In Response

We appreciate the response in the letter titled “Moving Toward Competency-Based Training” by DiBiase and Ballard.1 It is very encouraging to see other physicians endorsing competency-based training as a fundamental core of future training. While our original article focused primarily on developing an objective preclinical proficiency index for the training of first-year clinical anesthesiology residents and comparing it to graduating anesthesiology residents,2 we applaud the application of the core principle of competency-based training to practicing attending physicians as well and ensuring procedural competence.3 We strongly believe that simulator-based training is the way forward to enhance the quality of training provided and improve teaching. This reinforces our concept that purely time-based models of education requiring repetitive exposure should not be the standard to evaluate competence and proficiency as that system places more emphasis on quantity, rather than quality. To improve the standard of care for our patients, there is a need to reevaluate the methods being used to train physicians. Assessing proficiency through simulator-based training and motion tracking ensures objective evaluation by removing subjectivity. All learners engage in a pretest at the commencement of training to assess the baseline knowledge and skill set. Training can then be tailored to suit the learners’ needs and be individualized accordingly. Metrics may be used to provide individual feedback throughout training. After undergoing training, the efficacy of learning can then be assessed by a structured posttraining test. Learners can then be periodically assessed for retention of knowledge and skills at predetermined intervals. Similarly, we developed a curriculum for anesthesiology interns for training in perioperative ultrasound using simulators.4 This consisted of online didactics, simulation, live model scanning, and case-based learning, all combined into a single curriculum over the course of 13 days. Participants in this curriculum demonstrated increased knowledge retention and retention of manual skills after 3 months, with the interns’ skills exceeding those of graduating senior residents. Bortman et al5 also demonstrated significant improvement in clinical proficiency of residents in performing thoracic epidural analgesia by using patient-specific, 3-dimensionally printed, thoracic spine models for training. These residents had a significantly higher success rate in performing the procedure and required less assistance from supervising anesthesiologists as compared to those residents who underwent traditional teaching methods. As more training programs adopt simulator-based learning, trainees will be more proficient and feel more confident while performing procedures on patients unsupervised, while at the same time, ensuring that patient safety is upheld to the highest standard. With rapid introduction of technology in anesthesia, it is even more important to establish competence in orientation and appropriate use of technology in patient care. In the future, we hope there is development of an objective standardized curriculum based on preclinical proficiency to train all physicians. This metrics-driven approach will allow for the widespread adoption of true competency-based training resonate with the new Accreditation Council for Graduate Medical Education Milestones 2.0 paradigm.6 Ibrahim Quraishi, MDSyed Hamza Mufarrih, MDFeroze Mahmood, MDRobina Matyal, MDJohn D. Mitchell, MDDepartment of Anesthesia, Critical Care and Pain MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBoston, Massachusetts[email protected]