Saturday, 2 March 2019

An anesthetic view of the Core Clinical Competencies

An anesthetic view of the Core Clinical Competencies

An anesthetic view of the Core Clinical Competencies

Here are the Core Clinical Competencies with an anesthetic twist. The first two, patient care and medical knowledge, are the traditional things we’ve always taught. The last four are a bit softer and harder to nail down. But hey, you have to know all six, so let’s plow through them.

Patient care
Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.
Residents are expected to do the following:

communicate effectively and demonstrate caring and respectful behaviors when interacting with
patients and their families
gather essential and accurate information about their patients
make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment
develop and carry out patient management plans
counsel and educate patients and their families
use information technology to support patient care decisions and patient education
perform competently all medical and invasive procedures considered essential for the area of practice
provide health care services aimed at preventing health problems or maintaining health
work with health care professionals, including those from other disciplines, to provide
patient-focused care.

The anesthetic take on patient care
This is the most inherently obvious of the clinical competencies. We are patient care people, after all! You can wax dreamy about all the other educational rigmarole,but if the tube doesn’t find the trachea, or the spinal needle doesn’t splash down in cerebrospinal fluid, or the central line knifes through the pleura, then we’re doing it all wrong.

Patient care means taking care of the patient correctly,and to detail how you take care of a patient correctly, read Miller cover to cover and do a residency. Because it all boils down to taking good care of the patient:
Secure that airway.
Get the line in.
Keep an eye on those vital signs.
Provide good analgesia.
React to changes and problems.
Keep those lines open between you and the surgeon, the obstetrician, and the consultants so you don’t miss anything.
That is the anesthetic take on patient care, and there’s not a lot of room for interpretation.

Medical knowledge
Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g., epidemiological and social-behavioral) sciences and the application of this knowledge to patient care.
Residents are expected to do the following:
demonstrate an investigatory and analytic thinking approach to clinical situations
know and apply the basic and clinically supportive sciences that are appropriate to their discipline.

The anesthetic take on medical knowledge
The anesthetic take on medical knowledge is little removed from the anesthetic take on patient care. You need to know the medicine to care for the patient:
Chest pain, ST segment changes? You have to know the components of ischemia, know the latest on beta-blockade (good and bad), and know how best to intervene.
New device for securing the airway safely? You have to know how to use it to care for the patient.
New block (say, the transverses abdominalus planar (TAP) block for relieving abdominal pain)? You need to know the landmarks, how you can tell the transverses abdominus on echo, and how to lay the local anesthetic in there. This is just the knowing behind the doing, so there’s not much interpretive wiggle room in this Core Clinical Competency. So far, so good. Now things get a little mushier.

Practice-based learning
and improvement
Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents are expected to do the following:
analyze practice experience and perform practice-based improvement activities using a systematic methodology
locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems
obtain and use information about their own population of patients and the larger population from which their patients are drawn
apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness
use information technology to manage information, access online medical information, and support their own education.

The anesthetic take on practice-based learning and improvement
This means looking at the literature. None of us have enough experience in our own individual practice to draw meaningful demographic conclusions. We tend to stew in our empiric juices and say, “Well, I did this once and somehow the patient survived, so gee whiz, this must be the way to do it!” This n of 1 that we’ve all leaned on doesn’t hold up to statistical scrutiny, so we have to go to the literature. Hillary Clinton told us that “it takes a village” to raise a child. When it comes to interpreting medical information, it takes the global medical village to guide our therapy.Here’s one example that affected our recent thinking:
Beta-blockers are great! Studies drift out that seem to indicate that one beta-blocker pill given in the perioperative period will stave off death for a thousand years!
Hey, let’s give everyone beta-blockers, and all our patients will live forever.
This makes inherent sense because slowing down the heart prevents ischemia. Right!

Now, the literature looks at this more rigorously. Out comes the POISE study, looking at 80,000 plus
patients and giving them all beta-blockers. And there’s a fly in the soup!
Ischemia is, indeed, down.
But death and stroke rates are up.
Oh, no! The sacred cow of perioperative beta-blockade is slain.

Could any one of us, in our own experience, have come up with these conclusions? I don’t care how fast you turn over a room; you’re not going to rack up 80,000 anesthetics in a short time and study this issue – hence practice-based learning and improvement as a Core Clinical Competency. What’s the crucial skill you need in this area? You need to answer the question, is the information in the literature valid? Is it meaningful? Should I change my practice based on what the authors say? Every month, the journal articles are filled with studies – do you change your practice every time a new paper comes out?Do you snapupe very new procedure because it has an “Oh, that looks neat!” air about it? Obviously not.The connoisseur of the literature knows the good stuff from the bad, the Dom Perignon from the Listerine.

Interpersonal and communication skills
Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients’ families, and professional associates. Residents are expected to do the following:
create and sustain a therapeutic and ethically sound relationship with patients 
use effective listening skills and elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills
work effectively with others as a member or leader of a health care team or other professional group.

The anesthetic take on interpersonal and communication skills
This competency and the next one (professionalism) are damned hard to tease apart. I wish they would have checked with me before they split these into two. Here goes, but, as you will see, there’s a lot of overlap here. You can’t be an oaf, dolt,moron, or insensitive clod with the patient, and you have to get ideas to them and get ideas from them. Same goes for working with nurses, cardiopulmonary bypass techs, doctors, intensive care unit staff, respiratory techs, you name it. Anyone that crosses paths with you in the clinical orbit, you have to work well with the mand make sure you get the information right.

Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to do the following:
demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supersedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and ongoing professional development
demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical
care, confidentiality of patient information, informed consent, and business practice
demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities.

The anesthetic take on professionalism
As noted previously, this goes hand in glove with the competency of interpersonal and communication skills. A professional communicates well with patients, fellow doctors, and all other medical providers. (Core Clinical Competencies force you to use administrator speak, with stupid phrases like “health care providers” and crap like that.) Part of that communication is registering the different backgrounds your patients have different cultures, being sensitive to gender concerns, being sensitive to different disabilities. This is the Core Clinical Competency that steams most anesthesiologists (and, I suspect,most other specialties, too). Of course, we know to be professional! God all fishhooks, we went through premed and med school and are now in postgraduate training.Do I need the Core Clinical Competencies to tell me that I have to be ethical?We all took the Hippocratic oath; our whole life has been geared to taking good care of our fellow human beings. Now some education-wonk is telling me I have to be sensitive and appropriate around a person of different background, or a person with a disability?
Gimme a break! 
Systems-based practice
Residents must demonstrate an awareness of and responsiveness to the larger context and system of
health care and the ability to effectively call on system resources to provide care that is of optimal value. Residents are expected to do the following:
understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice
know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources.
practice cost-effective health care and resource allocation that does not compromise quality of care.
advocate for quality patient care and assist patients in dealing with system complexities
know how to partner with health care managers and health care providers to assess, coordinate,
and improve health care and know how these activities can affect system performance.

The anesthetic take on systems-based practice
Money makes the world go round, and medicine is no exception. For anesthesiologists, the main idea we glean from systems-based practice is related to money:
practice cost-effective medicine
know how you fit into the great big overall picture do QA things (they don’t call it that anymore – they say continuous quality improvement – but we all know that’s just more administrator–double talk) There you have it, the Core Clinical Competencies laid out, complete with the anesthetic take on them. Sound jaded? Yeah, it’s a little jaded. If you pull aside the average resident or attending and ask what he or she thinks about the Core Clinical Competencies, you’ll probably get some variant of my barbed comments. But they’re here to stay, and we have to know how to teach them, so that’s why this book exists. Rather than sit here and dwell on them and debate their relative merits, let’s do what we’re best at: clinical anesthesia. We’ll lay out a case, then wrap that case around the Core Clinical Competencies. That way, we’ll breathe some life and relevance into these bastards. So grab your hat and mask, and let’s have at it.

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