Article deposited according to agreement with BMC, December 6, 2010.YesFunding provided by the Open Access Authors Fund

Accreditation Council for Graduate Medical Education

AG Hill

C Bulte

CW Hayes

D Shanks

DJ Shulkin

EH Morrison

Elise Teteris

GC Huang

GC Wickstrom

GL Dunnington

Irene WY Ma

IW Ma

James M Roberts

Joint Royal Colleges of Physicians Training Board

M Mourad

Maria Bacchus

OT Cate

RK Reznick

Royal College of Physicians and Surgeons of Canada

RS Wigton

SE Card

SJ Millington

TE Norris

TL Schwenk

V Weiss

BMC Medical Education

English

PubMed

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Who is teaching and supervising our junior residents' central venous catheterizations?

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RESEARCH ARTICLE Open AccessWho is teaching and supervising our juniorresidents’ central venous catheterizations?Irene WY Ma1,2*, Elise Teteris2, James M Roberts3 and Maria Bacchus1AbstractBackground: The extent to which medical residents are involved in the teaching and supervision of medicalprocedures is unknown. This study aims to evaluate the teaching and supervision of junior residents in centralvenous catheterization (CVC) by resident-teachers.Methods: All PGY-1 internal medicine residents at two Canadian academic institutions were invited to complete asurvey on their CVC experience, teaching, and supervision prior to their enrolment in a simulator CVC training curriculum.Results: Of the 69 eligible PGY-1 residents, 32 (46%) consenting participants were included in the study. Therewere no significant baseline differences between participants from the two institutions in terms of sex, number ofICU months completed, previous CVC training received, number of CVCs observed and performed. Only 16participants (50%) received any CVC training at baseline. Of those who received any training, 63% were taught onlyby senior resident-teachers. A total of 81 CVCs were placed by 17 participants. Thirty-two CVCs (45%) weresupervised by resident-teachers.Conclusions: Resident-teachers play a significant role both in the teaching and supervision of CVCs placed byjunior residents. Educational efforts should focus on preparing residents for their role in teaching and supervisionof procedures.BackgroundThe ability to perform bedside procedural skills compe-tently is an important part of medical practice. Proce-dures such as lumbar puncture, thoracentesis, andcentral venous catheterization (CVC), are commonlyperformed for diagnostic and/or therapeutic reasons andare often taught in residency training programs [1,2].Indeed, for CVC, competency in this skill is a statedobjective for a number of postgraduate medical trainingprograms [3-7].However, despite efforts in improving the training oftechnical skills [8], many residents are uncomfortable per-forming procedures [9]. Inadequate clinical exposure toprocedures [2] and an insufficient supply of faculty profi-cient in teaching and supervising procedures have beenpreviously cited as barriers to procedural training [1,10,11].On the ward, resident teachers play an important rolein the education of junior learners [12,13]. With respectto procedural supervision, it has recently been reportedthat many residents supervised procedures prior to feel-ing comfortable with performing the procedure them-selves [14]. However, it is unknown to what extent doresidents participate in the teaching and supervision ofprocedures.Therefore, we aimed to evaluate the extent of teachingand supervision of CVC insertion by junior residentsat two Canadian academic internal medicine residencyprograms. An estimation of the prevalence of resident-supervision and resident-teaching will help guide medicaleducators in terms of where to focus their curriculumefforts.MethodsDuring the academic year of 2009 (July 2009 to May2010), all junior residents in their PGY-1 year from theUniversity of British Columbia (UBC) (n = 47) andUniversity of Calgary (n = 22) were invited to enrollin our simulation CVC educational curriculum. Detailsof this simulator curriculum have been previouslydescribed [15]. Only residents who provided written* Correspondence: ima@ucalgary.ca1Division of General Internal Medicine, University of Calgary, Calgary, AB,CanadaFull list of author information is available at the end of the articleMa et al. BMC Medical Education 2011, 11:16http://www.biomedcentral.com/1472-6920/11/16© 2011 Ma et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.informed consent were included in this study. The studywas approved by ethics review board from both aca-demic institutions.Prior to the start of the CVC course, which occurredthroughout the academic year, participants were invitedto complete an anonymous survey outlining their base-line CVC experience. In addition, they were asked to esti-mate the total number of and type of CVCs placed duringtheir training, as well as information of who supervisedthose procedures. Supervision at both institutions isinformally defined by the presence of a supervisor in theroom where the procedure is being performed. Thesupervisor may or may not be gowned and gloved. How-ever, a procedure performed without a supervisor directlyin the room is considered an unsupervised procedure.Data AnalysisBaseline group comparisons were made with the use ofWilcoxon rank-sum tests and Fisher’s exact tests whereappropriate. Comparisons in proportions were madewith the use of chi-square tests. All reported P valuesare two-sided. Analyses were performed using SAS sta-tistical program version 9.1 (SAS Institute, Cary, NC).ResultsA total of 32 participants were included in this study.Twenty-two participants out of 47 PGY-1 trainees (47%)were recruited from UBC and ten out 22 PGY-1 trainees(45%) were recruited from the University of Calgary.There were no significant baseline differences betweenthe cohort from UBC and that from the University ofCalgary (Additional file 1).Training and SupervisionPrior to the simulation training, only 16 (50%) participantshad received any training on CVC (Additional file 1). Tenout of these 16 participants (63%) were taught only bysenior resident-teachers. The remaining six participantswere taught by faculty members only (n = 3), a combina-tion of faculty and senior resident-teachers (n = 2), whileone participant was taught by a resident of the same levelof training as the participant (n = 1). Of the 16 participantswho received prior CVC training, majority of the trainingwas received within the context of patient care (n = 14,88%). One participant received prior simulator training,while one participant received training in the context ofpatient care as well as on simulators.At baseline, a total of 81CVCs had been placed by 17PGY-1 participants. Of the 81 CVCs performed, 71 (88%)were supervised. Overall, 39 of the 81 CVCs (48%) werereported to be supervised by faculty members and 32(40%) by residents (Figure 1). Ten of the 81 CVCs (12%),performed by three participants, were unsupervised. Allthree participants had previously placed more than nineCVCs.Supervision of CVCs Based on Line-typeOf the 81 CVCs placed, 37 were internal jugular lines, 23were subclavian, and 21 were femoral lines (Figure 1).Faculty members supervised 70% of subclavian, 41% ofinternal jugular, and 38% of femoral lines. Indeed, facultysupervision is significantly higher for subclavian linesthan for non-subclavian lines (P = 0.02).DiscussionThe results of this study confirm that resident-teachersplay an important role both in the teaching and supervi-sion of CVCs for junior residents. Resident-teachers wereresponsible for teaching 63% of the junior residents whoreceived any training, and much of this training occurredin the context of patient care. In terms of CVC supervi-sion, 40% of all CVCs were supervised by residents. Incontrast to subclavian CVCs, where faculty supervisionwas reported to occur 70% of the time, resident-teacherssupervised more non-subclavian CVCs than facultymembers (45% vs 40%). Lastly, only 12% of CVCs byjunior residents were unsupervised, and each of the unsu-pervised CVCs was placed by trainees with considerableCVC experience.A number of factors may potentially be responsible forsignificant involvement of residents in the teaching andsupervision of CVCs placed by junior residents. First,over the past twenty years, the number of general inter-nists who perform procedures has been shown to bedeclining [16]. By 2004 in the United States, only 16% ofgeneral internists reported performing CVC in their prac-tice, compared with 39% in 1984 [16]. Not surprisingly,internists are increasingly less confident in their ability toteach and supervise procedures [10]. As faculty membersbecome increasingly uncomfortable with teaching orsupervising CVC, resident-teachers perhaps may be tak-ing an increasing role in CVC teaching and supervision.Figure 1 Percentage of central venous catheters (CVC)supervised by faculty and resident-teachers. Bar graph ofpercent of of central venous catheters supervised by faculty andresident-teachers.Ma et al. BMC Medical Education 2011, 11:16http://www.biomedcentral.com/1472-6920/11/16Page 2 of 4Second potential reason behind high involvement of resi-dent-teachers is that performances of CVCs may beoccurring at times when faculty members are not asreadily available. For example, CVCs placed at night maynot have the same level of supervision as CVCs placedduring the day [17]. Such discrepancies in supervisionbetween weekdays and weekends/evenings have pre-viously been reported for the supervision of running car-diac arrest resuscitations in teaching hospitals [18].Third, having residents function as teachers or supervi-sors maybe mutually beneficial for both the senior resi-dent-teacher and the junior resident-learner [19]. Thevery act of teaching may enhance learning on the part ofthe resident-teacher [20], while junior resident-learnersmay learn better from a teacher whose performance levelis more similar to the learner’s than from an expert[19,21]. Indeed, in a recent survey of medical residents,86% of survey participants felt that medical proceduresshould be taught by a senior resident or fellow [11].However, the disadvantage of placing resident-teachers,not yet comfortable with the procedure [14], in the posi-tion of supervising others may potentially result inadverse patient safety consequences. Complication ratesof procedures supervised by resident-teachers, comparedwith those supervised by faculty, should be further evalu-ated. In a recent survey of internal medicine residents inCalifornia, up to 26% of PGY-2 residents reported super-vising central venous catheterization (CVC) before feel-ing comfortable with their own procedural performance[14]. The observation that resident-teachers play a signifi-cant role in the teaching and supervision of CVC forjunior trainees argues for the need for educational inter-vention for senior-resident-teachers. Indeed, a needsassessment of teaching skills for surgical residents haspreviously demonstrated that the item, “provide effectivecoaching with supervision of performance of technicalprocedures,” was rated as the most important teachingactivity by the survey participants [22]. What educationalintervention best suits the needs for teaching proceduralskills is unknown. In a systematic review of residents-as-teachers curricula, more than half of the reported inter-ventions consisted of a one-off intervention [23]. A com-bination approach of including a longitudinal teachingprogram with a one-off workshop for teaching proceduralskills has also been previously described [24]. Effective-ness of these educational interventions, however, remainsunclear [23].Our study has a number of limitations. First, the datawas obtained by self-reporting measures and accuracy ofthe data was not verified. However, given that most ofthe residents (84%) have performed fewer than fiveCVCs, accuracy of the recalled information is likelyhigher than a comprehensive survey administered to resi-dents at all levels of training. Second, results representonly on 46% of the combined PGY-1 population and maylimit the generalizability of the conclusions. Specifically,our study reports 40% of CVCs were supervised by resi-dents. Without capturing all CVCs placed by PGY-1s inboth institutions, the degree of bias is unknown. How-ever, the goal of our study was to evaluate the extent ofresident supervision. While the percentage of CVCsupervision may be subject to bias, a reported number of32 CVCs in two academic institutions is likely the mini-mum number of CVCs being supervised by resident-tea-chers. This represents a conservative estimate of theextent of involvement by resident-teachers. Thirdly,despite the fact that both academic institutions in ourstudy have a policy on having a faculty supervisor beavailable at all times for the trainees, whether or notfaculty members were less likely to be called upon tosupervise procedures outside the standard work hoursthan during standard work hours was not captured byour survey. Lastly, we did not survey the senior resident-teachers to ascertain their degree of comfort in supervis-ing or teaching procedures. However, based on work byothers [14], it is highly likely that a number of the seniorresident-teachers would be uncomfortable with theirrole. Future study should focus on the clinical conse-quences of having resident-teachers supervise proce-dures, types of teaching skills required for teaching andsupervising procedures, and how to optimize educationalinterventions for our resident-teachers.ConclusionsIn conclusion, resident-teachers play a large role in theteaching and supervision of CVCs for junior residents.Educational efforts should focus on preparing residentsfor their role in teaching and supervision of procedures.Additional materialAdditional file 1: Appendix A - Baseline Characteristics ofParticipants. Table of baseline characteristics of participants.AcknowledgementsThis work is supported jointly by funding from the Departments ofMedicine, University of Calgary and University of British Columbia. There areno financial disclosures related to the design and conduct of the study,collection, management, analysis, and interpretation of the data, orpreparation, review or approval of this manuscript.Author details1Division of General Internal Medicine, University of Calgary, Calgary, AB,Canada. 2W21C, University of Calgary, Calgary, AB, Canada. 3Division ofGeneral Internal Medicine, University of British Columbia, Vancouver, BC,Canada.Authors’ contributionsIWYM: participated in research design, acquired, analyzed and interpreteddata; drafted the paper. ET: participated in research design, acquired,analyzed data, and revised the paper critically. JMR: participated in researchMa et al. BMC Medical Education 2011, 11:16http://www.biomedcentral.com/1472-6920/11/16Page 3 of 4design and revised the paper critically. MB: participated in the interpretationof data, revised it critically. All authors read and approved the finalmanuscript.Competing interestsThe authors declare that they have no competing interests.Received: 12 June 2010 Accepted: 25 April 2011Published: 25 April 2011References1. Norris TE, Cullison SW, Fihn SD: Teaching procedural skills. J Gen InternMed 1997, 12(Suppl 2):S64-70.2. Card SE, Snell L, O’Brien B: Are Canadian General Internal Medicinetraining program graduates well prepared for their future careers? BMCMed Educ 2006, 6:56.3. Accreditation Council for Graduate Medical Education: ACGME ProgramRequirements for Graduate Medical Education in Critical Care Medicine.2011 [http://acgme.net/acWebsite/downloads/RRC_progReq/142pr707_ims.pdf], Accessed January 18.4. Royal College of Physicians and Surgeons of Canada: Objectives ofTraining in Internal Medicine. 2003 [http://rcpsc.medical.org/residency/certification/objectives/intmed_e.pdf], Accessed January 18, 2011.5. Joint Royal Colleges of Physicians Training Board: Specialty trainingCurriculum for General Internal Medicine. 2011 [http://www.jrcptb.org.uk/specialties/ST3-SpR/Documents/2009%20GIM%20curriculum.PDF], AccessedJanuary 18.6. Royal College of Physicians and Surgeons of Canada: Objectives ofTraining in Emergency Medicine. 2008 [http://www.rcpsc.edu/residency/certification/objectives/emergmed_e.pdf], Accessed January 18, 2011.7. Royal College of Physicians and Surgeons of Canada: Objectives ofTraining in the Specialty of General Surgery. 2010 [http://www.rcpsc.edu/residency/certification/objectives/emergmed_e.pdf], Accessed January 18,2011.8. Reznick RK, MacRae H: Teaching Surgical Skills – Changes in the Wind. NEngl J Med 2006, 355:2664-9.9. Huang GC, Smith CC, Gordon CE, et al: Beyond the comfort zone:residents assess their comfort performing inpatient medical procedures.Am J Med 2006, 119(71):e17-24.10. Wickstrom GC, Kelley DK, Keyserling TC, et al: Confidence of academicgeneral internists and family physicians to teach ambulatory procedures.J Gen Intern Med 2000, 15:353-60.11. Shanks D, Wong RY, Roberts JM, Nair P, Ma IW: Use of simulator-basedmedical procedural curriculum: the learner’s perspectives. BMC Med Educ2010, 10:77.12. Morrison EH, Friedland JA, Boker J, Rucker L, Hollingshead J, Murata P:Residents-as-teachers Training in U.S. Residency Programs and Offices ofGraduate Medical Education. Acad Med 2001, 76:S1-S4.13. Schwenk TL, Sheets KJ, Marquez JT, Whitman NA, Davis WE, McClure CL:Where, how, and from whom do family practice residents learn? Amultisite analysis. Fam Med 1987, 19:265-8.14. Mourad M, Kohlwes J, Maselli J, Auerbach AD: Supervising thesupervisors–procedural training and supervision in internal medicineresidency. J Gen Intern Med 2010, 25:351-6.15. Millington SJ, Wong RY, Kassen BO, Roberts JM, Ma IW: Improving internalmedicine residents’ performance, knowledge, and confidence in centralvenous catheterization using simulators. J Hosp Med 2009, 4:410-6.16. Wigton RS, Alguire P: The declining number and variety of proceduresdone by general internists: a resurvey of members of the AmericanCollege of Physicians. Ann Intern Med 2007, 146:355-60.17. Shulkin DJ: Like Night and Day – Shedding Light on Off-Hours Care.N Engl J Med 2008, 358:2091-3.18. Hayes CW, Rhee A, Detsky ME, Leblanc VR, Wax RS: Residents feelunprepared and unsupervised as leaders of cardiac arrest teams inteaching hospitals: a survey of internal medicine residents. Crit Care Med2007, 35:1668-72.19. Cate OT, Durning S: Peer teaching in medical education: twelve reasonsto move from theory to practice. Med Teach 2007, 29:591-9.20. Weiss V, Needlman R: To Teach Is to Learn Twice: Resident TeachersLearn More. Arch Pediatr Adolesc Med 1998, 152:190-2.21. Bulte C, Betts A, Garner K, Durning S: Student teaching: views of studentnear-peer teachers and learners. Med Teach 2007, 29:583-90.22. Dunnington GL, DaRosa D: A prospective randomized trial of a residents-as-teachers training program. Acad Med 1998, 73:696-700.23. Hill AG, Yu T-C, Barrow M, Hattie J: A systematic review of resident-as-teacher programmes. Med Educ 2009, 43:1129-40.24. Ma IW, Roberts JM, Wong RY, Nair P: A procedural teaching tree to aidresident doctor peer-teachers. Med Educ 2010, 44:1134-5.Pre-publication historyThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6920/11/16/prepubdoi:10.1186/1472-6920-11-16Cite this article as: Ma et al.: Who is teaching and supervising ourjunior residents’ central venous catheterizations? BMC Medical Education2011 11:16.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitMa et al. BMC Medical Education 2011, 11:16http://www.biomedcentral.com/1472-6920/11/16Page 4 of 4

Article deposited according to agreement with BMC, December 6, 2010.Funding provided by the Open Access Authors Fund.Ye

Ma, Irene W.Y.

Teteris, Elise

Roberts, James M.

Bacchus, Maria

PRISM: University of Calgary Digital Repository

Who is teaching and supervising our junior residents’ central venous catheterizations?

RESEARCH ARTICLE Open Access
Who is teaching and supervising our junior
residents’ central venous catheterizations?
Irene WY Ma1,2*, Elise Teteris2, James M Roberts3 and Maria Bacchus1
Abstract
Background: The extent to which medical residents are involved in the teaching and supervision of medical
procedures is unknown. This study aims to evaluate the teaching and supervision of junior residents in central
venous catheterization (CVC) by resident-teachers.
Methods: All PGY-1 internal medicine residents at two Canadian academic institutions were invited to complete a
survey on their CVC experience, teaching, and supervision prior to their enrolment in a simulator CVC training curriculum.
Results: Of the 69 eligible PGY-1 residents, 32 (46%) consenting participants were included in the study. There
were no significant baseline differences between participants from the two institutions in terms of sex, number of
ICU months completed, previous CVC training received, number of CVCs observed and performed. Only 16
participants (50%) received any CVC training at baseline. Of those who received any training, 63% were taught only
by senior resident-teachers. A total of 81 CVCs were placed by 17 participants. Thirty-two CVCs (45%) were
supervised by resident-teachers.
Conclusions: Resident-teachers play a significant role both in the teaching and supervision of CVCs placed by
junior residents. Educational efforts should focus on preparing residents for their role in teaching and supervision
of procedures.
Background
The ability to perform bedside procedural skills compe-
tently is an important part of medical practice. Proce-
dures such as lumbar puncture, thoracentesis, and
central venous catheterization (CVC), are commonly
performed for diagnostic and/or therapeutic reasons and
are often taught in residency training programs [1,2].
Indeed, for CVC, competency in this skill is a stated
objective for a number of postgraduate medical training
programs [3-7].
However, despite efforts in improving the training of
technical skills [8], many residents are uncomfortable per-
forming procedures [9]. Inadequate clinical exposure to
procedures [2] and an insufficient supply of faculty profi-
cient in teaching and supervising procedures have been
previously cited as barriers to procedural training [1,10,11].
On the ward, resident teachers play an important role
in the education of junior learners [12,13]. With respect
to procedural supervision, it has recently been reported
that many residents supervised procedures prior to feel-
ing comfortable with performing the procedure them-
selves [14]. However, it is unknown to what extent do
residents participate in the teaching and supervision of
procedures.
Therefore, we aimed to evaluate the extent of teaching
and supervision of CVC insertion by junior residents
at two Canadian academic internal medicine residency
programs. An estimation of the prevalence of resident-
supervision and resident-teaching will help guide medical
educators in terms of where to focus their curriculum
efforts.
Methods
During the academic year of 2009 (July 2009 to May
2010), all junior residents in their PGY-1 year from the
University of British Columbia (UBC) (n = 47) and
University of Calgary (n = 22) were invited to enroll
in our simulation CVC educational curriculum. Details
of this simulator curriculum have been previously
described [15]. Only residents who provided written
* Correspondence: ima@ucalgary.ca
1Division of General Internal Medicine, University of Calgary, Calgary, AB,
Canada
Full list of author information is available at the end of the article
Ma et al. BMC Medical Education 2011, 11:16
http://www.biomedcentral.com/1472-6920/11/16
© 2011 Ma et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
informed consent were included in this study. The study
was approved by ethics review board from both aca-
demic institutions.
Prior to the start of the CVC course, which occurred
throughout the academic year, participants were invited
to complete an anonymous survey outlining their base-
line CVC experience. In addition, they were asked to esti-
mate the total number of and type of CVCs placed during
their training, as well as information of who supervised
those procedures. Supervision at both institutions is
informally defined by the presence of a supervisor in the
room where the procedure is being performed. The
supervisor may or may not be gowned and gloved. How-
ever, a procedure performed without a supervisor directly
in the room is considered an unsupervised procedure.
Data Analysis
Baseline group comparisons were made with the use of
Wilcoxon rank-sum tests and Fisher’s exact tests where
appropriate. Comparisons in proportions were made
with the use of chi-square tests. All reported P values
are two-sided. Analyses were performed using SAS sta-
tistical program version 9.1 (SAS Institute, Cary, NC).
Results
A total of 32 participants were included in this study.
Twenty-two participants out of 47 PGY-1 trainees (47%)
were recruited from UBC and ten out 22 PGY-1 trainees
(45%) were recruited from the University of Calgary.
There were no significant baseline differences between
the cohort from UBC and that from the University of
Calgary (Additional file 1).
Training and Supervision
Prior to the simulation training, only 16 (50%) participants
had received any training on CVC (Additional file 1). Ten
out of these 16 participants (63%) were taught only by
senior resident-teachers. The remaining six participants
were taught by faculty members only (n = 3), a combina-
tion of faculty and senior resident-teachers (n = 2), while
one participant was taught by a resident of the same level
of training as the participant (n = 1). Of the 16 participants
who received prior CVC training, majority of the training
was received within the context of patient care (n = 14,
88%). One participant received prior simulator training,
while one participant received training in the context of
patient care as well as on simulators.
At baseline, a total of 81CVCs had been placed by 17
PGY-1 participants. Of the 81 CVCs performed, 71 (88%)
were supervised. Overall, 39 of the 81 CVCs (48%) were
reported to be supervised by faculty members and 32
(40%) by residents (Figure 1). Ten of the 81 CVCs (12%),
performed by three participants, were unsupervised. All
three participants had previously placed more than nine
CVCs.
Supervision of CVCs Based on Line-type
Of the 81 CVCs placed, 37 were internal jugular lines, 23
were subclavian, and 21 were femoral lines (Figure 1).
Faculty members supervised 70% of subclavian, 41% of
internal jugular, and 38% of femoral lines. Indeed, faculty
supervision is significantly higher for subclavian lines
than for non-subclavian lines (P = 0.02).
Discussion
The results of this study confirm that resident-teachers
play an important role both in the teaching and supervi-
sion of CVCs for junior residents. Resident-teachers were
responsible for teaching 63% of the junior residents who
received any training, and much of this training occurred
in the context of patient care. In terms of CVC supervi-
sion, 40% of all CVCs were supervised by residents. In
contrast to subclavian CVCs, where faculty supervision
was reported to occur 70% of the time, resident-teachers
supervised more non-subclavian CVCs than faculty
members (45% vs 40%). Lastly, only 12% of CVCs by
junior residents were unsupervised, and each of the unsu-
pervised CVCs was placed by trainees with considerable
CVC experience.
A number of factors may potentially be responsible for
significant involvement of residents in the teaching and
supervision of CVCs placed by junior residents. First,
over the past twenty years, the number of general inter-
nists who perform procedures has been shown to be
declining [16]. By 2004 in the United States, only 16% of
general internists reported performing CVC in their prac-
tice, compared with 39% in 1984 [16]. Not surprisingly,
internists are increasingly less confident in their ability to
teach and supervise procedures [10]. As faculty members
become increasingly uncomfortable with teaching or
supervising CVC, resident-teachers perhaps may be tak-
ing an increasing role in CVC teaching and supervision.
Figure 1 Percentage of central venous catheters (CVC)
supervised by faculty and resident-teachers. Bar graph of
percent of of central venous catheters supervised by faculty and
resident-teachers.
Ma et al. BMC Medical Education 2011, 11:16
http://www.biomedcentral.com/1472-6920/11/16
Page 2 of 4
Second potential reason behind high involvement of resi-
dent-teachers is that performances of CVCs may be
occurring at times when faculty members are not as
readily available. For example, CVCs placed at night may
not have the same level of supervision as CVCs placed
during the day [17]. Such discrepancies in supervision
between weekdays and weekends/evenings have pre-
viously been reported for the supervision of running car-
diac arrest resuscitations in teaching hospitals [18].
Third, having residents function as teachers or supervi-
sors maybe mutually beneficial for both the senior resi-
dent-teacher and the junior resident-learner [19]. The
very act of teaching may enhance learning on the part of
the resident-teacher [20], while junior resident-learners
may learn better from a teacher whose performance level
is more similar to the learner’s than from an expert
[19,21]. Indeed, in a recent survey of medical residents,
86% of survey participants felt that medical procedures
should be taught by a senior resident or fellow [11].
However, the disadvantage of placing resident-teachers,
not yet comfortable with the procedure [14], in the posi-
tion of supervising others may potentially result in
adverse patient safety consequences. Complication rates
of procedures supervised by resident-teachers, compared
with those supervised by faculty, should be further evalu-
ated. In a recent survey of internal medicine residents in
California, up to 26% of PGY-2 residents reported super-
vising central venous catheterization (CVC) before feel-
ing comfortable with their own procedural performance
[14]. The observation that resident-teachers play a signifi-
cant role in the teaching and supervision of CVC for
junior trainees argues for the need for educational inter-
vention for senior-resident-teachers. Indeed, a needs
assessment of teaching skills for surgical residents has
previously demonstrated that the item, “provide effective
coaching with supervision of performance of technical
procedures,” was rated as the most important teaching
activity by the survey participants [22]. What educational
intervention best suits the needs for teaching procedural
skills is unknown. In a systematic review of residents-as-
teachers curricula, more than half of the reported inter-
ventions consisted of a one-off intervention [23]. A com-
bination approach of including a longitudinal teaching
program with a one-off workshop for teaching procedural
skills has also been previously described [24]. Effective-
ness of these educational interventions, however, remains
unclear [23].
Our study has a number of limitations. First, the data
was obtained by self-reporting measures and accuracy of
the data was not verified. However, given that most of
the residents (84%) have performed fewer than five
CVCs, accuracy of the recalled information is likely
higher than a comprehensive survey administered to resi-
dents at all levels of training. Second, results represent
only on 46% of the combined PGY-1 population and may
limit the generalizability of the conclusions. Specifically,
our study reports 40% of CVCs were supervised by resi-
dents. Without capturing all CVCs placed by PGY-1s in
both institutions, the degree of bias is unknown. How-
ever, the goal of our study was to evaluate the extent of
resident supervision. While the percentage of CVC
supervision may be subject to bias, a reported number of
32 CVCs in two academic institutions is likely the mini-
mum number of CVCs being supervised by resident-tea-
chers. This represents a conservative estimate of the
extent of involvement by resident-teachers. Thirdly,
despite the fact that both academic institutions in our
study have a policy on having a faculty supervisor be
available at all times for the trainees, whether or not
faculty members were less likely to be called upon to
supervise procedures outside the standard work hours
than during standard work hours was not captured by
our survey. Lastly, we did not survey the senior resident-
teachers to ascertain their degree of comfort in supervis-
ing or teaching procedures. However, based on work by
others [14], it is highly likely that a number of the senior
resident-teachers would be uncomfortable with their
role. Future study should focus on the clinical conse-
quences of having resident-teachers supervise proce-
dures, types of teaching skills required for teaching and
supervising procedures, and how to optimize educational
interventions for our resident-teachers.
Conclusions
In conclusion, resident-teachers play a large role in the
teaching and supervision of CVCs for junior residents.
Educational efforts should focus on preparing residents
for their role in teaching and supervision of procedures.
Additional material
Additional file 1: Appendix A - Baseline Characteristics of
Participants. Table of baseline characteristics of participants.
Acknowledgements
This work is supported jointly by funding from the Departments of
Medicine, University of Calgary and University of British Columbia. There are
no financial disclosures related to the design and conduct of the study,
collection, management, analysis, and interpretation of the data, or
preparation, review or approval of this manuscript.
Author details
1Division of General Internal Medicine, University of Calgary, Calgary, AB,
Canada. 2W21C, University of Calgary, Calgary, AB, Canada. 3Division of
General Internal Medicine, University of British Columbia, Vancouver, BC,
Canada.
Authors’ contributions
IWYM: participated in research design, acquired, analyzed and interpreted
data; drafted the paper. ET: participated in research design, acquired,
analyzed data, and revised the paper critically. JMR: participated in research
Ma et al. BMC Medical Education 2011, 11:16
http://www.biomedcentral.com/1472-6920/11/16
Page 3 of 4
design and revised the paper critically. MB: participated in the interpretation
of data, revised it critically. All authors read and approved the final
manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 12 June 2010 Accepted: 25 April 2011
Published: 25 April 2011
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A prospective randomized trial of a residentsas-teachers training program. Acad Med

A systematic review of resident-asteacher programmes. Med Educ

Accreditation Council for Graduate Medical Education: ACGME Program Requirements for Graduate Medical Education in Critical Care Medicine.

Are Canadian General Internal Medicine training program graduates well prepared for their future careers? BMC Med Educ

Beyond the comfort zone: residents assess their comfort performing inpatient medical procedures.

CL: Where, how, and from whom do family practice residents learn? A multisite analysis. Fam Med

Colleges of Physicians Training Board: Specialty training Curriculum for General Internal Medicine.

Durning S: Peer teaching in medical education: twelve reasons to move from theory to practice. Med Teach

Durning S: Student teaching: views of student near-peer teachers and learners. Med Teach

Fihn SD: Teaching procedural skills.

IW: Improving internal medicine residents’ performance, knowledge, and confidence in central venous catheterization using simulators. J Hosp Med

IW: Use of simulator-based medical procedural curriculum: the learner’s perspectives. BMC Med Educ

Keyserling TC, et al: Confidence of academic general internists and family physicians to teach ambulatory procedures.

Like Night and Day – Shedding Light on Off-Hours Care.

Needlman R: To Teach Is to Learn Twice: Resident Teachers Learn More. Arch Pediatr Adolesc Med

Residents-as-teachers Training

Royal College of Physicians and Surgeons of Canada: Objectives of Training in Emergency Medicine.

Royal College of Physicians and Surgeons of Canada: Objectives of Training in Internal Medicine.

Royal College of Physicians and Surgeons of Canada: Objectives of Training in the Specialty of General Surgery.

RS: Residents feel unprepared and unsupervised as leaders of cardiac arrest teams in teaching hospitals: a survey of internal medicine residents. Crit Care Med

Supervising the supervisors–procedural training and supervision in internal medicine residency.

Teaching Surgical Skills – Changes in the Wind.

The declining number and variety of procedures done by general internists: a resurvey of members of the American College of Physicians. Ann Intern Med

file:///data/remote/core/dit/data/Springer-OA/pdf/73d/aHR0cDovL2xpbmsuc3ByaW5nZXIuY29tLzEwLjExODYvMTQ3Mi02OTIwLTExLTE2LnBkZg==.pdf

Who is teaching and supervising our junior residents' central venous catheterizations?

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