The Need for Simulation-Based Procedural Skills Training to Address Proposed Changes in Accreditation Council for Graduate Medical Education Requirements for Pediatric Residency Programs.

Pediatric residents must be able to safely and successfully perform procedures used by pediatricians in general practice.1 Therefore, it is critical that pediatric residents develop and demonstrate competency with specific “core” procedures during training. Prior iterations of the Accreditation Council for Graduate Medical Education (ACGME) Requirements for Graduate Medical Education in Pediatrics delineated specific requirements for procedural competence that trainees must meet. However, a recent set of proposed changes to these guidelines included near-complete removal of these requirements. While a subsequent update restored some of the “core” procedures found in the prior guidelines (ie, bag-mask ventilation, lumbar puncture, peripheral intravenous catheter placement, neonatal delivery room resuscitation, and simple laceration repair), intraosseous needle placement, bladder catheterization, giving immunizations, incision and drainage of abscess, neonatal endotracheal intubation, reduction of simple dislocation; simple removal of foreign body; temporary splinting of fracture; umbilical catheter placement; and venipuncture remain conspicuously absent IV. B. 1. b). (2). (a). (vii)–(xviii).2 In addition, the ACGME has proposed a significant decrease in required resident inpatient time within the neonatal intensive care unit, pediatric intensive care unit, and emergency department (Section IV.C.6.c).3 The proposed revisions are intended to improve resident education and patient care by allowing programs to focus on those procedures relevant to the community's needs and the resident's future career, creating more local flexibility for residency directors. We recognize that these changes are made with the best of intentions, with the ostensible goals of reducing the regulatory burden on individual institutions, focusing residency education more directly on general pediatrics, identifying “core” procedures and allowing residents to develop a more customizable course of study. We also recognize the responsiveness of the ACGME with regard to the concerns raised about the initial suggested language. That being said, we remain concerned that even the current proposed guidelines may have unintended consequences on learner procedural competence. Our objective in this editorial is to discuss these unintended consequences and advocate for a simulation intervention that can maintain the tailored course of residency while still supporting the basic standards needed to ensure adequate training in critical skills. CURRENT STATE Pediatric residents in the United States already experience fewer opportunities to attain procedural experience now than they did a decade ago.4 Recent data suggest that by the time they graduate, residents only perform an average of three of each procedure currently required by the ACGME.5 While programs such as the Neonatal Resuscitation Program and Pediatric Advanced Life Support are commonly used to teach critical resuscitation skills, current research shows that simple participation does not guarantee competency.6,7 As pediatricians and medical educators, we have concerns that eliminating training in lifesaving procedures, such as those still excluded within the current draft of the ACGME guidelines, will compound these already serious limitations. The pediatric workforce is also unequally distributed in the United States.8 Generally pediatricians are the only healthcare professionals available in some rural and disadvantaged locations. A 2018 study indicated large differences in the geographic availability of pediatric care. Rural areas experienced steeper declines in pediatric services, with a 24.2% decline than urban areas, where the number of pediatric inpatient units decreased by 18.6%.9 For children living in remote or rural areas, the general pediatrician is often required to serve as a front-line acute care provider in conditions of duress, a role that will not be unfulfilled without adequate training in all needed procedures. Thus, it is crucial that they be competent in a broad array of procedures. However, the revised draft of the ACGME guidelines contains language stating that “It will be up to the program to provide instruction and opportunities for residents to perform other procedures to prepare residents for future practice,” an approach that may result in significant variation in training standards. Such variation may create a lack of readiness to fully meet the healthcare needs of the children in their communities, hence perpetuating disparities in pediatric care. Accordingly, methods for ensuring access to adequate competency-based training must be developed. Simulation: An Evidence-Based Solution to Demonstrate Procedural Competency Systematic simulation-based medical education provides a viable means to bridge the procedural gap and address the inadequacies in procedural experience created by the new guidelines. By basing this approach on proven educational frameworks and pedagogies, we believe that the skills-based educational needs of pediatric residents can be met within the current ACGME framework, ensuring that trainees gain the benefits of the new ACGME requirements without experiencing the inherent potential drawbacks. Indeed, the revised guidelines themselves suggest this as a possibility.2 Simulation-based procedural skills training should follow an evidence-based approach to be maximally effective.10 Rapid cycle deliberate practice (RCDP) is a simulation-based education model where learners rapidly cycle between short simulation-based practice periods and directed feedback within the scenario until competency is achieved.11 Learners do not advance to the next objective until the current one has been achieved. By continually providing formative testing of learner performance against ACGME-established standards, RCDP-based skills training can support the achievement of procedural competence even when opportunities to perform these procedures on patients are at a minimum.12,13 The current literature suggests that RCDP procedural skills training is associated with positive learner outcomes.14 Other competency-based skill-training paradigms carry a similar breadth of literature to support their use in healthcare professions, such as mastery learning, in situ (ie, at the bedside), and “just-in-time” simulation training, proficiency-based curricula.15–17 Simulation has been successfully used for the competency of procedural skills in specialties such as surgery,18 internal medicine, and orthopedics.19 Given the breadth of proven methodologic options available, we believe that it is incumbent on pediatric programs to use them to standardize procedural curricula for future pediatric residents. As simulation educators, we acknowledge that these interventions are not without cost in terms of finance and resources. However, this need not be a barrier as effective, low-cost simulators exist that have proven effective in other venues. Indeed, some of the largest studies documenting the effectiveness of critical procedure-based in situ simulation have used low-cost simulation programs in resource-poor environments.20,21 Given the innovative low-cost options available,22,23 the potential reduction of healthcare costs of errors and complications related costs attributable to the use of simulation,24 and the positive impact of simulation-based curricula for procedural proficiency on educational outcomes,25 we believe that the cost-benefit analysis is squarely in favor of the use of simulation with the “value added.”24,26 A CALL TO ACTION: THE ACGME PEDIATRIC SIMULATION TASK FORCE In light of this, we propose the development of an ACGME Pediatric Simulation Task Force charged with leveraging simulation-based education to achieve procedural skills competency. Such a task force could leverage the multiple methodologies referenced previously to develop longitudinal and other curricula over trainee years and advocate for their use at ACGME-accredited sites. Furthermore, this task force could also be charged with refining existing simulation-based assessment tools for pediatric procedural skills, producing valid evidence for their use in various contexts of care, and conducting ongoing cost-benefit analyses. The pediatric simulation community has pioneered much of the scholarly work cited in this article and could skillfully and effectively direct that expertise toward achieving these goals.11,27 CONCLUSIONS As leaders of national and international pediatric simulation sections, groups, and organizations, we jointly advocate for the development of comprehensive simulation-based training programs for procedural skills in pediatric residencies and support the current use of these pedagogical methods to improve the cognitive, technical, and behavioral skills of the pediatric physician workforce. As residency programs adjust curricula to the new ACGME requirements, such programs will perform a critical function in assuring adequate training and competence. We hope that our recommendations here can serve as scaffolding to proactively address this issue, mitigate any unintended consequences, and leverage the beneficial effects of simulation-based education.