COUNCIL ON PERIOPERATIVE ECHOCARDIOGRAPHY (COPE) COMMUNICATION Training in Echocardiography—Top-Down or a Bottom-Up Approach? Since patients come to hospitals for treatment, medical training should be considered a desirable by-product of clinical care. With safety as the prime concern, the ‘‘first do no harm’’ paradigm necessitates that one patient should undergo one procedure. This is particularly challenging for clinical techniques that are invasive and require manual dexterity for acquisition of clinical proficiency; therefore, today’s medical educators are being asked to do more and better in less time. While these conflicting demands are logistical challenges, they also offer considerable opportunities for innovation and quality improvement. Current graduated medical education is based on an apprenticeship model in which physicians learn with time spent in accredited and supervised training programs. However, medical education is evolving into a competency-based model that requires demonstration of specific milestones for progression during training and ultimate graduation. While cognitive knowledge can be tested with standardized questionnaires, adequate clinical performance is implied with successful completion of accredited training.1 Due to variations in clinical exposure during training, environment and clinical exposure, the level of clinical expertise can vary considerably. Training in echocardiography in general, and perioperative transesophageal echocardiography (TEE) in particular, exemplifies these contradictions. It requires repetitive performance in a time-limited clinical exposure to acquire manual dexterity skills. Clinical exposure is neither graduated from simple to complex nor integrated with formal didactics. Understanding of echocardiographic anatomy and display also requires significant spatial re-orientation. There is also an expectation of rapid acquisition of motor skills required for probe manipulation and handling without an objective system of performance feedback.2-4 Also, using the clinical arena for training does not ensure a skillappropriate level of training,4 nor does it allow the instructor to ensure that the manual and cognitive education are coordinated. Success in task completion is subjective and endpoint-based (ie, image quality). Technological impediments have precluded the use of motion analysis to objectify manual dexterity skills during clinical imaging. Finally, achievement of certification is based on cognitive testing with an assumed component of manual dexterity. Improvements in technology have heralded an era of ‘‘mixed simulators,’’ which have elements of physical and virtual models, to enhance the educational experience. Trainees can interact with the virtual environment and perform physical maneuvers, resulting in virtual consequences necessitating further corrective physical maneuvers. With no consequences of failure or risk, invasive techniques can be practiced to facilitate the acquisition of psychomotor skills. These simulators are being used to create ‘‘facilitated learners’’ with reduced learning curves and improved clinical transferability of simulator acquired motor skills. There are numerous commercially available mixed echocardiography simulators.4 Probe manipulations made during image acquisition maneuvers with these simulators can be captured in the threedimensional space. This data can be graphically displayed in near realtime to provide an objective feedback with motion analysis.1,5,6 The use of simulators as performance assessment tools is a significant improvement from their classic role as situational or task training tools.4 Other specialties have formally introduced exposure to these mixed simulators during accredited training. Fundamentals of Laparoscopic Surgery and Fundamentals of Endoscopic Surgery are such curriculum-based programs, introduced in accredited surgical resi-

18A Journal of the American Society of Echocardiography

dency programs. Surgical residents now have to demonstrate a basic level of knowledge in a written exam and manual dexterity skills with a task trainer prior to clinical exposure in the operating room. Despite the availability of advanced echocardiography simulators, their role in formal training has not been defined. A combination of interactive online didactics and hands-on training with these simulators offers an opporFeroze Mahmood, tunity to improve the current echocardiogra- MD phy education model. In this multi-modality approach, the didactics can be coordinated with hands-on training in a curriculum-based approach.7 For example, trainees can learn about mitral valve anatomy via webbased lectures and practice acquisition of mitral valve views, enhancing the quality of both theoretical background and manual dexterity skills.7 Motion metrics have also been utilized to objectify the acquisition of motor skills and evaluate the readiness of trainees for clinical performance.1,8 Analysis of total time, path length, lag time and probe accelerations can be used to track the progression of skill acquisition and the intuitive nature of probe motion.7 This can also help identify trainees who require additional training, thus improving the quality of instruction. Various echocardiographic disease states (eg, wall motion abnormalities) can also be utilized during the performance evaluation phase and possibly using this technology as a performance evaluation tool after completion of training. After undergoing such an integrated training program, echo-na€ıve residents have demonstrated improved TEE image acquisition skills on the simulator. They also showed clinical transferability in that they were able to perform an actual unassisted intraoperative comprehensive TEE examination.1 With a multitude of logistical and clinical challenges for echocardiography education, such innovations provide opportunities to improve our current training paradigm. The current echo training program is based on a ‘‘top-down’’ approach, with well-defined criteria for certification. In contrast, the Fundamentals of Laparoscopic Surgery and Fundamentals of Endoscopic Surgery programs are ‘‘bottom-up,’’ with specific prerequisites for initiation of clinical training.9 Commercially available echocardiography simulators can display cardiac disease states and capture motion analysis during image acquisition. Ideally, trainees should go through a comprehensive program of Web-based didactics and simulator-based training prior to actual clinical exposure. This will ensure that the training experience is wholesome and satisfying. With orientation achieved in the skills laboratory, the trainees should acquire meaningful experience on their first clinical exposure. Recent investigations have clearly demonstrated the complementary nature of simulator-based education during clinical echocardiography education.1-3,10,11 It would be prudent to introduce this technology formally as a tool for clinical training and adopt a bottom-up approach to echocardiography training as well. REFERENCES 1. Matyal R, Mitchell JD, Hess PE, Chaudary B, Bose R, Jainandunsing JS, et al. Simulator-based transesophageal echocardiographic training with

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motion analysis: a curriculum-based approach. Anesthesiology 2014; 121:389-99. Bose RR, Matyal RR, Panzica PP, Karthik SS, Subramaniam BB, Pawlowski JJ, et al. Transesophageal echocardiography simulator: a new learning tool. J Cardiothorac Vasc Anesth 2009;23:5. Bose RR, Matyal R, Warraich HJ, Summers J, Subramaniam B, Mitchell J, et al. Utility of a transesophageal echocardiographic simulator as a teaching tool. J Cardiothorac Vasc Anesth 2011;25:212-5. Shakil O, Mahmood F, Matyal R. Simulation in echocardiography: an everexpanding frontier. J Cardiothorac Vasc Anesth 2012;26:476-85. Pfau PR. Colonoscopy and kinematics: what is your path length and tip angulation? Gastrointest Endos 2011;73:322-4. Obstein KL, Patil VD, Jayender J, San Jose Estepar R, Spofford IS, Lengyel BI, et al. Evaluation of colonoscopy technical skill levels by use of an objective kinematic-based system. Gastrointest Endos 2011;73: 315-21.e1.

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7. Mitchell JD, Mahmood F, Bose R, Hess PE, Wong V, Matyal R. Novel, multimodal approach for basic transesophageal echocardiographic teaching. J Cardiothorac Vasc Anesth 2014;28:800-9. 8. Shakil O, Mahmood B, Matyal R, Jainandunsing JS, Mitchell J, Mahmood F. Simulation training in echocardiography: the evolution of metrics. J Cardiothorac Vasc Anesth 2013;27:1034-40. 9. Vassiliou MC, Dunkin BJ, Marks JM, Fried GM. FLS and FES: comprehensive models of training and assessment. Surg Clin North Am 2010;90: 535-58. 10. Sohmer B, Hudson C, Hudson J, Posner GD, Naik V. Transesophageal echocardiography simulation is an effective tool in teaching psychomotor skills to novice echocardiographers. Can J Anaesth 2014;61:235-41. 11. Neelankavil J, Howard-Quijano K, Hsieh TC, Ramsingh D, Scovotti JC, Chua JH, et al. Transthoracic echocardiography simulation is an efficient method to train anesthesiologists in basic transthoracic echocardiography skills. Anesth Analg 2012;115:1042-51.

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