Mastery learning of thoracentesis skills by internal medicine residents using simulation technology and deliberate practice

BACKGROUND: Thoracentesis has been identified as a core competency for hospitalists. Residency training may not provide adequate preparation to perform this procedure. OBJECTIVE: Our aim was to use a thoracentesis simulation to assess graduating residents' proficiency in thoracentesis procedural skills and to evaluate the impact of an educational intervention on skill development to mastery standards. DESIGN: This was a pretest-posttest mastery learning design without a control group. SETTING: Participants were 40 third-year internal medicine residents in a university-affiliated program. INTERVENTION: Using an observational checklist, each resident underwent baseline assessment of thoracentesis skill using a standardized clinical history, radiograph, and thoracentesis simulation. After baseline testing, residents received two 2-hour education sessions featuring a videotaped presentation and deliberate practice with the thoracentesis simulator. MEASUREMENTS: Residents were retested after the intervention. Skill mastery was defined as meeting or exceeding the minimum passing score (MPS) set by an expert panel at thoracentesis posttest. Those who did not achieve the MPS had additional deliberate practice and were retested until the MPS was reached. RESULTS: Performance improved 71% from pretest to posttest on the clinical skills examination. All residents met or exceeded the mastery standard. The amount of practice time needed to reach the MPS was the only predictor (negative) of Posttest performance. The education program was rated highly. CONCLUSIONS: A curriculum featuring deliberate practice dramatically increased the skills of residents in thoracentesis. Residents enjoy training and receiving evaluation and feedback in a simulated clinical environment. This mastery program illustrates a feasible and reliable mechanism to achieve procedural competency.