JAMA: Trainee protocols may lead to more evidenced-based care
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Researchers from the University of Pennsylvania in Philadelphia found that students in high-protocol critical-care environments fared equally well on certification exams as those who studied in low-protocol environments, according to a study published Sept. 6 in the Journal of the American Medical Association.
Researchers looked at 88 programs that had trainees who completed the American Board of Internal Medicine's Critical Care Medicine Certification Examination. Of those programs, 42 were classified as high-intensity—based on the number of implemented protocols—and 46 as low-intensity, with 304 trainees and 249 trainees, respectively. In an analysis of their test scores, researchers found no difference in mean scores between the two groups.
“The main thing we wanted to address was this controversy that protocols are bad,” lead author Meeta Prasad, MD, from the department of medicine at University of Pennsylvania, told Healthcare Technology Management. “Maybe they’re not so bad with regard to education.”
The controversy stems from a lack of hands-on experience for trainees in the high-protocol environments. Among some of the protocols implemented in programs included in their study, Prasad noted ventilation liberation, sedation management and lung-protective ventilation.
“Most of the protocols are driven either by nurses, respiratory therapists or both,” she said. “Instead of a student or trainee making a decision about a change in a ventilator, a respiratory therapist does it, according to a protocol.”
Some in the medical community feel that those protocols limit the formulation of decision-making skills for trainees.
“There is a big controversy in the critical-care community about the effect of protocols on education. There’s controversy about protocols in general, but particularly, the fear is that it might be taking residents and trainees out of decision-making—a very important experiential component of their learning,” she said. “The fear is that it might result in less well-trained, less competent, less confident physicians at the end of the day. This study didn’t indicate that.”
Prasad noted that the exams are limited in their ability to test how someone would perform in the real-world setting. “They don’t measure everything,” she said, “and that’s one of the limitations of the study, unfortunately. But on the other hand they’re one of the best available measures of knowledge we have.”
The important thing regarding the implementation of protocols is striking a balance between providing safe and quality care for patients, but also providing an adequate education for junior clinicians. When asked how to do that, Prasad said:
“In some ways, these protocols are doing that. They are standardizing care, giving us ways to optimize the evidence and incorporate it into our practices,” she said. “As it turns out, it doesn’t look like it’s harming our education. Some argue that protocols enhance education by providing a concise summary of what best practices should be. One argument is that, in fact, this is one way to balance those two things.”