.
And so the way it's playing out isn't, it's not always going to be a perfect. They do simulation before they do the bedside, procedure, but at least it gives them, some baseline of the, baseline training in that procedure as they progress through their residency. And so I think that, you know, having some amount of training and having a way to, assess competency, I think is important.
for whatever works for your training program.
[00:17:51] Meredith: I think on the fellowship side, recognizing that we do not operate at all in anything close to a perfect world. we realized [00:18:00] very early on that we did not have the, the organization and the time to do a full curriculum as, was described in the VCU papers, but it's most critical for us to have an adequate training, adequate supervision, and then a standardized approach.
To establishing competency for procedures in our, in our fellowship. And so what this has looked like for us is first I start collecting data about our incoming fellows procedural experience from their residency programs before they even hit the ground in our program. and I, I collect. Not only the number of procedures and ask for information about procedure logs, but I also query whether or not their training program had a competency-based, way of, of assessing procedures.
then during our orientation for our fellows, I meet with each trainee one-on-one and hear a little bit more about [00:19:00] their. Procedural training so that we can personalize, the high yield aspects of their procedure and hands-on training during those first few weeks of fellowship. Then we developed, a robust jumpstart curriculum that includes some high fidelity simulation, some, model in some cadaver based training for the procedures that our fellows do most commonly, including bronchoscopy, thoracentesis, chest tubes, and central venous catheters.
Then, we utilize a program that allows, me to see, how our faculty are rating procedural list. and that gives me information not only about the number of procedures they're doing, but whether a faculty supervisor has rated them as novice, intermediate. Or expert or practice ready. And so for our program, for example, we, we do [00:20:00] require a certain number of procedures and a certain number of expert or practice ready evaluations, in order to allow a trainee to proceed with a performing, a procedure with indirect supervision, meaning not having a, a faculty member directly at the bedside with them.
[00:20:18] Eddie: Yeah, that makes, that makes a lot of sense. We know that, you know, learning curves for all things, not just procedures are different for different individuals. So it makes a lot of sense. But I, I'd just like to highlight that, I think one of the things that is really coming out of this conversation is that though we may not live in an ideal world, that it's important to think about at any kind of be moving in that direction.
and that maybe that's a lofty goal we'll never achieve, but I think it's really, really important to just. Just have active thoughts and, and to be moving that direction. So we thank you for all, for both of you, for all you're doing there.
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[00:21:21] Eddie: I wanna come back to a point that, Meredith, you mentioned at the very beginning, and as Meredith Kaley, either of you can comment on this, but talking about not just.
Sticking a needle into spaces, but also, ultrasounds, ultrasounds, point of care, imaging. It's really become ubiquitous in the ICUs. It's pretty ubiquitous on the wards as well, and the clinics even. how much of the conversation that we've just talked about changes when we're talking about ultrasound used as a diagnostic tool, or you could call it quote in an imaging procedure, so to speak.
[00:21:53] Meredith: Yeah, so I'll start off by mentioning that the A BIM does recognize ultrasound as an important skill [00:22:00] specifically for pulmonary and critical care. It's mentioned, that, that fellows must achieve competency and, and use of ultrasound for placement in central venous catheters. However. Other, other statements talk about the importance of procedural and technical skills of bedside ultrasound, including image interpretation, and image acquisition.
which are, you know, skills, outside of just utilizing it to successfully place a essential venous catheter. And I think there are, several implications of these recommendations and, the, the, the need to, observe our trainees. Performing point of care ultrasound one is you have to, as a program, have enough ultrasound machines to make sure that trainees have access.
Two, you need to have adequate numbers of faculty who are competent in the use of ultrasounds and have availability of faculty and ways within your program where faculty will be present to observe fellows or trainees performing ultrasounds and be able to [00:23:00] provide feedback on that. three. It is exceptionally helpful to have an image archiving system so that images could be reviewed, perhaps not in real time, but in, at, at a separate point in time.
and that trainees can then have an archive of what they've done to demonstrate, that they're able to, to proficiently obtain images. And so. Even those three requirements are, are a lofty goal for some programs. You know, depending on where you're, you're practicing. You know, we're fortunate here, to, have availability of faculty within our own pulmonary and critical care program, but also we rely on expertise from other divisions.
Like our emergency medicine has a wonderful ultrasound fellowship and are heavy utilizers of. Ultrasound. And so we realized that we did not need to reinvent the wheel and that we had experts, in our own community that could help and partner with us in the training of our [00:24:00] fellows. And so that's been a wonderful, a way to kind of help cross train at our own institution.
the other thing, spec specific to ultrasound is that, uh. And really is true for a lot of these things that we've been talking about is that, you know, we're not going at this alone. Like as an individual program director, as an a PD and the residency program like Kaele, we can rely on the expertise, the wisdom, the experience of our national community.
And already there are a lot of discussions and surveys and input, from the Association of Pulmonary and Critical Care Medicine program directors, for example, which is, oftentimes a litmus test for me to understand if my own experiences that I'm feeling are similar to what's happening in the national community.
And from learning from each other. and then in terms of training, there's also already great established curricula, that are available some online and some in person [00:25:00] through national organizations. And so, I, I think that, uh. Program directors, and faculty should take heart that if you're hearing this and you, and you're thinking, well, I don't have all of these things available to me at my institution, there's some really great resources available nationally, that can help fill this gap, in, in helping you train your, residents and fellows.
[00:25:23] Kaele: I would also just like to add that, ultrasound is becoming more common, within just the general internal medicine space as well, and the experience that residents get is variable across different programs and some actually are coming in from medical school with ultrasound experience. and so.
Having a way to support at least some ultrasound education alongside your procedure, training I think is really helpful, especially since the majority of these bedside procedures we're doing with the ultrasound [00:26:00] guidance. And so finding a way to at least incorporate that. along with your bedside procedure training, I think is really helpful.
And I agree with, Meredith, it's not just the pulmonary and critical care national organizations. There's also general internal medicine, organizations that have, excellent courses. if people would like to get further certified in those things.
[00:26:23] Eddie: Yeah. That, that part of you're talking about like medical students coming in with ultrasound experience has really, has really, I've really noticed that I do some teaching with the medical students.
Where, they are far beyond where I was talking about ultrasound skills and knowledge as a medical student, as all, all this knowledge I learned during residency or during my fellowship training. so it really is a kind of like a shifting landscape and it, it will be, it will depend on people like you and Meredith to, adapt as a landscape continues to shift underneath us.
But, I wanted to come back a little bit to like, talk about general internal medicine, bring it back to the, the procedures, the [00:27:00] classic procedures, and I wanted to talk about this kind of phenomenon that's been going on. Talking about procedure teams, so they're, they're more and more common. These are teams of clinicians who have an interest in procedures and they can be run by general internal medicine, or in some places it's run by pulmonary critical care.
How does this impact, I think both patient care and then separately the trainee experience.
[00:27:24] Kaele: No, that is a, that is a great, point and we've, seen this at our institution, how this has sort of changed the procedure landscape. I think in general, having a procedure team of, people who are, have an expertise in procedures is going to improve, you know, patient care and patient experience.
I think that the way we have it structured, residents can opt to rotate through, this procedure service. Um. After their intern year. And that is a great way for them to get dedicated high volume, procedures [00:28:00] where you have a built in supervisor, you're getting high quality teaching and you get a lot of reps at one time.
And so the residents who are interested in procedures can self select into, I want to get more experience. With these procedures and so I wanna do this. And that can help them become competent in, these bedside procedures. I think the other effect of that is. It allows or, or reduces the number of bedside procedures that residents are doing because it allows them to say, I, from time constraint perspective, I don't have time to do all these procedures.
I, I need help. and then. If their senior resident on the team is not signed off on procedures, they aren't able to supervise the intern who might be interested and that often gets passed onto the procedure team. Now, kinda a way to combat this is, the way our procedure team works is. When [00:29:00] requested that procedure, service attending can be the supervising provider for that intern.
But again, I think it, you know, requires some initiative and the, the time, to do those things. So I think that there are certain, you know, pros and cons to, this procedure service. but it really has allowed the residents interested in procedures to get some of this extra hands on time. Mm-hmm.
[00:29:28] Meredith: And I think there's some advantages too from a supervision standpoint.
You know, I mentioned that, when we're thinking about, competency and establishing what competency looks like, it's not just the number of procedures, but it's, but it's having a standardized approach. At our institution, it's a checklist for a procedure. And so it, it's having a, a group of faculty who are very facile and familiar with that checklist, who understand the steps that it takes to perform a thoracentesis, start to [00:30:00] finish like an expert.
and then to have, you know, the trainee, observe the trainee, be able to execute that, and then to provide very um. Very specific feedback about why a trainee wasn't at expert level. And so I think with a procedure service you have kind of distilled down, a select group of faculty who may be very familiar with that process and, and even understand the technology that we use and the program that we use that, you know, houses this information.
And that's another benefit, for training and education we've even considered, in the pulmonary and critical care realm. You know, not, not so much in the ICU, but with a high volume of pulmonary consults and a large volume of, of bronchoscopies and pleural procedures that's done at our institution.
You know, we've thought too about, you know, a specific, plural procedure service, and I know that there are, peer training programs in the country who already are doing. in, in a way to have their fellows achieve very [00:31:00] focused procedural training, you know, with lots of repetitions over the span of several weeks, to, to really focus in on that training.
[00:31:08] Eddie: Yeah. And, and it, it is interesting because if you're saying all these, these providers are interested or specialized, and they themselves, the supervisors have a lot more experience that you could say that, I'm not sure if there's data for this, that potentially the patient care experience is enhanced as well.
But I think there's, there's a couple of ways that we, we. Can aid our trainees. one is through having, you know, boots on the ground, experts and a lot of people with a lot of skill who are willing to teach. but another one is, is I think Meredith, you mentioned familiarity with technology. and I think listeners, this podcast might think I'm getting kickbacks from big ai.
I, I promise that's not the case, but it, it really is a, a real world that there's a rapid turnover of technology. There's now AI and technology driven procedural aids. There's ultrasounds with needle finders. There's [00:32:00] new different types of bronchoscopy with cone beam and robotic bon bronchoscopy. Is there value in teaching the old ways here?
And if you, if you do think there's value in that, how, how can you find the time in the same training program, three years, internal medicine, three years pulling critical care to teach the old ways and then also prepare people for, for the new things that are coming up? I
[00:32:24] Kaele: think that's a great question, Eddie.
And I'm not sure that I have all of, all of the answers to what sort of the, the future of AI holds, but I think that. To answer that, I would have to think about procedures. Specifically rather than in general, because I think this varies by the procedure and your particular practice environment. So in my training, I've used ultrasound or other technology in the vast majority of my procedures that I've done.
But I practice in a high resource setting and I always have access to ultrasound in the ICU for an emergent [00:33:00] procedure, whereas that might, might not be the same for somebody who practices elsewhere. However, you know, technology's not foolproof. and some technology, especially the newer AI technologies are not well studied.
So there is still a benefit, I think, to understanding how to do procedures blind or without this technology. So an example of this, maybe video laryngoscopy, which has shown to be shown to increase first pass success for intubations. But I personally believe it's important too. Learn how to do direct laryngoscopy for intubation because the light in the, or the camera might not work in, you're having an emergent intubation, or there's a lot of HESIs or hemoptysis that are, is obscuring your view.
And so I think it's still important to have, some training in how to, maybe do di direct laryngoscopy, I think for. Other [00:34:00] things, say bronchoscopy, for example, that may be less emergent. you know, relying on something like ebis, endobronchial ultrasound is going to significantly improve your diagnostic yield.
And so that is something that. I don't know, or I personally did not learn how to do an you know, biopsying of lymph nodes in the mediastinum blind, whereas I did all of mine with ebis, and so I don't necessarily know the utility of learning that without that ultrasound tool where navigational bronchoscopy you bring up.
The landscape is continuously changing. and not all of this technology is well studied or well studied against each other. and so I think it's helpful to one, study this to find out, hey, is this new flashy technology actually helpful and worth the cost versus the older technology? And then also some providers [00:35:00] in other locations, like I've talked to, providers in Canada, for example, who don't have access to robotic bronchoscopy.
And so they are learning in more of the older ways of, biopsying, lung nodules and things. And so I think that that might be more location or provider specific, such as if you were an interventional pulmonary, doctor, you may want to, um. Have greater breadth in the different procedures you can perform.
[00:35:30] Eddie: It's one of the, one of the strengths of our kind of ability to have access to a lot of different techniques and otherwise, because I remember one of my, co-fellows was going off to practice somewhere and he was facile with video laryngoscopy, but they only use a specific brand that is completely different.
and we had access to the, at least said something similar to that brand. And so he was able to get a, a couple of repetitions with that and some practice and supervised practice with that before he ended [00:36:00] up, starting practice. So I think that's really important.
[00:36:02] Meredith: And I, I think it's really important too, what you said, Kaele, just to emphasize again, the importance of research, and really understanding the value add.
You know, I am fortunate enough to be part of a generation. You know, when I started learning central venous catheterization of the internal jugular vein, it was done just with palpation. There was no ultrasound. Right? And so that's how I learned to place IJs. And then during my residency, ultrasound really became, um.
Available, to, to be utilized. And I, I would never go back, you know, and I think, I think now we have enough, time to really, see the advantages of the use of ultrasound. I'm not sure that every AI tool that comes down the pike will be as revolutionary. so I think it's important as you, as you said, to have things be studied and critiqued.
so that we know the technology that we're using is really of benefit, for safety and for. For the [00:37:00] patient. And then the other important piece of this is, again, it's, it's necessary to have supervisors and faculty that are keeping up with the technology. And I, I don't know if this is unique to my own environment, but it seems that sometimes learners are adapting and, to new technology at a faster pace than perhaps some of the supervising faculty.
And so I, I do think this brings up. questions about maintenance of certification, faculty continuing medical education, you know, making sure that the people supervising the thoracentesis of today are aware and the chest tube of today are most up to speed with the technology and, and the, and the resources of available that our trainees are gonna want to, to use.
[00:37:48] Eddie: Yeah, no, that makes, that makes a lot of sense. I, I think this is. Been a really enlightening and enriching discussion for me. I I was wondering if, if either of you had any closing thoughts or [00:38:00] any thoughts on what we can do as educators to continue to promote procedural excellence, whether, whether it be as the procedural list or the, the providers who are taking care of the patients patients before and after.
[00:38:12] Meredith: So some thoughts that I have, would be, it is really important to, have program directors and other faculty involved in education to have a common voice together and to be sharing experiences. And so I think we all learn best from each other and, and we learn in community. And so I'm really grateful to.
People who've done good work ahead that I, that I can learn from and, and be a voice to contribute to that. the, the other thing is, to really recognize that, your program experience, while there are some common things that, you know, all pulmonary and critical care trainees should be exposed to that are.
Outlined very clearly in the A-C-G-M-E and A BIM, procedural competency, documents. There are some unique aspects of your [00:39:00] training, and so if you're at a place that has adequate, navigational bronchoscopy exposure, you know, your training program may have that. As a procedure done by fellows.
Whereas if you're not you, you may not be in that same way. And there doesn't have to be a completely uniform experience across programs. And so I think having the freedom as a, as a program director and, and as a, as a leadership team to really focus in on a curriculum that makes sense for you, that's gonna give your fellows what they need, but then also, take advantage of the unique aspects of your training environment.
I think that ultimately in the end is, is what makes. training. Great.
[00:39:40] Kaele: I would echo, everything that, Meredith just said. And just to add to that, sort of thinking back on a, a comment that was made earlier during our discussion is that, you know, this is not just about the trainee that's in front of us, it's about the patients and the patient care that we're providing and.[00:40:00]
Having a good supportive sort of progression in procedural training is both good for the trainee 'cause they're gonna feel more comfortable, confident, and supported. But it's also important for the patients who are ultimately undergoing these procedures. And so just wanting to, to bring that, back together, that's something that I always emphasize when I'm talking about procedures to my, trainees, is that.
This isn't just about you, although I'm focusing on you, but this is about the patient and the patient comfort and patient outcomes, and. I think that is all I have to say.
[00:40:38] Eddie: Yeah, that's that's awesome. I, I, I, I think that's a great point to close on that we're, we're all here for the patients, and I think that patients, and at least I can speak for myself, I can rest assured that there's, dedicated and smart people like, you, Kaele and Meredith as well, who are thinking about this and making sure that the next generation providers are able to kind of take care of the [00:41:00] patients.
Before, after, and during procedures. But so I, I'd like to thank everybody for joining us for today's ATS Brief, easy episode. Please subscribe and share this episode with your colleagues. I know this is something that sneaks up on me every year, so I'll just remind everybody that the ATS abstract submission season is here.
Deadline November 4th. don't miss out, and we will see you next time.
[00:41:21] Kaele: Thank you so much for having us. This was really great. Thanks, Eddie.
[00:41:28] non: Thank you for joining us today. To learn more, visit our website@thoracic.org. Find more ats, breathe Easy podcasts on transistor, YouTube, apple podcasts, and Spotify. Don't forget to like, comment, and subscribe, so you never miss a show.