Journal of Pediatric Critical Care

: 2020  |  Volume : 7  |  Issue : 6  |  Page : 309--310

Procedural competency in pediatric critical care trainees – The past, present, and future

Manu Sundaram1, Ikram Ul Haque2,  
1 Division of Critical Care, Sidra Medicine; Weill Cornell Medicine, Doha, Qatar
2 Division of Critical Care, Sidra Medicine, Doha, Qatar

Correspondence Address:
Dr. Manu Sundaram
Division of Critical Care, Sidra Medicine, Doha

How to cite this article:
Sundaram M, Ul Haque I. Procedural competency in pediatric critical care trainees – The past, present, and future.J Pediatr Crit Care 2020;7:309-310

How to cite this URL:
Sundaram M, Ul Haque I. Procedural competency in pediatric critical care trainees – The past, present, and future. J Pediatr Crit Care [serial online] 2020 [cited 2021 Jan 26 ];7:309-310
Available from:

Full Text

Pediatric critical care medicine (PCCM) fellowship trainees need to acquire the skills necessary to provide airway support and vascular access to critically ill patients. Because of the assumption that “practice makes perfect,” the number of procedures performed is often looked upon as a measure of achieving competence. The regulatory bodies such as the Accreditation Council of Graduate Medical Education (ACGME) in the USA, the American Board of Pediatrics (ABP), and the Royal College of Paediatrics and Child Health (RCPCH) in the UK expect PCCM fellows to become proficient in procedures such as endotracheal intubation and arterial and central venous catheterization; during the period of training.[1] However, neither the ACGME, ABP, nor RCPCH states the required number of completed procedures to demonstrate competence but relies on the individual fellowship training program to ensure proficiency. Despite this emphasis, studies suggest that the number of in-training critical care procedures by trainees is declining,[2],[3] likely due to multiple reasons including improved processes for early detection of the deteriorating patients, better noninvasive monitoring, and an increase in the use of noninvasive respiratory support, e.g., high-flow nasal cannula oxygen appears to reduce the need for endotracheal intubations.[4] Furthermore, in a modern practice with reduced total training time due to duty hours' regulations,[5] limited opportunities for the procedure are available to obtain competency. It is also known that failure to complete a procedure is associated with an increased risk of patient safety events.[6]

So how, new pediatric critical care fellowship training programs in developing countries are performing in this area given such constraints. In this issue of the Journal of Pediatric Critical Care, Qurat-ul-Ain et al. reported a descriptive study of the critical care procedures performed by the trainees of their program. The study concludes that trainees gained independence in performing specific procedures during the fellowship with adequate numbers, as previously suggested by some experts in the field. With the limitations identified by the authors in this study, e.g., number of attempts and complication rates, it is challenging to assess competency thoroughly. This study is an excellent effort to determine procedural competency training needs in a highly specialized field in a developing country.[7]

Clinical exposure alone cannot be solely relied upon to offer procedural skill training scaffolded by direct observation and feedback. The RCPCH has used Directly Observed Procedural Skills (DOPS) to evaluate practical procedural skills in pediatrics. The trainees need to be judged as competent to perform a range of procedures without supervision. They may need to repeat a DOPS for a specific procedure until this standard is achieved. Workplace-based assessments aim to encourage authentic learning by asking students to solve real-life clinical problems. They aim to assess what the student does in the clinical environment.

Deliberate methods must be developed and administered to ensure adequate procedural skills and educational opportunities like spending time in the theater to gain intubation and central venous line insertion skills. Virtual reality (VR) and augmented reality (AR) are two contemporary simulation models currently upgrading medical education. VR provides a three-dimensional and dynamic view of the structure and the user's ability to interact with them. The recent technological advances in haptics, display system, and motion detection allow the user to have a realistic and interactive experience. One of the most common utilities for AR currently being investigated is procedural learning. A simplified hydraulic pump has been used to simulate a femoral pulse for needle placement in interventional radiology. Using AR, the authors simulated the clinical environment and the actual needle insertion.[8] Magnetic resonance-based images have been used to create anatomically correct airways to teach learners appropriate techniques for endotracheal intubation.[9] By overlaying images using AR, facilitators demonstrated the changes in airway patency with changes in positioning, such as the sniffing position, extension, and hyperflexion.

With the goal of skill mastery or, more realistically, proficiency, procedural skills, teaching, and learning can be divided into two stages. First is the cognitive phase, which essentially involves conceptualization, where the “broader context of the skill” is appreciated by learning the comparative anatomy, indications, contraindications, and complications related to the procedure. Second, visualization and verbalization require opportunities to see and describe the procedure from start to finish. As per the Miller's pyramid, as the skills progress from a novice to an expert, so does their attitudes, skills, knowledge, cognition, and behavior. This move of competence from a learner to a teacher will help the ultimate goal of improving patient outcomes.


1ACGME Program Requirements for Graduate Medical Education in Pediatric Critical Care Medicine; 2013. Available from: [Last accessed on 2020 Sep 29].
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