Medical students and basic skills acquisition

The world of medical education is becoming progressively more structured, particularly with an eye to standardization of curricula, and a great deal of this is being done in the name of patient safety.  I’m going to preface the rest of this post with an acknowledgement that I believe that it is important for our students to graduate with their MD with a certain basic and essentially universal skill set, and that they should learn to do that in a way that will not harm patients.  This is why simulation has become a core feature of medical education, and why I’ve had to learn to embrace it, as someone who came into education from the assessment and curriculum side.  However, sometimes good intentions can get in the way of medical education, and that seems to be happening to my students right now.

Let’s use Foley catheter placement as an example of the larger question at hand here, though it could apply to many basic technical skills.  All hospitals have a tremendous focus on CAUTI elimination in this day and age, which is appropriate.  However, many hospitals have placed a moratorium on medical students placing Foley catheters because administrators believe that students are by definition a risk factor for a CAUTI (Note:  NO literature supports this assertion.  None.) However, it’s not simply my expectation but that of the American College of Surgeons that entering interns know how to insert and maintain a Foley catheter.  This isn’t “just” a surgeon issue either; in fact, the core medicine clerkship guide published by what is now the Alliance for Academic Internal Medicine indicates that Foley catheterization is a core skill that should be demonstrated during the internal medicine clerkship (p.80-81).

Clearly there is an expectation that students learn how to place Foley catheters, but it’s not clear when and where they are truly learning this skill.  A recent survey of members of the Association for Surgical Education about basic technical skills had some fascinating findings, one of which included the teaching of Foley catheterization.  68% of respondents thought that Foley insertion was being taught as part of a course at their institution, while 18% did not think it was and 15% weren’t sure.  In terms of when Foley insertion was being taught, 41% thought before the surgery clerkship, 28% thought on the surgery clerkship but before the OR, and 19% thought it was being taught “on the fly.”  This single set of results highlights two big problems- one, that no one actually seems to know when and how basic skills acquisition is happening, and two, that there is still a culture of basic skills being taught in real time when simulation is readily accessible for these skills.  Stay tuned for more on this topic; we’re working on the manuscript.

With regard to the question about students increasing the risk of CAUTI, there is evidence to the contrary- at least in the face of a structured training paradigm.  A few years ago UPenn found itself in a similar situation to the one I currently face, in which their students were not being allowed to place Foleys because of concern about CAUTIs.  Rachel Kelz and her team initiated a credentialing program for the students as part of the surgical clerkship that is quite similar to the current checklist we use at Utah.  The findings from their study showed that Foleys inserted by credentialed medical students had a CAUTI rate that could not be differentiated from non-medical student inserted Foleys. I was asked to write a commentary on their manuscript, and in it I noted that structured training paradigms for skills are to the benefit of both our learners and our patients.

So, yes, I am on board for the idea that the students should be formally trained before we allow them to insert a Foley catheter- or place an IV or suture a laceration.  As medical educators and advocates for the care of our patients, it’s simply the right thing to do.  However, if my students are formally trained via simulation and have been “credentialed,” it’s important that they get this opportunity.  I hope that administrators everywhere can come to understand that.